A total of 29 accident and emergency units are facing closure as NHS trusts struggle to cope with record deficits, new figures have revealed. A nationwide survey has identified for the first time the casualty departments in England that are most at risk under plans to reorganise services. The Conservatives, who carried out the study, said the plans would seriously undermine patient care and leave hundreds of thousands of people facing much longer journeys to reach their nearest A&E unit. They said the scale of the potential closures underlined the impact of a financial crisis which saw front line trusts run up a £1.3 billion deficit last year. But they also claimed that the cuts were being partly driven by the European working time directive, which will cut the number of hours that junior doctors can work from 56 to 48 by 2009. The restrictions on working hours will hit A&E units particularly hard and make it much more difficult for hospital managers to ensure that there is round-the-clock medical cover.

Andrew Lansley, the shadow health secretary, warned last night that significant populations in areas such as Hertfordshire, West Sussex, Cornwall, Lincolnshire and Lancashire would find they now faced lengthy treks to reach their nearest casualty unit. ‘Of course financial and staffing concerns need to be taken into account when designing NHS services,’ he said. ‘But so too do issues of patient safety and patient access. In too many places, blatant NHS cuts are being thinly disguised as measures designed to improve patient care.‘Patients and members of the public will not accept the consequences of these sham consultations.’ In a letter to David Nicholson, the chief executive of the National Health Service, Mr Lansley expressed concern that there was little evidence to show reviews of casualty services were being driven by medical priorities. ‘Even if some patients can be treated by paramedics in ambulances during transfer, what does the NHS regard as an acceptable delay in transfer?’ he wrote. ‘What distances to A&E for what scale of population is acceptable, and what size of population would demand the continued provision of A&E services on safety and accessibility grounds?

The reason why the local consultations are so lacking in such evidence is because they are being driven by finance and staffing. ‘Patients will be paying the price for financial mismanagement of the NHS and for cost escalation driven by centrally-imposed pressures.’ The Conservatives stressed that three quarters of the A&E units under threat were in trusts that ended last year deep in the red. One in three trusts is in deficit. Managers in each of the trusts have already launched reviews of casualty services or warned that the departments could face closure or downgrading. The 29 departments at most risk had a combined deficit of £287.2 million last year. They include West Hertfordshire Hospitals Trust, which was £26.8 million in the red, and the North West London Hospitals NHS Trust, which had a deficit of £24.1 million. Only seven of the trusts considering closing or downgrading their A&E units finished the year in surplus. Mr Lansley said the health service needed to be much more open with local people about the real reasons for their decision to ‘review’ A&E services in particular areas. People needed to be told if a unit was facing closure because the trust could not afford to pay for it or find the doctors to staff it. Mr Lansley said: ‘If the NHS financial crisis — rather than a desire to improve patient care — is driving the closure of an A&E department, then Patricia Hewitt needs to be honest enough to admit that her mismanagement is causing it.’



Millions of patients could be denied NHS dental treatment in the coming months as funding runs out at up to half of all practices. Rising numbers of dentists are meeting treatment targets ahead of schedule, and will not be paid to provide any further NHS treatment before the next financial year, the Dental Practitioners' Association is warning. The result will be that even children, pregnant women and those on benefits, who are all entitled to free NHS treatment, will have to pay, or wait. A new dentists' contract, launched with great fanfare by the Department of Health earlier this year, was supposed to make it easier for people to access NHS dentistry. However, the system included quotas for NHS work. Once a practice has carried out a preset number of treatments, no further funding is available.

Derek Watson, the chief executive of the Dental Practitioners' Association, which represents the UK's high street dentists, said: ‘This problem was always going to become apparent at some point. It is especially worrying that it has become apparent now, with a third of the financial year to go. ‘Dentists who want to do NHS work should be encouraged, but they are running up against the Department of Health's buffers. The poorest patients are disadvantaged the most, because they don't have the choice of going private.’ Anthony Smith, 57, a dentist in Grantham, Lincolnshire, met his treatment targets earlier this month. He has now been forced to introduce charges for his patients, 2,500 of whom are entitled to free treatment. ‘We were halfway through the financial year when I realised that we were going to have a problem. We tried to ration our units, so that they would last longer.

Even so, I am now 15 per cent over my allocation. We have cancelled all our check-ups and we are charging our patients for treatment now. ‘When I asked for additional funding, my local trust told me that they did not wish to commission any further services at the present time. It's a cunning way to cap dental expenditure and save money, but my patients are furious.’ Three hundred of Mr Smith's patients have written to the Lincolnshire Primary Care Trust, which administers the practice's contract, to complain. A spokesman for Lincolnshire PCT said that it was trying to arrange a meeting with Mr Smith, to discuss their concerns. ‘It's ridiculous,’ said Susan Smart, 38, a mother-of-four and a long-standing patient of Mr Smith. ‘I notice that our dental treatment is being withdrawn, but not our taxes or national insurance.’ Eddie Crouch, a dentist in Birmingham, said that he was hearing similar stories from around the country. Mr Crouch is a founder member of a dentists' group called Challenge DoH, created to ‘collect evidence of the damage the new contracts are inflicting on dentists and patients alike’. Challenge DoH launched just two months ago and 3,000 dentists have signed up. ‘Quite a lot of dentists are running short of their allocations. The contracts are based on dentists' performances in 2004, but many NHS practices have expanded since then, to try to meet demand.’ Twenty-eight million patients have received dental treatment in England in the past 24 months. However, fewer than 50 per cent of people are registered with NHS dentists.

The new dental contracts, introduced in April, aimed to improve access to dental services by attracting more dentists to NHS work. Under the new contracts, the funding process has been simplified: dentists are paid a fixed sum for completing a fixed number of ‘courses of treatment’ rather than for individual items such as fillings. Earlier this year, however, it emerged that more than 1,600 dentists had left the NHS rather than sign the new contracts. Patients deprived of NHS dental care are likely to pay higher prices if they choose to go private. At present, for NHS patients an inspection with a scale and polish costs £15.50. An unlimited number of fillings, or root canal treatments, costs £42.40. The maximum charge for a complex course of treatment is £189. Private dental providers tend to charge for each item individually, with no maximum fee. Last night Peter Ward, the chief executive of the British Dental Association, said that the new contract was creating problems for patients and dentists alike. ‘Fewer than a quarter of our members believe that the targets are reasonable and realistic,’ he said. ‘It is shambolic.’ A spokesman for the Department of Health denied that the problem was widespread. ‘The majority [of dentists] are adapting well to the new way of working,’ he said. ‘However, there may be a minority who need to change their working patterns in order to achieve the intended benefits for patients.’