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Views & Reviews From the Frontline

Who’s to blame for overcrowding in accident and emergency departments?

BMJ 2013; 346 doi: (Published 07 May 2013) Cite this as: BMJ 2013;346:f2871

Rapid Response:

Re: Who’s to blame for overcrowding in accident and emergency departments?

It seems likely GPs will be invited to take over out of hours (OOH) responsibility for their patients once more.

In Cornwall we used to have a very successful GP co-operative for doing exactly that. It was called Kernowdoc, a non profit making organisation which was well supported by local practices and operated to a high standard, with regular meetings for training and an enjoyable work ethic. When the Primary Care Trust opened the OOH contract for tendering in 2006 (at government insistence) it was taken away from Kernowdoc and awarded - amidst persistent rumours of an uneven playing field - to a private company called Serco.

This was followed by some unpopular changes to the infrastructure (pared down) and pay system (no superannuation contributions, for example) and a significant fall in doctors willing to engage with the new provider. There has been criticism about questionable work practices (1,2,3) that simply did not occur under Kernowdoc. Difficulty in attracting doctors to work shifts (leading to expensive short term solutions) has led to problems with service provision which may be compounded by Serco’s fiduciary duty to make a profit. This conflict of interest and the robust evidence showing that primary healthcare (as opposed to private or specialist led systems) consistently results in better standards of health care at lower cost (4) seem to be lost on government , though whether this is because they are ignorant or disingenuous is an open question.

Kernowdoc wasn’t perfect but if it had been not been dismantled then at least one element of the current A&E crisis would have been in better condition and we would not now be being asked to re-create it. As the King’s Fund has indicated (5) there are many other factors such as the introduction of the NHS 111 system and the chronic underfunding of staff levels in A&E units that have contributed to the current difficulties with unscheduled care.

History suggests that political interference carries a significant risk of destabilising systems that are running well, followed by criticism of the re-ordered system that was introduced – or more accurately those still working within it.

It is a shame this lesson was not learned before the latest changes to the NHS were driven through against the wishes of the medical profession and the majority of the electorate.

(1) ‘Health chiefs and Serco criticised.’ This is Cornwall, 25/4/13
(2) Lawrence F ‘Who will hold NHS contractors like Serco to account?’ the Guardian, 23/4/13
(3) ‘Memorandum on the provision of out of hours care in Cornwall’ National Audit Office 7/3/13
(4) Starfield B, Shi L, Macinko J ‘Contribution of primary care to health systems and health’ Milbank Q 2005; 83 (3) 457-502
(5) ‘Urgent and Emergency care’ King’s Fund Report 14/5/13

Competing interests: No competing interests

31 May 2013
Christopher G Tiley
Mevagissey Surgery
River Street, Mevagissey, PL26 6UE