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A doctor’s view of Charing Cross Hospital A&E decision

By a Consultant at Charing Cross Hospital

A doctor’s view of Charing Cross Hospital A&E decision 15 April 2019

Local politicians ‘contribute nothing useful’ on this subject

The decision to “save” Charing Cross Hospital does not improve the health of residents in Chiswick, and potentially makes it worse. It is purely a political decision which has nothing whatsoever to do with provision of the best quality healthcare. It is not a cause for celebration. I write this as a hospital consultant who works at Charing Cross hospital (and Hammersmith and Chelsea and Westminster), loves working there, and thinks it provides excellent care. The fundamental problem it exposes is that everyone wants a truly local hospital that provides the very best healthcare; this is simply neither possible nor safe in today’s age of increasingly complex medicine. Local politicians (MPs, councillors) of all political parties are never useful in this discussion: they will not support any healthcare changes that even hint at moving services away from their local residents, even if this is only five miles away (surely still “local”?) and would improve care, and is supported by evidence and facts. Evidence and facts have no chance faced with these emotions, so local politicians are usually disruptive and contribute nothing useful.

Why your local hospital cannot do everything to a world class level

Some basic facts to remember: healthcare now requires large teams of professionals, the support of complex imaging (CT scans, MRI, ultrasound), pathology departments, nursing, physiotherapy and more. Increasingly, healthcare is about the long term management of chronic diseases in older people, and less about dealing with acutely sick patients. A minority of the care the population needs is delivered by acute hospitals (though this consumes the majority of money spent) and a minority by A+E (better called Emergency Departments). We do not have enough staff working in healthcare in any area, from doctors to therapists, radiographers to dieticians. Finally, an Emergency Department cannot exist in isolation: it needs the support of complex imaging 24/7 (CT and MRI scanning), an intensive care unit to take severely unwell patients, surgeons resident and immediately available, physicians to make complex diagnoses, and manage patients with sepsis, pneumonia, liver and kidney failure, and much more.

Several years ago NHS London took the brave and correct decision (based on clinical evidence from trials, not based on money) that if an ambulance crew suspected you were having a heart attack, they would take you to a “heart attack centre” and not to your local Emergency department. They would drive you past Charing Cross Hospital and continue to Hammersmith Hospital (where the Heart Attack Centre is located). You would not have a choice. This would allow you to be taken immediately into an operating room straight from the ambulance, have an immediate angiogram and have your blocked coronary artery opened up immediately. No waiting, anywhere. A heart attack centre has staff available 24/7, all the kit and technology, to save lives from heart attacks. This is proven to save lives. Yes, you will be in hospital for a few days much further from where you live, making it harder for your family to visit, but you will not be dead. I know which I prefer.

The same has happened for patients with strokes: you will be taken to a major stroke centre which may not be your local hospital, which will make it harder for your family, but make it much more likely you will live and will not be disabled. This cannot be offered in every single hospital.

If you are cycling and are hit by a car on Chiswick High Road, your ambulance will drive past Charing Cross hospital, and take you to St Mary’s Hospital, Paddington, where there will be a major trauma team waiting with orthopaedic surgeons, neurosurgeons, abdominal surgeons, anaesthetists, ITU, CT and MRI scanning all available 24/7. Your chance of surviving, with minimal disability, will be hugely improved, even though you have travelled further. It is simply not possible to provide this level of care in every hospital in NW London: there are not enough staff to run an MRI scanner in every hospital 24/7; there are not enough surgeons; not enough nurses, and never can be, with any amount of funding. This is not about money.

Let’s take another example not involving an emergency department: if you find a breast lump it is now possible to attend a single clinic at Imperial NHS Trust where in one day you will see a breast surgeon, have a mammogram, an ultrasound, a biopsy. You will get the results from all of this before the end of the day. Fantastic. This is world class care. This is only possible by putting all these people in one place, including the pathologist who needs to look at the biopsy, and the multiple pieces of equipment and technology. This service happens to be at Charing Cross Hospital, but could have been at St Marys or Hammersmith Hospital, but could not be in all three. Would you really mind travelling one hour to get all this done in one day (but much less if you cycled!), with all your questions resolved, rather than needing 2 or 3 visits to a slightly more local hospital over several days or weeks, with ongoing anxiety and stress?

Finally, if you need complex surgery, for example for bowel cancer, involving the newer robotic technologies, which will likely minimise complications and severe side effects, this cannot be provided in every hospital: no healthcare system can afford such expensive equipment nor in fact train enough surgeons to use it, in every single hospital. It is worth having to travel a little further to have these benefits. It is up to us as doctors to explain clearly the benefits. In this circumstance there is no reason you cannot attend an outpatient clinic in a local hospital (Charing Cross for example) before and after the operation, and it is only your inpatient stay which needs to be somewhere a little further away (such as Paddington).

Campaign ‘disingenuous’

This is what the healthcare plans in NW London were trying to achieve. Excellent care delivered by excellent staff, with the right support, to give you the best chances, which might not be completely “local”. The headlines “Charing Cross to be closed” is disingenuous but good for publicity, and was never part of the plans. Plans existed (amongst other things) to improve outpatient and community care and day case surgery at Charing Cross, and try and centralise complex care in various locations in NW London, to make improvements for patients, such as I have described above.

Decision to “save” Charing Cross Hospital does not improve the health of residents

Let’s finally return to Emergency (A+E) Departments. The one at Charing Cross is clearly well used, and offers high quality care, but a very large proportion of people attending do not need a full blown Emergency centre – they need a doctor to look at a rash, or an earache, or treat a urine infection, but for some reason did not want to attend their own GP. This care does not need a full blown A+E. And if you are truly sick, and arrive in the middle of the night to Charing Cross Emergency Department, your chance of been seen or reviewed by a consultant is very small, since there are not enough consultants to be present 24 hours a day in all Emergency departments. So your care may be managed by a relatively junior doctor. Clearly to manage the true emergency work load in fewer Emergency Departments does require expansion in those remaining, but this would allow for consultant presence 24/7 and better support from surgeons, imaging and all the newer technologies. But surely, if I have to travel further to an A+E in Chelsea rather than Charing Cross I will be sicker and more likely to die? This is simply not true. As I have shown in the previous examples, the extra travel time is completely offset by the improvement in your care by having an appropriate team of staff ready to treat you.

This is why I urge you all to think about how you can have the best quality healthcare in an era of increasingly complexity of medicine, and from whom you ask advice. It is your choice, but it is a choice. You cannot have your cake and eat it! You can have a truly local hospital (eg Charing Cross) which CANNOT deliver everything at a world class level, or you can have truly excellent healthcare here in NW London, but may need to travel a little bit further (to Hammersmith, or St Mary’s or Chelsea and Westminster hospitals). Politicians may understand this but they will never support the movement of a service away from their patch, regardless of the evidence. They are wrong. The decision to “save” Charing Cross Hospital does not improve the health of residents in Chiswick, and potentially makes it worse.

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