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The real reasons why A&E departments are bursting at the seams

By Dr Clive Peedell, co-leader of the National Health Action Party

A&E services across England are in crisis, with the Director of Patient safety at NHS England, Mike Durkin, admitting that patients are likely to have been harmed. Health Secretary Jeremy Hunt is trying to pin the blame on GPs. He points to contract changes nearly a decade ago which took responsibility for out-of-hours cover away from GPs. This argument is illogical. How could an event in 2004 cause a sudden crisis in 2013? And, obviously, it was not GPs who designed these changes but the Department of Health, influenced by private sector lobbyists wanting to privatise out-of-hours services.

This scapegoating of GPs suggests that Mr Hunt and the Coalition Government are desperate to distance themselves from blame for the NHS system collapse they themselves have caused.

In summary, there are five main factors which are fuelling England's A&E crisis after a period of record satisfaction with NHS services just three years ago: massive cuts by successive governments of hospital bed numbers which mean patients end up stuck in A&E beds and can't be moved onto wards; a lack of community care resources leading to hospital bed blocking; inadequate out-of-hours GP-replacement services; the use of unqualified staff at call centres to screen patients and advise if and where to seek treatment; and the closure of A&E departments. All form part of the overall NHS privatisation set out in last year's controversial Health and Social Care Act.

Both New Labour and the Coalition have enabled and encouraged commercial operators to make profits from providing out-of-hours GP services, replacing the not-for-profit GP cooperatives that previously provided this service. It is more lucrative for outsourcing companies to run NHS services with as few doctors as possible; it is reported, for example, that Serco staffed the out-of-hours service for Cornwall with a single on-call GP to cover the entire county. (http://sercofilm.co.uk/index.php/news/12-serco-film/news/40-serco-cornwall-s-gp-service). Many patients understand these cut-price services to be unsafe and therefore go straight to A&E services where they know treatment is available from a properly trained doctor working within a credible NHS team.

Simultaneously the government is closing busy A&E services and forcing patients to use the newly contracted-out "111" telephone service to get medical help outside normal working hours. To make matters worse, the government is allowing those running 111 services to use non healthcare professionals to man these important helplines. They are staffed by laypeople with a few days' basic training and minimal clinical supervision. Members of the public are naturally afraid of the risks of these arrangements, or frustrated by the delays and errors of undertrained, under-supervised 111 staff, and decide to go straight to A&E.

Furthermore, because telephone call handlers usually have only a few days' training and in the vast majority of cases no medical qualifications, they are inclined to send an ambulance "just in case it's serious": they too perceive A&E as the only safe option. Staff at one call centre operated by Harmoni Ltd estimated that they sent six times as many ambulances as were actually needed. As well as filling A&Es with people who should not be there, this arrangement ties up ambulances and so delays care to those in a genuine life-threatening medical crisis.

Thus for multiple reasons, many more patients are going to A&Es outside GPs' hours, causing overload of emergency staff and of ambulance services which were already overstretched. And yet the government is responding not by increasing A&E capacity to cope with the impact of their error in privatising out-of-hours services, but by shutting casualty departments down.

Why would they do this, when the public clearly needs those services and more? The closure of A&E departments is the first step in the government’s plan to free up NHS hospital sites for sell-off to property developers. Indeed Jeremy Hunt now controls a property company which was created by last year's new NHS law. It was designed and set up specifically to sell off our hospitals and NHS land.

Worryingly, there is already evidence from the Government's own records, which shows that these A&E closures may be costing lives. (http://www.dailymail.co.uk/news/article-2323141/Shocking-proof-Accident-Emergency-closures-cost-lives-Death-rate-jumps-THIRD-department-closes.html). Closures result in delays in accessing services at other hospitals some distance away. For some, a delay in care may result in acute life threatening consequences or long term serious harm and permanent disability. Plainly, therefore, it is important for hospitals not to shut their A&Es, as the extra travel time will result not only in more patient deaths but also more unnecessary disabilities among survivors.

Jeremy Hunt's allegation that GPs have abandoned their patients to the mercies of commercial call centres is also quite wrong. For many years, GPs clubbed together in rotas to provide care for those urgently ill at night and weekends; about 10% of GPs continue this service. In Hackney in North London they are trying to do this again, but have been prevented by the government's own rules about competitive tendering.

There have been a string of dangerous incidents in Hackney and the needless death of a baby while the out-of-hours service has been run by the private company Harmoni, incidentally now owned by CareUK, the very company which funded the last Health Secretary's office to the tune of £21,000 just before the Coalition took over. Baby Axel Peanberg King died after reportedly inadequate care at the Harmoni out-of-hours service, resulting in his parents becoming active anti-privatisation campaigners. (http://www.guardian.co.uk/society/2013/feb/28/doctor-baby-dies-privatised-gp).

The problems were summarised by one of Harmoni's own staff: "the current system is putting patients' health at severe risk". (http://www.guardian.co.uk/society/2012/dec/17/harmoni-dangerous-pressure-appointments). The GPs in Hackney have tried to address the failure of this contracted-out after-hours service by Harmoni and have got together and agreed to provide a not for profit service to replace Harmoni. However, this has been refused by the local health commissioners because they were afraid of legal action from the company's owners. (http://www.opendemocracy.net/ournhs/deborah-colvin/harmoni-preferred-to-local-gps-realities-of-britains-new-health-market )

So the situation we now find ourselves in, of A&E departments seriously overwhelmed and on “a cliff-edge” according to NHS leaders, has been created by the policy of successive governments of cutting public provision of hospital and community services, and using privatisation to plug the gap. The parallel policy of shutting down our A&Es is also linked to privatisation: private hospital operators are keen to sell their services to the NHS, but only in more profitable fields. They have no interest in A&E services, which are costly to provide because they cannot be broken up into simple routine tasks which can be done by anyone at low salary cost. However they do want to take over some hospitals in more affluent urban areas if these can be freed from their A&Es, and for the rest, the construction industry is keen to redevelop NHS hospital sites into residences or commercial buildings.

It’s time for the government to stop blaming GPs and patients, and answer for the human consequences of its own ill-advised policy choices in deliberately destroying our essential medical services. The best way of making A&E services meet the needs of the public adequately would be for the government to cease shutting them and also provide adequate care and facilities in the community to stop the hospital bed blocking that is clogging up hospitals. The best way to make the NHS as a whole function efficiently would be to stop treating it as a free-for all for big business.

Isn't it time for Jeremy Hunt to admit that his enthusiasm for cut-price private services to replace traditional NHS provision is already costing lives and will cost countless more?

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