Performance Watch: Details of the ‘A&E Local’ model revealed

The health secretary’s decision last week to designate Telford hospital as an “A&E Local” will likely set a precedent for other smaller emergency departments deemed unviable in their current form to follow. Performance Watch can today reveal the key principles the new A&E Local model will be based around and the pitfalls which system leaders must avoid.

Health secretary Matt Hancock last week gave the green light for the long-debated downgrading of the accident and emergency department at Princess Royal Hospital in Telford, a decision which will likely have far-reaching consequences.

But his statement also appeared to conflate two different potential models for urgent and emergency care departments, and arguably raised as many questions as it answered about what services will be provided at the hospital, run by Shrewsbury and Telford Hospital Trust.

To recap, as we reported last week, Mr Hancock said: “I have asked NHS England to come forward with proposals within a month on how they will keep the A&E in Telford open as an A&E Local, so that [the hospital] can continue to deliver the urgent and emergency care the residents in the growing town of Telford need.”

So, Telford, it would appear from this statement, would become the NHS’ first officially designated “A&E Local”. But what is an A&E Local?

The “A&E Local” label has been kicking around for several years as part of the discussion around how best to reform A&E departments deemed too small to be viable in their current form, often due to staffing and/or economic constraints.

For example, could the NHS, as one senior figure recently proposed to HSJ, have A&E departments which were physician led? Absolutely not, the Royal College of Emergency Medicine would answer: a type 1 A&E must be led by an emergency care consultant.

Significantly, the term was included in the NHS long-term plan published in January.

The document said, where possible, trusts should separate out planned services onto “cold” sites, while complex and emergency care should be provided on “hot” sites.

It added: “In those locations where a complete site shift to ‘cold’ elective services is not feasible, we will also introduce a new option of ‘A&E locals’.”

HSJ asked NHSE for a definition of the model, including what services such a unit would provide, and what the staffing model would be. Would it, for example, be led by an emergency consultant?

NHSE declined to comment in January, but was able to elaborate a little further this week.

A spokesman told HSJ: “The A&E Local model is in development and will be part of the package of NHS emergency care services delivered through our long-term plan, set up to deliver A&E services during core hours in a small number of health systems.”

And HSJ understands from sources familiar with the process there is growing agreement within NHSE/I that the principles underpinning the model should be as follows:

• The main difference between a fully-fledged type 1 consultant-led accident and emergency department and an A&E Local will be the opening times. A key criteria for a major A&E department is that it provides emergency consultant-led services 24/7. An A&E Local will, however, not provide those services overnight.
• The “Local” element comes in two parts: firstly, a local decision will be required on what opening hours work best, and are viable given local staffing constraints and night-time travel times and access to other A&E units. Will it close at 10pm or midnight, for example?
• The second local question to answer is what will happen at that point – during the night – when the unit is not operating as a type 1 A&E? Will it, for example, open its doors as an urgent care centre, or will it be shut altogether? Again, local staffing constraints and travel times to other A&E units will vary.

Such principles are already being put into practice at small hospitals, including Weston Area Health Trust and Grantham and District Hospital, run by United Lincolnshire Hospitals Trust.

The overnight closures at both Grantham and Weston were, however, couched by system leaders as a temporary move to be revisited if safe staffing ratios could be boosted to retain a 24/7 service.

So, what is the confusion about what is happening with Telford?

One thing HSJ has been told an A&E Local was not is simply an urgent care centre. UCCs or urgent treatment centres are often community or primary care-led units to deal with minor injuries and ailments.

An A&E Local must provide consultant-led type 1 services and be furnished with the required facilities during the day, albeit with a reduced or closed service overnight. An urgent care centre does not provide such an offer.

However, under the Shrewsbury and Telford Hospital Trust’s reconfiguration plans – the controversial and much-delayed “Future Fit” programme – the emergency department at the Princess Royal Hospital in Telford is to be downgraded to an urgent care centre.

All emergency services would be transferred to the Royal Shrewsbury Hospital in Shrewsbury, the document said.

Following Mr Hancock’s statement last week, local system leaders must decide whether Telford will become a UTC or an A&E Local, because – certainly as I understand the A&E Local model – it cannot be both.

There will always be political pressure to make A&E downgrades appear less radical than they are. And perhaps calling a unit an A&E Local sounds an easier sell to patients than calling it an urgent care centre.

But if the NHS gets into a scenario in which patients are being wilfully tricked into thinking they have a proper emergency department, when it’s only an urgent treatment centre, it would just be plain wrong. It could have horrendous consequences, including potential fatalities.

Mr Hancock’s letter is clear that NHSE will advise on the model.

The onus is now on the national commissioner to set out the parameters for the A&E Local model and ensure the badge is not misused to present an urgent treatment centre as something that it is not.