Accidents will happen, but as near as possible please

YOU MIGHTcall it a lucky break. When Frederick Ashforth fell and fractured his arm last week, the nearest casualty unit was virtually on his doorstep. If the same accident happened in the future, he could be forced to endure prolonged pain as he travels more than three miles further for treatment.

Mr Ashforth, 73, lives within walking distance of the Royal Hallamshire Hospital, slightly to the south of Sheffield city centre. Under proposals to go before the city's health authority next month, the hospital faces losing its accident and emergency unit (A & E). Staff and facilities would be moved to the Northern General Hospital, on the north side.

As he awaited treatment, Mr Ashforth, who himself worked in the hospital's orthopaedic unit before retirement, voiced concerns shared by thousands of other residents of the city's southern suburbs. 'It is silly,' he said. 'You can't expect people to go to the other side of the city if they are injured. It just isn't fair - especially for older people. And when you get there, it'll be so busy you'll have to wait longer to be treated.'

Michael Skinner, 49, who drove his son-in-law, Nigel Phillips, 30, to the Royal Hallamshire, after he twisted his ankle last week, is also aware of the added inconvenience. 'It took us 20 minutes to get here from where we live. If they move everything to the Northern General it will take us another 20 minutes at best. It is straight through the city centre, and if the traffic is heavy it will take longer.'

The prospect of Sheffield, a city with 450,000 people, losing one of its A & E units has provoked tough opposition. Staff at the Royal Hallamshire, backed by politicians, health unions and locals, have launched the 'Keep casualty in the heart of Sheffield' campaign. More than 100,000 people have signed petitions and letters of support.

They cannot understand the apparent enthusiasm to shut the Royal Hallamshire's A & E. The 52,000 accident victims it treats every year account for more than two-thirds of the city's total. The hospital also offers expertise in vital support services such as neurosurgery. Sister Pat Harwood, a campaign spokeswoman based at the Royal Hallamshire, said: 'Our case is that Sheffield is big enough to warrant two casualty units. But we say that if one is to close, then we should be the one to stay open. We are more central, we are busier, and we have the back-up facilities.'

Sheffield's proposals are the culmination of an extensive review based on current thinking in health management, which in turn is based on a 1988 report by the Royal College of Surgeons. That report detailed how the number of accident deaths could be cut if specialist care was concentrated on one site rather than spread over a number of locations.

Dr Keith Little, president of the British Association for Accident and Emergency Medicine, said: 'If you have three hospitals with A & E departments which are geographically close together, your resources are split three ways and therefore your department is staffed at a minimal level.

'If you amalgamate those departments on one site, you immediately have three times the staff. Also, the staff become more adept in the treatment of major trauma.'

That philosophy led to the establishment of Britain's first US-style major trauma centre, at North Staffordshire Royal Infirmary, Stoke-on-Trent, to deal with all serious accident injuries from a wide catchment area. Its three-year trial period has yet to be fully assessed but estimates suggest it has been very successful.

The RCS report also produced a series of closures and mergers along the same lines as the proposed Sheffield scheme. As we report today on page one, since its publication, the number of hospitals with an A & E unit has fallen from 301 to 213.

However, despite the increased know-how and efficiency that specialisation can bring, the medical establishment realises there is a price to pay.

Dr Little said: 'There is an issue of community access. If you amalgamate three units into one, then perhaps two- thirds of the town no longer have a casualty department just round the corner.'

Sheffield is not the only place where the two arguments have been aired vociferously. In Liverpool, the casualty department of Broadgreen Hospital is to close in two years' time. Despite a strong campaign, its workload will be taken on by neighbouring sites. The unit is already shut at night as plans are phased in.

John Carson, chairman of Liverpool Eastern Community Health Council, which fought the plans, fears a hidden agenda. 'This is just the start. Once you lose the A & E, the heart and soul of the hospital goes, essential services go, and eventually the whole hospital has to be shut.'

Some cities have already seen the changes put into place. Three years ago, Edinburgh abandoned A & E care at the Western General, in the north of the city, and spent pounds 1m improving the Royal Infirmary, to take the additional load. Officials say patient care has improved as a result.

Other A & Es 'merge' for only part of the day. On Teesside, patients seeking night- time treatment for ear, nose and throat injuries must now go to Middlesbrough General Hospital rather than the North Riding Infirmary.

Elsewhere, casualty services are under scrutiny as part of a wider review. Manchester and Belfast are among cities that appointed expert teams to look at theirs.

While the campaigners in Sheffield and Liverpool complain that they are being left to pay the price of progress, there is little prospect of their succeeding. The big guns of the medical profession are in favour of concentration and specialisation, and so is the Department of Health.

Dr Littl e said: 'The results are much better. What the community loses in terms of inconvenience is more than gained in quality of service when you arrive at the hospital.'

(Photograph omitted)