A&E Q&A

Health trusts managing hospitals in the two towns want to centralise care provided so doctors can maintain their skills and medical specialities can flourish.

But it could mean patients having to travel farther for emergency treatment.

The Argus has been campaigning with a petition against any such move.

RACHEL PALMER looks at some key questions and the board's answers.

Q Why can't we carry on as we are? Why are we considering changing the A&E service at the Princess Royal Hospital? Surely we should be investing in it?

A A&E is a vital service. For many people A&E is the "front door" to hospital services. But it cannot work in isolation. Behind that front door are a whole range of people and departments that must be in place to support a safe and fully functioning A&E. It is the availability of these supporting services, and the specialist doctors to run them, which forces us to look at how A&E services might be provided in the future. Without those specialists in place to advise on patients' treatment, we could not guarantee good quality and safe care for patients coming into A&E. Therefore, investing in A&E alone would not be enough.

Q Why are we not investing in more specialist doctors?

A Doctors are becoming more specialised because of advances in modern medicine. Doctors' training has become more specialist to get the benefit of new technologies and treatments, especially in surgery. This specialisation brings numerous benefits to the patients treated by these doctors. People feel safer in the hands of an expert in his or her field. But, in order for doctors to see enough patients to keep up that expertise, hospitals need to draw their patients from larger populations. The Royal Colleges advise us that hospitals should collaborate in future to serve populations of 450,000 to 500,000. Neither the Princess Royal nor the Royal Sussex County Hospitals serve this many patients on their own.

Q Why don't we train more generalists?

A The generalist doctors working today provide high quality care but the pool of generalists is becoming ever smaller. Many generalists are actually becoming more specialised.

Many are simply due to retire in the coming years and new ones are not being trained. Therefore, it would be irresponsible for us to plan on the assumption that these generalists will be available in the future. As they retire they will be replaced by doctors who are more specialised. If we stayed as we are (with smaller-than-recommended populations) these future specialists would not be able to see enough patients to retain their vital skills. If we allowed this to happen then patients' care would not be as good or as safe as if they went to a hospital which treated more patients.

Q Why not recruit generalists from abroad?

A We do and we will continue to recruit doctors from abroad. But doctors everywhere are specialising when outcomes for patients are better by doing so.

Q So why can't Princess Royal's A&E department carry on as it is?

A At the moment there are four general surgeons who form a rota to care for all emergency patients coming into A&E. This covers patients for 24 hours a day, seven days a week.

In the next few years three of those surgeons are likely to retire.

Q When they do, they will be replaced by more recently- qualified, specialised doctors.

A These specialists would not be able to participate in a rota to cover all types of general emergency. And if we recruited doctors to form a separate rota for each specialist area, they would not be able to see sufficient patients to maintain their expertise.

Q Does this apply to all areas of hospital care?

A No. But it applies particularly to surgery where procedures are becoming more and more specialised. The majority of patients have medical conditions (heart attacks, strokes, etc) rather than conditions needing surgery. In the care of medical patients there are more doctors because there are more patients and they are not so specialised.

Q Why can't they rotate with Brighton?

A Because they need to be available to treat emergencies 24 hours a day and cannot safely be on call at one hospital and also at the other.

Q Why not build up services at Princess Royal and downgrade services at the Royal Sussex County Hospital?

A The Princess Royal Hospital has room for expansion whereas the Royal Sussex County Hospital is a constrained site. The Princess Royal is easier to get to than the Royal Sussex County.

If we agree that we cannot treat every type of condition at every hospital we have to make some difficult decisions. The specialist support available at Brighton is already greater with the larger number of county wide specialist services there (cancer services, renal services, etc). These vital services for more than one million people would be under threat if the Brighton hospital was downgraded. In addition, Brighton's local population is double that of Mid Sussex and, taken as a whole, arranging services in this way would reduce the number of people across central Sussex who had to travel. This does not mean that the services at the Princess Royal Hospital will be in any way second rate. It simply means that the people of central Sussex will be able to use two major centres of expertise.

Q But what about the new homes planned for Mid Sussex?

A Even the highest estimates of population growth would not be sufficient for the Princess Royal Hospital to function independently.

The existing population is 150,000 compared to Royal College guidance for hospitals to plan services for the future in terms of populations of 450,000 to 500,000. This is not the same as merger or combining services altogether on one site. Patient care will be enhanced if hospitals collaborate, whatever the size of population.

Q The traffic in Brighton is dreadful and there is nowhere to park. Many people do not have access to cars or public transport. How can we be considering centralising all trauma and emergency treatments there?

A When a patient is ill enough to require specialist trauma or emergency surgery they would be conveyed to Brighton by ambulance. Ambulance services would know to which hospital patients must be taken. Any patients arriving at the Princess Royal Hospital who required emergency surgery would be monitored and stabilised and then transferred to Brighton. Transport is a key issue, not only for patients but their visitors. We want to ensure that transport needs are at the forefront of our plans so we have set up a transport group including local authorities, the ambulance service and voluntary transport providers.

Q Won't patients die because it takes longer to get to A&E?

A We have a major concern that patients and staff would become seriously compromised if we leave things as they are. A patient arriving at an A&E department without specialist back-up could be more at risk than one that was travelling a little further to a specialist centre where they were guaranteed expert care.

Q But the A&E at the Royal Sussex County Hospital is already overloaded. Surely both Brighton and Mid Sussex residents lose out if more patients go there?

A Many hospitals are under pressure. But if changes to health services in central Sussex go ahead the A&E of today will not be the A&E of tomorrow. It will be essential to ensure that the A&E department has all the necessary facilities and staff to treat all patients quickly. The advent of NHS Direct and developments in GP and social services all have the potential to reduce pressure on A&E.

Q Won't GPs and ambulance services lose confidence in which services are available at Princess Royal Hospital and take patients to the Royal Sussex County Hospital in case they need specialist surgery?

A GPs and ambulance services will be working to clear guidelines. They will all be clear to which hospital patients should be sent.

Q Wouldn't it just be better to centralise all the experts, both surgeons and physicians together? That way if patients have uncertain diagnosis a whole range of specialists are available.

A Some people favour this option. It is described as Framework 2 in the discussion document and it does have advantages. However, the downside is that many more people would have to travel than under Framework 3. In order to accommodate all emergency services at one hospital, all non-emergency services would have to be located there.

Q Under Framework 3, would patients have to travel for day case surgery and outpatient appointments?

A No. The vast majority of these would be provided locally. The only exceptions would be very specialised services.

Q What about children's services or having a baby?

A These services would remain unchanged under Framework 3.

Q Why can't doctors travel instead of patients?

A For the safety of patients, doctors work in teams and have specialist equipment and advice on hand. The teams work in rotas to make emergency services available for patients 24 hours a day, seven days a week. They could not safely be at one hospital and also covering emergencies at the other.

Q What about telemedicine? Couldn't that be enhanced so patients could be seen locally?

A Telemedicine (where, by using new technologies, a doctor and their patient do not even have to be in the same town) is developing rapidly. Eventually, it could revolutionise some hospital care. However, there are likely to be limits on its use. It is unlikely, for instance, that it could be used to allow a surgeon to supervise a specialist operation being undertaken by less skilled staff over a video link.

Q What about the future? Won't the Princess Royal Hospital become a cottage hospital?

A No. The Princess Royal Hospital will remain a busy acute general hospital. Under Framework 3, where medical emergencies continue to be seen locally, the Princess Royal Hospital will be treating all its current patients except those requiring emergency trauma or surgical care.

This means around 70 per cent of patients currently using the Princess Royal Hospital A&E department will continue to use it, including those with heart attacks, strokes and asthma. In addition, under this framework it is proposed that a range of other services are built up at the Princess Royal Hospital to serve the whole of central Sussex, making good use of its modern facilities.

Q What services could be developed at the Princess Royal Hospital and how will patients benefit?

A range of options is being considered which might include orthopaedic surgery, breast surgery, endocrine surgery, low risk colo-rectal surgery and vein surgery. Patients could expect fewer cancellations because there would be less disruption in operating theatres resulting from emergencies. This would lead on to shorter waiting times. Other options for service developments at the Princess Royal Hospital include developing breast care services and services to treat diseases, particularly affecting women, such as eating disorders and osteoporosis.

Q Surely a new hospital is the right answer?

A A new hospital would be ideal if there were no other factors to take into account. But we simply do not have the time to wait. Planning, resourcing and building a new hospital can take many years. This would be longer than the timeframe within which we need to plan for the increasing specialisation of hospital practice. The very poor state of some facilities in Brighton such as at Brighton General Hospital, the Royal Alexandra Hospital for Sick Children and some parts of the Royal Sussex County Hospital site means these services cannot continue as they are. Staff are providing excellent services from sub-standard facilities but they will not be able to do so in the long term. Morale and recruitment would suffer. At the same time we need to make the best use of taxpayers' money and this means making better use of the facilities we already have.

Q Why do we need to change now?

A Changes are being made constantly to improve services in line with latest developments, for example, speeding up cancer diagnosis and treatment. We also need to keep an eye on the longer term and that is what this discussion document is about.

Q Isn't this all about saving money?

A No. It is about making sure we can provide high-quality care to you and your families for the foreseeable future. It is about finding the right balance between the distance people have to travel and the availability of expert doctors. Any of the frameworks, (including no change to the existing organisation of services) will mean investing more in the NHS in future.

Q Haven't you already decided what to do?

A No. We are at a very early stage of planning. The discussion document sets out all the issues in detail and three possible frameworks for discussion. It is not a consultation on firm proposals that have already been developed. A variant framework may come out of discussion. The only thing that has been decided is that we cannot "do nothing". Avoiding change can only lead to a deterioration in services for the future.

Q How can we comment if we don't know all the details?

A We wanted to involve the public at an early stage, even though that has meant we don't have categorical answers to everything. We wanted you to know the issues we were wrestling with so that you could make informed comments based on that information. If any changes arise from these discussions, people will be given another opportunity to comment, through full public consultation.

Q When are the detailed proposals going to be developed?

A During the last part of 2000 and in early 2001. The exact timescale will depend on the outcome of the discussion period and the amount of work involved in developing detailed proposals.

Q Are the two trusts going to merge?

A The two trusts are collaborating very well without the need for merger. This will be kept under review. The trusts will consider what level of integration best serves patients.

Q Shouldn't you wait until the outcome of the North Sussex "Strategic Planning Forum" (looking at the longer term health requirements in north Sussex) is known at the end of 2001? Surely planning should be more strategic, taking account of a wider area? It might demonstrate that a new hospital serving the whole area is the right way forward. Any investment in Brighton would undermine this.

A We shall be taking account of the outcome of the planning forum. Brighton hospitals and the Princess Royal Hospital need to collaborate to provide a broader range of high quality services to local people.

This does not preclude working with other surrounding hospitals. There will be a need to ensure Brighton, Hove and its environs are served by good quality facilities, whatever the outcome of the North Sussex Strategic Planning Forum and the Central Sussex Partnership Programme.

Argus petitions must be returned to our offices by tomorrow. General comments should be directed to the Central Sussex Partnership Programme, Springman House, 8 North Street, Lewes, East Sussex, BN8 2PB, faxed on 01273 485346 or e-mailed to projectadm@esbhhealth.cix.co.uk