Emergency pyramid is inverting already
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7379.49 (Published 04 January 2003) Cite this as: BMJ 2003;326:49
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Maybe I'm a little jaded after a few busy emergency GP shifts over
Christmas, but I'm taken aback by the assertion that there is no such
thing as inappropriate demand.
I think this can only be written by someone who inhabits the rarefied
atmosphere of a Government Agency, cut off from the realities of the NHS
at the sharp end. Someone who sleeps soundly at night.
Examples include:-
Calls to depressed and suicidal patients which are alcohol
fuelled, violent domestic incidents.
Calls to replace "lost" methadone doses before in the early morning before morning surgery
Demands for a consultation for (inappropriate) antibiotics for a sore
throat in the early morning before morning surgery so patients can go to work.
These are a minority of contacts but their effect on the out of hours
service is significant
I think that there is an urgent need for a realistic debate about what is
appropriate demand in an underfunded, over stretched NHS.
Competing interests:
None declared
Competing interests: No competing interests
Contrary to Cooke and Castilles assertion that advanced access in
primary care does not result in increased workload, our practice has had
to abandon this initiative as we couldn't cope with the demand it created.
'Doing today's work today' only seems to work if one first redefines
'work'.
Competing interests:
None declared
Competing interests: No competing interests
I work in a general practice that (by NHS standards) offers
reasonably good access to its services. We will see patients with acute
problems the same day and the waiting time for routine appointments is
usually only 1-2 days. Despite this, some of our patients will still
attend one of the three accident & emergency departments in the
locality to obtain a medical opinion for a problem that could have been
managed within the practice. In recent months, I have begun to discuss
with these patients their reasons for attending an accident &
emergency department, rather than consulting myself or one of my
colleagues. The patients I have talked to give three main reasons for
their actions.
The most common reason they give is that they "wanted a thorough
checkup" of their illness. By this, they mean that by attending an
accident & emergency department, they expect to obtain a lengthy
physical examination, followed by a battery of investigations. Invariably,
the findings are always normal but "you never know, doc, it could have
been something serious". When unimpressed by the 'thoroughness' of a
consultation in one department, they will often attend another accident
& emergency department for a second opinion.
The second reason they give is they wanted a specialist opinion and
perceive the quickest way to get this is through an accident &
emergency department. This can mean seeing a specialist the same day for
an acute problem or being placed on an outpatient waiting list for a more
chronic problem. "If I’ve got a problem with my ear, doc, it stands to
reason that I should have it sorted out by an ear specialist".
The third reason they give is that they wanted to be seen at a time
convenient for them. This usually means being seen during the evening or
at weekends "so I don’t have to take time of work, doc".
With their current level of resources, neither accident &
emergency departments nor general practices can hope to meet these kinds
of expectations. Many doctors would argue that the NHS should not even try
and that, instead, patients should be educated to make more 'appropriate'
use of NHS services. However, we then get into a debate about to what
extent health care is a consumer good and how much the NHS should adapt
itself to meet the public’s demands. Furthermore, what do we do if
patients refuse to be 'educated' to use the NHS in a way that doctors (but
not the public) see as being appropriate? Hence, there are likely to be no
easy solutions to these challenges, which may eventually lead to the
demise of the NHS as we currently know it.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
I do not think the sentiments in this letter (1) reflect the views of
the majority of Accident & Emergency (A & E) consultants. The
"see and treat" concept was developed at a single hospital, and worked
well for them. It has not been subjected to critical appraisal nor peer
review.
I have serious concerns that diverting SENIOR clinicians from
treating ILL patients will be detrimental. It is a waste of years of
training and expertise to concentrate the most experienced medical
resources of an A & E department on those patients who have the least
serious conditions, some of whom, one could argue, should not be there at
all. I find the term "the faded idea of inappropriate attendance"
inappropriate in itself. I think this is an experession of political
correctness.
I trialled a similar scheme in my own department in 1999, as a run-up
to the Millennium New Year's Eve. I abandoned the idea when I found that
I was in the process of reassuring a patient that he would come to no harm
from a domestic house spider bite, whilst my registrar was struggling in
the resuscitation room with a critically-ill patient, and did not widh to
disturb the 'great experiment'.
NHS Direct, despite its much-trumpeted development has not reduced
the numbers of patients attending A & E departments, nor has the
opening of Walk-in Centres- at least not in my area.
A & E, in common with the rest of the NHS remains under-
resourced, and such schemes as see and treat - whilst laudable in the 'big
picture' - are methods of massaging the figures towards achieving the
government's 4 hour A & E targets without adequately addressing the
real problems.
Bruce Finlayson
Reference:
Matthew Cooke and Karen Castille
BMJ 2003; 326: 49
Competing interests:
None declared
Competing interests: No competing interests
Cooke and Castille's letter provides a timely update on recent
developments in our specialty in this country. However their comparisons
with similar developments in primary care access are somewhat
oversimplified.
In primary care, the vast majority of patients are already seen by
"seniors", i.e. by fully trained general practitioners. In this situation,
moving to a system providing "advanced access" can be relatively easily
achieved, and probably without significant funding implications.
In emergency medicine, on the other hand, the vast majority of
patients are still seen by inexperienced senior house officers. There
simply aren't yet sufficient numbers of trained emergency physicians to
take on this workload. Those senior emergency physicians that are
currently in post find their time occupied with critically ill patients,
together with complex medical and surgical cases. They simply do not have
the time to deal with "minor" cases as they walk through the door.
The NHS Modernisation Agency needs to realise that there will not be
a quick-fix solution to emergency care access in this country, at least
not without substantial and sustained investment in appropriately trained
staff.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR – Whilst I agree that having senior medical staff as the first
clinical contact in Emergency departments is in general a positive step,
some of the other opinions of Cooke and Castille(1)need to be challenged.
In contrast to their statement, for those of us working in the real
world, there IS such a thing as an inappropriate emergency department
attender. Many of these choose the local “casualty” as a first point of
contact with the NHS because of the ease of access. Access to General
practice is difficult for many patients, and appointments may be offered
some days later, which may not satisfy today’s demand for “instant fixes”.
I defy Cooke and Castille to suggest how a patient I saw today with an 8-
year history of wrist pain can possibly be an emergency. Can they tell me
how the services and skills of an Emergency department should become
involved in the management of such a condition? Seeing patients like this
immediately simply reinforces the view that "casualty" is the place to go
for all conditions. I trained to manage emergencies and acute injuries,
not chronic conditions or minor ailments. How long is it since Cooke and
Castille worked clinically, full time in an understaffed emergency
department?
I applaud any initiative to speed up the often intolerably long
waiting times in our Emergency departments, but to carry out this “meet
and treat” many more appropriately trained and experienced doctors are
needed. I notice that in this letter from the NHS modernisation agency no
mention is made of this. Where are we going to get these doctors from? I
just assume there will be no funding!
It seems to me that once again the Governments aim is off target.
More emphasis should be placed on ensuring that primary care meets its
obligations to patients, providing timely access to care and advice,
including during the “out of hours” period. If more patients were able to
attend their GP as conveniently as they can walk into an Emergency
department, and more were directed back to primary care from triage then
waiting times for all would be improved.
David J Hall
Consultant in Accident and Emergency Medicine
Accident and Emergency Department
Pinderfields General Hospital, Wakefield, WF1 4DG.
David.Hall@panp-tr.northy.nhs.uk
1. Cooke M, Castille K. Emergency pyramid is already inverting. BMJ
2003;326:49.
Competing interests:
None declared
Competing interests: No competing interests
See and Treat
I must admit that I had trouble understanding the letter from Matthew
Cooke and Karen Castille (as did my partners) because it seemed rather
full of managerial buzz words and I did wonder if they have ever worked in
General Practice or A&E.
I have no argument with the concept of "See and Treat", but surely the
problem with A&E departments is that there are NOT ENOUGH senior
people to do just that, and there is no slack in the system to enable a
senior person to be there all the time waiting for people to
arrive.Hence,it seems to me, nurse triage etc. I can't see how their
system could work without more people, unless they intend to divert
attenders via NHS direct, walk-in services etc-surely something which will
take a great deal of education of the public?
Competing interests:
General Pracitioner for 15 years
Competing interests: No competing interests