Jeremy Laurance: Locals won’t like this – but it could be a healthy sign

It could have been worse. Lewisham could have lost its A&E altogether. But residents and medical staff still have plenty to shout about. They are being penalised, with the downgrading of the unit, for the sins of their neighbours – the failing South London NHS Trust which has run up debts of £153 million in the last three years.

Ed Miliband complains the decision is made on cost, not clinical, grounds. This is, ultimately, a false distinction. Spending £153 million to prop up a failing trust in south London means denying that sum to patients in the rest of London. Moreover, if the trust is bailed out there is no incentive for other trusts to stay within budget.

Why are some trusts failing? In large part because services are in the wrong place to provide the best care to meet local needs. That is especially true of A&E. We have known for years that it is safer, with better outcomes for patients, when medical expertise is concentrated in fewer, larger units even though that means longer travelling time for patients.

Despite this, politicians persist in playing one tune in public and another in private when it comes to hospital closures – joining the public protest march whilst agreeing with health officials about the need for reconfiguration in private. William Hague, Chris Grayling and Iain Duncan Smith are among coalition government ministers who have intervened to oppose threats to local A&E and other services in their constituencies.

Sir Bruce Keogh, NHS medical director, is examining a plan to rank A&E units as first or second tier, which would mean more local units linked in a network to facilitate swift transfers to the centres of expertise. Lewisham could be the harbinger of such a plan. It won’t please the locals and a big question remains over costs – but it could point to a better future for emergency care.