The secret is out: not all A&Es are equal

Woman with finger to lips A&E services have been evolving for years

It has been an open secret in the NHS for years, it's just that nobody has been honest enough to tell patients. Until now.

In unveiling his new vision for urgent and emergency care, NHS medical director Prof Sir Bruce Keogh was upfront. "Not all A&Es are equal," he said.

In fact, you probably have to go back to the 1970s to find a time when all A&Es could offer the best treatment of the day.

Since then the advancement of medical science has meant specialist care has had to be focussed at fewer and fewer sites.

Take heart attacks, for example. Forty years ago patients were treated with bed rest and the hospital mortality rate was about 25%.

Over the years specialist units were set up and clot-busting drugs used.

Then in the 1990s it become clear the way forward was to mechanically unblock arteries.

Mortality rates have now been reduced to 5%.

But only about half of hospitals have the specialist equipment and doctors to provide the latest expert care.


Similar changes have happened in other areas from stroke services to trauma care.

One in five A&Es don't even have specialist children's services now.

It means the brand A&E has become almost meaningless.

Take Leeds and its surrounding areas stretching from Harrogate in the north to Barnsley in the south.

There are 10 hospitals with an A&E unit, all with varying degrees of expertise. By far the biggest and most important in the region is Leeds General Infirmary which deals with all the major trauma.

Comparing that to the unit at say, Dewsbury, is like comparing apples and pears. They are simply not the same.

And that is why splitting A&Es into two distinct groups - as Sir Bruce is proposing - makes a great deal of clinical sense.

But the problem now is the politics of it.

While in many areas the creation of a two-tier service has already happened in all but name, there are plenty of areas where it has not.

If and when that happens there will be a sense - rightly or wrongly - of some areas losing out.

As a result, making those decisions will become highly controversial, as Nigel Edwards, of the King's Fund think-tank acknowledges.

He says while the solutions are the right ones they will be "hard to sell" and "difficult to implement".

Nick Triggle Article written by Nick Triggle Nick Triggle Health correspondent

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  • rate this

    Comment number 24.

    When things go wrong in the NHS, how come it's always the "staff's" fault ?

    Why not the Health Secretary ? Does the buck not stop there ?

    I think Jeremy Hunt has slopey shoulders.

  • rate this

    Comment number 23.

    There are many who go to A&E with a genuine emergency, but which does not need the full range of facilities. Bad cuts, minor burns etc. A secondary treatment centre located adjacent to the main A&E, with a triage nurse able to assess and direct the patient immediately on presentation, whether it be one way for quick stitching, or straight in for more life threatening cases at a less busy centre.

  • rate this

    Comment number 22.

    Every positive has negative consequences.

    Why not just have one massive UK hospital that has constant experts on tap so it better meets conspired statistics, instead of local need.

    Maybe locate it on the moon.

  • rate this

    Comment number 21.

    Let us not forget who are the guys who own energy companies. They are are the same bankers who bankrupted the country. The have no scruples to do the same again and again. Unfortunately the same breed is running the country. A bit harsh but it is true.

  • rate this

    Comment number 20.

    the statistics have been showing that concentration of expertise leads to better patient outcomes for years, but that contradicts the gospel of the free market so gets ignored.

    why would they care about improving care when they could make money instead?

  • rate this

    Comment number 19.

    God help if you have bad cut or minor fracture in Ealing - the lower tier they offer would be unable to cope. Probably about 4 hours min. I am being generous here as I had to wait 12 hours one weekend in A&E for a broken hand. I was old my GP would xray my hand and fix it. Yeah right..

  • rate this

    Comment number 18.

    It genuinely is a postcode lottery sadly. The 2 tier system has been in use for years, this is no change at all and will make not an ounce of difference to the current pressures faced by the NHS acute services.

    The 2 tier system works well for the critcally ill, but it is not an answer to the huge pressures faced by the NHS acute services.

    - NHS Paramedic

  • rate this

    Comment number 17.

    Interesting idea that solutions will be "hard to sell". I wonder who is going to be sold to. Some politicians will be in favour, others will be anti, as will the employees and unions. This is a default position that is pretty much unchanging. Patients, of course, are irrelevant.

  • rate this

    Comment number 16.

    My local A&E is Dewsbury, as mentioned in the article. This hospital is in the process of being downgraded with major surgery and consultant-led maternity being focused in Wakefield, a considerable distance away. The stated aim is for a better quality of care for patients, but residents around Dewsbury don't feel it is fair as their local hospital is being downgraded to pay for it.

  • rate this

    Comment number 15.

    There's already a 2-tier system here. A maildrop tells us that our 2 local A&Es now only cater for life-threatening conditions or broken bones. For lesser problems we have to go to a Minor Injuries Unit. My nearest is in the next town, not on a bus route and open 8:30-4:30 Mon-Fri. My next nearest is 20 miles away. Heaven help you if you have a wound that needs cleaning/stitching on a weekend.

  • rate this

    Comment number 14.

    If changes are made for the right reasons, they find support. However, the lies and smokescreen that fly out of politician's mouths means few trust ANY of their words about the NHS.
    The way the NHS is currently managed leads to a postcode lottery. Even if this report has sensible suggestions to rectify that for A&E, it will fail at implementation due to politics and mismanagement of the changes.

  • rate this

    Comment number 13.

    The vision for the NHS, in 1945, was that the government would spend a lot of money initially getting the country healthy then the bills would tail off. What happened was medical research, which brought on new treatments and drugs and the bills ballooned. , the days of your local district hospital doing everything are long gone we need a proper nonpolitical debate on this & I just saw flying pigs

  • rate this

    Comment number 12.

    It's the way forward. provided adequate supportive care can be given in an ambulance on the way to the specialist centre. A friend who recently had a heart attack was sent over 20 miles for treatment, but had a stent fitted within an hour and was home within a couple of days. The unit (North Staffs) was state of the art and the treatment couldn't have been bettered. Definitely the way to do it.

  • rate this

    Comment number 11.

    Not only am I fairly sure we all knew this anyway - rural and urban services have always had a divide - but it makes perfect sense.

    People that make good paramedics and emergency care staff should be focussed on response & stabilisation, whilst patients are prepped for and transferred to specialist units.

    If enough money is put into it - emergency air xfers would be vital - it would work well.

  • rate this

    Comment number 10.

    I totally agree with 7.
    The BBC cannot leave the NHS alone for a day.
    Even the most positive changes are shown in a negative light.
    Your editorial team are disgraceful.

  • rate this

    Comment number 9.

    ... or just invest in the NHS instead of privatising it?

  • rate this

    Comment number 8.

    barrie higgs, you seem somewhat paranoid, maybe stop wearing the tinfoil hat!

  • rate this

    Comment number 7.

    What secret? This is typical BBC bias.

    Does the BBC think that the public are so stupid as to believe that a small rural hospital would ever have had the same facilities that a major city hospital? I think not.

    This article is a crude attempt by the BBC to stir distrust and perpetuate its own ideological and institutional bias.

    Whatever happened to unbiased reporting or comment?

  • rate this

    Comment number 6.

    At a recent conference a clinician stated 'If something is perceived a free it has no value, an whilst that concept prevails the NHS in its current form is bankrupt.'
    A system, designed and funded to treat workplace injuries, cannot support the current A&E malstrom. The proposed A&E restructuring, will allow the NHS to charge small admission fees at non-critical facilities and instill value.

  • rate this

    Comment number 5.

    Who are you implying has been hiding the truth Nick?
    Are you really being impartial here?


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