Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Disintermediation
- Paul E Shannon (22 July 2007)
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Re: Disintermediation
- L S Lewis (23 July 2007)
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Health for London perhaps, but the death knell for emergency medicine?
- Rowland L Cottingham (24 July 2007)
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Paul E Shannon, locum consultant anaesthetist Doncaster Roysl Infirmary, DN2 5LT
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Dear Sir, I don't know exactly what Ara Darzi's vision is for polyclinics, but all I can say is that, having worked in France, polyclinics there work very well. In France, a typical polyclinic is nothing to do with primary care. Rather, it is a small, private practice of surgeons and anaesthetists, performing straightforward, elective procedures. The key feature, though, is that patients can access these specialist services directly, i.e. without seeing a GP first, thereby cutting out the 'middleman'. This is known in business-speak as 'disintermediation', and has a good track record in other industries of reducing costs. For example, let's say it costs £50 to see a GP and £75 to see a specialist (these figures are purely for illustration, since GP's salaries are reportedly so huge, it may cost a lot more!). For a patient with, say, a hernia, it is a waste of time and money for them to be seen twice (£125 versus £75). Clearly, the trick is to direct the patient in the right direction early on, which could be done with decision-support software. NHS Direct and (NHS 24 in Scotland) are ideally placed to provide such a service. It would be very easy technically for NHS Direct to directly book a patient into any secondary-care setting using Choose and Book. This would be a very neat and cheap solution to improve access to specialists, which patients would love! It should also help GPs, since they are often complaining that NHS Direct doesn't reduce referrals to them. So, we would have a 'win-win situation' all round; the GP would be completely by-passed, the patient would get rapid access to the right person and costs would fall. Vive la difference! Kind regards, Dr Paul Shannon FRCA MBA Competing interests: None declared |
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L S Lewis, GP Surgery, Newport, Pembrokeshire SA42 0TJ
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sounds so simple - "cutting out the middle-man" attractive, until you realise that burgeoning direct attendances at A&E are producing major strain on hospitals locally. The British GP refers less than one-tenth of those consulting. Time was when he made the most intelligent decisions at the cheapest price.. "the Gatekeeper Role". These days out-of-hours and NHS-Direct are taking the strain, but act as a glorified phone-centre signpost system. Many patients just take themselves to A&E. Is today's GP outmoded and priced too high ( the DoH is certainly pressing that propaganda ) ! Having given of my best to the NHS, I do not think so. We do need evidence-based healthcare. Direct-access specialist polyclinics would be easy to trial - Let London have it, and tell the rest of us in the control group just how much benefit, with what harms, and at how much cost. Competing interests: None declared |
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Rowland L Cottingham, Consultant in Emergency Medicine Royal Sussex County Hospital, Brighton BN2 5BE
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There is much to applaud in this interesting and wide-ranging report into the future health needs of Londoners. I am particularly pleased with his 'consistent response' strategy, as I have been espousing that cause for 15 years. However, I need to ask what the future for my speciality is. ‘Traditional’ Emergency Departments are for some reason seen as a service which people need actively to be discouraged from attending. Instead, patients are being asked to use urgent care centres and polyclinics, and sick patients will bypass hospitals for specialist centres. A great deal of work has been undertaken in the Emergency medicine community to improve seniority of staff available around the clock and hence the service to patients by expanding the numbers of Consultants and also Specialist Registrars in training. The success of this approach in terms of seeking expert health care is such that even in the report Darzi acknowledges that patient perception is that, “A&E departments are the solution to their health care needs.”1 However, his solution appears to be that this success should not be praised but annulled. What role does he envisage for Emergency Departments and Emergency Medicine? Exactly what will trainees in this speciality find themselves practising? After all, minor injuries are being dealt with by emergency nurse practitioners, minor illness by peripatetic GPs, medical conditions by acute physicians, major trauma by trauma centres and the rest will be triaged by polyclinic staff to specialties. What then is the Emergency Consultant to do? These proposals, which presumably will form the basis for Professor Darzi’s national recommendations in due course, appear to sound the death knell for Emergency Medicine. Can this be the case? 1. Healthcare for London. Framework for action. 2007. http://www.healthcareforlondon.nhs.uk/framework_for_action.asp Competing interests: None declared |
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