The NHS in Scotland has been blighted by creeping centralisation. Hospital services have been progressively been sucked into the large, university-based hospitals in the major cities. The result has been growing problems with accessibility and equity, and a sense of alienation from the population that these hospitals serve. People do not simply want the best medical care possible – especially not if if means they have to travel away from their communities and their families in order to receive it. There are now many parts of Scotland where there is no cover on evenings and weekends, and over an hour’s travelling is needed to get help. Health care is all about social protection, and the first, basic rule is to make sure that people are covered when they need it. The resistance to the closure of Accident and Emergency (A&E) facilities in Monklands and Ayr is symptomatic of this. The understandable fear that people have is that the services will not be there when they need them, and they will have to travel long distances to get essential cover. One of the first actions of the new SNP executive has been to refer the issue back to the health boards for reconsideration.
The reform of A&E is not, however, just another example of centralisation. On the contrary, the development of A&E is itself an example of over-centralisation – formed in the belief that a unit can only function adequately if it has a critical mass, and all the bells and whistles that might be needed. The current arrangements don’t work – it’s not very long since A&E in Lanarkshire was virtually overwhelmed by the number of people reporting with a respiratory virus.
The Kerr report, Building a health service fit for the future, argues that the problems of A&E can be dealt with by more decentralised, local services. The report makes a crucial distinction between Casualty and Emergency services. Kerr proposes a network of casualty units, each with the capacity to deal with lesser injuries and to stabilise life-threatening conditions. Kerr suggested that “as a rule of thumb, each current hospital offering A&E services should be able to sustain services for urgent care.” Emergency services, by contrast, will be more specialised, typically serving about a quarter of those who currently come into A&E.
The NHS boards in Lanarkshire and Ayrshire and Arran proposed, in line with the Kerr report, to replace A&E with a split between Casualty and Emergency units. In Lanarkshire, the plan would have increased the number of units dealing with casualities from three to five, with new units in Cumbernauld and Lanark. These 5 units were to cover 70%-80% of the load currently done in three places. Each, then, wouldl have only half the load of current A&E provision. Two further Emergency units, at Hairmyres and Wishaw, were to act as specialised backup. A&E in Monklands was to be downgraded – not closed – as part of a process which would have redistributed staff and facilities across seven units in five locations. The same pattern was proposed by NHS Ayrshire and Arran. Instead of two A&E departments there were to be five causalty departments and one emergency unit. A&E in Ayr would therefore be downgraded.
The purpose of these plans was to make services more local, less centralised, more accessible and much less overburdened. That is what people are now opposing. An attempt to decentralise is at risk of unravelling because of a demand to keep things as they are.