Lauren Waterman on the value of an ED doctor.

Social media allows the journal to communicate with our readership in a way that is more rapid than in print, or even on our online first pages. A good example is a letter received this week. Lauren Waterman asks us what the true value of an EM consultation is following suggestions that patients should be charged for their attendance.

We think the best way to answer this is to share with the readership and to ask for your comments via twitter using our twitter address @EmergencyMedBMJ

So, read on and tell us what you think.


Simon Carley

Social media editor EMJ



So, Doctor, was I worth £10?

Dear Editor,

I am writing this letter in response to the recent survey which showed a third of general practitioners to support patient fees for ‘unnecessary’ A&E visits1. The idea is that patients would be charged £5-£10 and this refunded if doctors deemed the visit appropriate. I propose three key reasons why this charge would be impractical, unethical and dangerous.

Firstly, A&E doctors would have to get into discussions with patients as to why their payment cannot be refunded. These discussions will be awkward for the doctors to have, impact upon the doctor-patient relationship and also take up the doctors’ time, where resources are what we are trying to save in the first place.

Secondly, it stops the NHS being ‘free at the point of care’ which is a fundamental feature of its constitution. This may defer certain lower-economic patient groups (those groups that may have less education about heath and illness in the first place) from presenting to A&E when something may actually be wrong.

photoThirdly, when a patient presents to A&E they do not wait in a busy waiting room for fun! They believe that something needs urgent medical attention. This intervention would not educate patients, as it is unlikely that doctors would have time to fully explain why a patient’s visit was justified or not. There would be discrepancy between different doctors in what they believe to be a ‘legitimate visit’, with some willing to refund for certain presentations that others believe to be ‘not warranting a visit’. This would confuse patients further and not help them to make ‘better decisions’ the next time.

To conclude, although vast costs are incurred by patients that attend A&E without requiring urgent treatment2, charging patients is not the answer. Patients who are without extensive medical knowledge are not trained to know when symptoms signify something sinister. However, perhaps further educational intervention that teaches the public more about the different options available to them would help to direct them to the right place.

Yours sincerely,

Lauren Waterman





  1. 1.       ‘Third of GPs back charging £10 to keep timewasters away from A&E units.’
  2. 2.       ‘A&E timewasters cost NHS £27m’.

  • Jonathan Zammit

    I fully agree with all the points you mentioned Lauren.
    As an ED doctor for the past 6-7 years, I have often (like many) felt frustrated at inappropriate attendances in the past. However as you said, charging patients for inappropriate attendances is not the way forward at all.
    As you pointed out, what may be an inappropriate attendance to me does not seem so to the patient. We all change when we are faced with pain, the unknown and cross over to the other side. Many doctors who were patients – or relatives of patients – will tell you how surprised they were at their own panicky reactions despite their medical education and experience. This is after all what makes us human and not robots or automated machines.
    I can easily be judgemental when faced with figures and lists of ‘inappropriate attendances’ and come out with neat policies. But how can I ever look at the face of a person with ‘no fixed abode’ and charge them a fee for attending with some seemingly trivial complaint? How could I ever face an elderly couple who have worked so hard all their lives and arrogantly charge them?
    Despite the challenges and frustrations we feel when we go in for a night shift and face scores of patients who presented inappropriately for the umpteemth time, we should in the end realise that their story is not my story. I cannot even walk 10 mins in their shoes.
    In the end, this is what makes me and so many of my colleague doctors and nurses proud to work in the ED. That all NGO’s, governmental agencies, voluntary organisations, shelters, homes, religious institutions, private hospitals etc can have exclusion policies, ‘full up’ notices and turn people away from their doors.
    But A&E is the only department as far as I know who leave their doors open at any hour, 24/7 to any person of any age, ethnic group, gender, religion, sexual orientation, poor or rich presenting with any complaint and at whatever capacity the department itself is functioning at the time. This is our challenge and this is what we as a team took up so many years ago.

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