CRISIS-HIT Lothian accident and emergency departments are set to be radically overhauled, with scaled back services expected to lead to an increase in pressure on the already over-stretched Royal Infirmary.
A deepening staffing crisis has led health bosses to admit some patients attending A&E at St John’s Hospital in Livingston overnight are likely to instead be diverted to Edinburgh.
The move will force the sick and injured to travel more than 20 miles east and ramp up demand at the ERI, which in recent months has seen record numbers of patients lying on trolleys in A&E for hours on end due to a lack of staff and beds.
While pressure over medical staffing has been a growing issue for many months, it is believed that the crisis has come to a head after a workforce risk assessment painted a stark picture of the sustainability of emergency services across the region.
NHS chiefs insisted that they would do everything in their power to keep services at St John’s Hospital, while the department will remain open 24-7.
However, the possibility of an out-of-hours downgrade has been met with dismay, with one MSP branding proposals “completely unacceptable” and a hospital campaigner labelling health bosses “butchers”.
Currently, patients experiencing medical emergencies such as heart attacks and major broken bones are diverted from St John’s to Edinburgh, but from August patients with far less serious conditions could also be rerouted between the hours of 11pm and 7am.
Dr David Farquharson, NHS Lothian’s medical director, admitted that the health board had been forced to adapt to make the best out of an increasingly challenging situation, with demand for services growing at a time when staff were becoming increasingly difficult to recruit.
He said: “What we are saying is that depending on how successful we are in staffing emergency departments, we may need to look at some of our policies in terms of the sorts of patients that may need to be diverted.
“We explored all the usual avenues in terms of medical staffing. The vast majority of patients will not notice a difference. The standard of care can be assured. The department is not closing and they should treat it in the way they have up to now.”
While a remodelling of staffing levels is currently being undertaken and no final decisions have been taken, Dr Farquharson said if changes were brought in elderly patients with more complex conditions would be likely to be sent from West Lothian to Edinburgh, as those staffing the St John’s department at night may not have the appropriate skills for the more complicated cases.
Those who need specialist tests may also have to be sent to the Royal Infirmary, although consultants are likely to work for longer in the evening at St John’s.
Dr Farquharson claimed the result could be an improved service overall, with less reliance on trainee doctors with varying skill levels.
But Lothians Labour MSP Neil Findlay led calls for Health Secretary Alex Neil to intervene.
He said: “This situation is completely unacceptable. The proposal to divert accident and emergency patients from St John’s to Edinburgh will mean long journeys and more suffering and inconvenience for patients and a greater chance of people becoming more ill on the journey.
“In 2007, we heard SNP politicians commit to keeping healthcare local – that commitment now lies in tatters.
“The Scottish Government must intervene now to stop this downgrade of services at the hospital.”
NHS Lothian has said that between 11pm and 7am, an average of seven patients per hour arrive at A&E at the Royal Infirmary, while two visit the emergency department at St John’s.
The crisis in accident and emergency at the hospital follows a similar shortage in paediatric staff, which led to the children’s ward being closed overnight and at weekends for three weeks last summer.
Since then new staff have been recruited following a worldwide search and Dr Farquharson said a similar drive could be launched in emergency medicine.
MSP Jackson Carlaw, health spokesman for the Scottish Conservatives, said it was clear that a “major staffing problem” existed at St John’s Hospital.
He said: “The people of West Lothian will be rightly concerned if they are turning up to their local A&E with serious injuries or illnesses and then being told to travel several miles to an emergency unit which is already over-stretched.
“Sadly, this is just the latest in a catalogue of problems to affect NHS Lothian, which once again demonstrates a lack of leadership at the top.
“The Health Secretary cannot simply continue to watch from the sidelines while this crisis continues to unfold. We need urgent action before patient safety is compromised.”
Gordon Beurskens, a former councillor for the Action to Save St John’s Hospital Party, described the proposals as “devastating”. He said: “This is nothing short of a despicable betrayal of West Lothian’s long-suffering population. St. John’s Hospital is at huge risk in the hands of these butchers of a board.
“This is just the latest in their pathetically short-sighted excuses for failed resource planning. Alex Neil must stop this proposal dead in its tracks, or get rid of these disastrously inadequate people.”
The potential solutions to the A&E staffing situation are set to be discussed on Wednesday at a meeting of the NHS Lothian board. It is expected that any downgrade at St John’s will be strongly opposed by West Lothian representatives, and health chiefs are braced for fierce political opposition.
NHS Lothian has admitted that the A&E at the ERI, the largest department of its kind in Scotland, is its first priority as it treats trauma patients and serves as a regional centre.
Over the past 10 months the health board has added the equivalent of six-and-a-half consultants in emergency medicine, 25 nurses and three emergency nurse practitioners.
However less than half of speciality doctor posts, which it had been hoped would cover the out-of-hours gap left by reducing trainee numbers, were filled. From August, the number of trainees is expected to fall from five to two at St John’s, and from 12 to eight at the ERI. It had been hoped that GPs could be found to cover the out-of-hours service, however, only one doctor applied following an advertisement.
Stuart Wilson, NHS Lothian’s director of communications and current affairs, said: “We are doing everything in our power not just to maintain the service but make it better, with less of a reliance on trainees.
“People will always get the service they need but they might not get it in the place that they want it.”
Priority is the right level of care
Dr Jason Long, a consultant in emergency medicine and chair of the Scottish board of the College of Emergency Medicine, said: “Staffing in emergency departments has been an increasing problem for a number of years. There aren’t the trained doctors there to safely staff all departments at the moment. It’s an issue that’s similar across the country, this isn’t just happening in Lothian. But I think it’s up to each area to decide what’s best for them.
“Some of it is down to the job becoming a bit more unattractive – the hours are hard and it’s tough work. The nature of emergency medicine means that it’s much more antisocial. People will do it as a junior, but for more to do it as a career, we have to make it more attractive.
“The main thing is that departments are safe, with appropriate staffing levels at all times. That’s the main thing that the College of Emergency Medicine has been pushing for.
“Whether you’re having a heart attack, or whether it’s paediatric patients, you sometimes have to travel to get the type of care that’s safe. It’s about building safe models of care, not just buildings, and what will work for the local population.
I can’t comment on the situation at Lothian, but we can’t have hospitals with unsafe staffing levels – that’s the worst solution.
The priority is that we are getting the right level of care, not necessarily where we get it. In Glasgow and Fife, they’ve reduced the number of emergency departments.
It will take a lot of time to fix the situation, but we’ve been working with the Scottish Government for the past year and I think we’re starting to address it.”
ERI A&E at breaking point
Patients being diverted to the ERI is set to add strain to a department that is already at breaking point.
The number of patients waiting beyond a four- hour target has rocketed to record levels in recent months.
And hundreds of patients have waited beyond 12 hours to be processed through A&E and admitted on to wards.
The crisis has been blamed on a lack of beds in other areas, as patients are stuck in A&E until a place is free. An audit in January found that the flagship hospital was running at 101 per cent capacity.
Dr David Farquharson admitted: “Any additional activity is not exactly welcome.”