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EDITORIALS: Malcolm Woollard Paramedic practitioners and emergency admissions BMJ 2007; 335: 893-894 [Full text]

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At what cost?

benjamin dean   (3 November 2007)

At what cost?

Andrew Webster   (16 November 2007)

At what cost? 3 November 2007
benjamin dean, sho oxford Send response to journal: Re: At what cost?	I have no doubts that this new breed of practitioner can reduce the workload of A&E departments, however at what cost? The study (1) had no way of showing that some of the patients did not have important diagnoses missed or problems mismanaged. For example an elderly patient may not attend A&E within 28 days and be very satisfied despite having been poorly medically managed. Much larger numbers of cases are needed to ensure that the tricky rarer cases that at first appear "minor", but are in fact much more serious, are not missed by the practitioners. While I have no doubts that the majority of "minor" problems can be managed adequately by paramedic practitioners, it has yet to be proven that a significant minority of problems are not mismanaged. Patient satisfaction is a notoriously unreliable measure of "clinical effectiveness"; I think that in the name of patient safety much more rigorous evidence is provided before this kind of scheme is rolled out. Simple measures such as PCTs actually paying GPs for minor injuries would be far more cost effective than this idea. 1. Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial. S.Mason et al. BMJ 2007;335:919 Competing interests: None declared
At what cost? 16 November 2007
Andrew Webster, Consultant in Emergency Medicine Royal Lancaster Infirmary Send response to journal: Re: At what cost?	Dr Dean does have a point in that some patients may end up having a more serious condition missed on the initial assessment. However, that can happen following contact with any type of health professional in an urgent/emergency care setting. Undifferentiated disease may seem trivial initially, however in some patients the condition will deteriorate with adverse health outcomes. However this study did not find significant differences in mortality between the two groups. I am not convinced in an urban environment that paying GP's an extra sum of money would be more cost effective to see minor injuries. This group of patients would still phone 999 and with present call handling mechanisms would still get contact with an emergency health care professional from the ambulance service. Competing interests: None declared