David Oliver: Why force GP streaming on NHS emergency departments?BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m992 (Published 18 March 2020) Cite this as: BMJ 2020;368:m992
All rapid responses
David Oliver is quite right that the national policy of putting GPs at the front door of A&E is an ineffective waste of money. Competent analysts of A&E data and observers of how A&Es work knew this before the policy was rolled out.
He is also right in pointing out that the policy was based on bad analysis of the causes of long waits. They are not caused by "too many people turning up". Most analysis shows little relationship between attendance volume and average waits or 4hr performance. And that analysis also clearly shows that the majority of long waits are suffered by the cohort of patients who are very ill or injured (who usually need to be admitted) not those with minor complaints.
But NHSE has commissioned analysis to justify diversion policies (GPs at the front door is a subset of diversion). It is true that many patients attending A&E could have been treated elsewhere. It is also irrelevant for at least two main reasons. One is that, even if successful, diversion would certainly not improve A&E performance and might even make it worse (the divertable cohort are usually treated quickly so improving reported performance; good A&Es already stream those patients to simple, fast processes so they are easy to treat quickly). So diversion strategies focus on the wrong cohort of patients. The analysis NHSE should have done would have looked at which groups of patients have the longest waits and why? But this would not have supported any of the recent strategies and would have clearly shown the futility of diversion.
Most well organised A&Es have been streaming patients into appropriate care pathways since the 4hr target was introduced. "Minors" get streamed to efficient, cheap, simple and fast pathways; "majors" go into pathways where more investigation and treatment is needed. Putting GPs at the front door adds capacity to the minors stream which might sometimes help if the department is under capacity, But does essentially nothing for the patients who already suffer long waits.
All this is pretty obvious in the detailed patient level HES data.
The net result of dodgy analysis and unwarranted extrapolation from what was thought to work at Luton is that NHSE have spent hundreds of millions on an initiative that didn't work. David Oliver should be praised for pointing this out.
Competing interests: No competing interests