Distance Matters: Rural A&Es are special cases and need protection

Tuesday, August 16, 2016
Dr. Jonathan Stanley


The financial pressures on Accident and Emergency wards in Lincoln and Boston are increasing, as Grantham A&E could soon reduce working hours due to long-standing issues at United Lincolnshire NHS Foundation Trust.

Data from the Nuffield Foundation shows that the average distance from patient’s homes to A&E in much of Lincolnshire is above the national average. In South Holland, more than three quarters of people live more than 12 miles from their nearest A&E. Rutland is, likewise, poorly served; this is before even considering the effects of potential reductions at Grantham taking place.

Lincoln has already treated more patients than Newark’s A&E since its closure several years ago.

People in Lincolnshire know they have had a raw deal from the emergency services for years. Even considering closing Grantham A&E at night would be a kick in the teeth for a huge number of people. 


As a Doctor, I am calling for a special ambulance trust to cover all people living more than 12 miles from their A&E. This proposal aims to take the burden from smaller A&Es, such as the one at Grantham, so that urgent care is integrated by regional need instead of being fixed on-site.

Paramedic practitioners on the doorstep would mean that ambulances and staff could be available for seriously ill patients. A&E Doctors in minor injuries units could see and treat less urgent cases. We should base many more ambulances in rural areas to focus on getting isolated patients to A&E rapidly.  

By cutting out the long waits for ambulances to respond and having doorstep triaging, we can make sure that the most isolated patients receive care as urgently as those in city centres do.  Cutting existing A&Es is proving a disaster. Common sense says we need to think and act locally.

Smaller A&Es have been under pressure for years and in many cases where there is a larger A&E close by, closures are regrettable but do not compromise safety. In hard to reach places, smaller A&Es are literally lifelines.

Worryingly, changes to tariffs paid for by urgent care mean that the NHS can afford to underpay A&Es that remain open by closing smaller ones if the redirected workload is seen simply as excessive local activity.

These marginal tariffs must not be allowed to form any part of decisions to downgrade A&Es. Falls in activity at Grantham, should this downgrade happen, must be transferred in full to surrounding A&Es as a minimum to ensure the full tariff is paid for transferred work and not a marginal rate. Local MPs must be aware of this tariff and its implications in decision making.

This report from 2013 shows that:

“The change from block contract to payment by results in acute medicine has given hospitals a financial incentive to admit more patients. Following concerns about the growth in emergency admissions, the Department introduced the 30 per cent marginal rate rule for emergency admissions in 2010-11. Under this rule, commissioners only pay hospitals 30 per cent of the tariff for emergency admissions above the hospital’s level of emergency admissions in 2008-09. The Department expected some of the savings made to be reinvested in demand management schemes to prevent inappropriate hospital admissions by improving patient care outside of hospital. From 2013-14, commissioners are required to invest the remaining 70 per cent of the tariff income in demand management schemes. However, this rule was not consistently applied by commissioners and it is unclear how much of the remaining income has been reinvested.”

The marginal tariff has been increased from 30 to 70 per cent since last year but it still poses a risk to local services.

One third of the cost of A&E, which remains held back, can’t be accounted for in terms of patient care in marginal rate cases.

Emergency admissions within 30 days following a previous hospital admission have also been increasing, rising by 69 per cent between 1997-98 and 2012-13 to one million. The Department considers that some of these readmissions may reflect poor quality of care in hospitals or may be due to inappropriate early discharges. Between 200607 and 2010-11, payment guidance had provided flexibility for commissioners not to, or partially, pay for some readmissions within 14 days of discharge, and from 2011-12, commissioners may not pay providers for any of these readmissions within 30 days (apart from a specific set of exclusions). This rule has also not been consistently applied.”

These are failed discharges ie. they were kicked out too soon with their beds were still warm when someone else went in them.

Other factors that may have contributed to the slowdown in the rate of increase is the focus placed on reducing admissions by commissioners as part of local plans for efficiency savings (see paragraph 1.7) and changes to the way some emergency admissions are recorded by some trusts. A number of trusts we visited had changed parts of their patient pathway over the last few years, for example by introducing medical assessment units and clinical decision units. Activity through these units is not recorded consistently between trusts; some record the activity as admissions, others record it as outpatient activity or day cases. Therefore, a substantial number of cases previously recorded as short-stay emergency admissions by some trusts are now recorded as outpatients or day cases.”

Basically,  the figures are unreliable in many cases.

Small, rural A&Es should be fully exempt from the marginal rate tariff. The same principles as applied to the Small Pharmacy Scheme should apply to smaller A&Es if the population would be placed more than 12 miles from the next nearest A&E in the event of reduced hours or closure.

Dr. Jonathan Stanley is a Junior Doctor, a Fellow of the Royal College of Surgeons and Health Contributor at the Bow Group