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The view from the F2…..

14 Jan, 15 | by scarley

The view from the F2

As an aspiring emergency physician I have been keeping a close eye on the latest media frenzy regarding the NHS crisis. My own feeling is that from working in the NHS over the Christmas and New Year period is that the hospitals are considerably busier than this time last year.

Headlines such as ”hospital declares ‘major incident’ in NHS A&E crisis”1 have become common place and mutterings from GPs, consultants and juniors alike are saying the NHS is at breaking point.

Is it clear that the A&E departments across the country are facing an unprecedented number of admissions than ever. It is worrying that the strains demonstrated by hospitals declaring themselves as ‘major incidents’ could indicate the demise of the NHS , unable to cope with the extra demand.

Why is this? I wish to explore this topic and discuss some of what I believe to be the most crucial contributing factors to this NHS crisis.

I have asked myself, my colleagues and scoured the reports on this ‘ NHS crisis’. Why has there been such a high demand on the NHS this winter? What can I or my colleagues do to alleviate this?

The following are some of contributing factors which I believe have placed the NHS under more strain than ever. I have also discussed action plans that we as physicians could implement to try to alleviate some of these pressures.

 

  1. Ageing population: Medical advances have allowed an extended life expectancy for our population. 30 years ago a myocardial infarction carried a mortality rate of over 40%, now with advances such as PCI, time limits of 60mins from onset of chest pain to catheter table , cardiac rehabilitation & medications the mortality rates have significantly improved. This has consequences for the health service in other ways – people are living longer in the community with now more chronic illness. Our population is also living for longer , there are over ten million adults aged over 65 years living in the UK currently and this is projected to increase by an additional 5.5 million in twenty years time.2 We are now experiencing the conse of this situation with more patients with chronic illnesses unable to cope in the community and requiring hospital admission.
  2. Four hour target in the A&E department – The government and media have publicised the 4 hour target in the Emergency department. This is a potentially lucrative enticement to a patient who cannot get an immediate appointment from their GP in that they can be seen / investigate / treated / admitted or discharged within 4 hours from the emergency department. Should this target be abolished? – there does not appear to be much evidence that it improves healthcare and it seems that it in fact has created additional waiting / clinical assessment unit type wards in the hospital. If the targets were dropped and patients were seen purely on clinical need, perhaps not so urgent / acutely unwell patients would attend and instead try and attend their GP.
  3. GP out of hour’s service access – Since the GP contract changed in 2004, it has placed an extra strain on access of healthcare ‘out of hours’. Patients often think that after 6pm there are no GP services available and therefore present directly to the emergency department as they know its open 24/7. Some patients are unaware that a GP out of hour’s services exist. Is there an opportunity to educate patients in the community about accessing healthcare out-of-hours?
  4. NHS budget – in the financial climate, austere measures have been placed upon all public services. The NHS has also been affected by this. The NHS budget has been frozen for around 5 years, more productivity has been demanded from it and as the population has risen demand upon it has increased. The NHS is paid for by the taxpayer, and it is difficult to ask more from the taxpayer to contribute to the NHS. This calls into question privatisation of the NHS (I do apologise if this word causes offence to anyone reading). Should some fees be introduced to the NHS? e.g. fines for those who continually fail to attend appointments , recurrent drunks in the ED , a small fee for calling upon ambulance services and attending the ED?? Imposing fees could have major consequences. It is known that those who are in the lowest socio economic state have the poorest health. If fees were placed would we be neglecting those who could not afford a small payment towards their health? What do we do if patients refuse to pay? Do we set litigation against them? Would fee for service environment result in a more litigious society?
  5. Societal attitudes to illness and health – With the advent of social media , constant and instant information is available from Twitter , Facebook and Google. Society has become more risk averse. People are generally unwilling to accept any health risks (and why should they accept risk?). Therefore attending the hospital /emergency department whereby health can be assessed quickly with bloods & imaging and quick decisions can be made is now an expectation. It is not uncommon to hear colleagues complain that more patients are attending the emergency department for non emergency ailments such as simple coughs and sore throats. I don’t think there is any solution to this rather than acceptance of society’s shift in their health beliefs and health seeking behaviours. Perhaps its time we roll with this change and consider making healthcare more accessible to people’s lifestyles e.g. running more evening clinics in general practice when people can attend after work.

 

Rant over, I feel like a weight has been lifted off me however the gravidity of this situation is bearing down on the NHS and it appears to be unravelling before our eyes (maybe I am being a tad dramatic here but it is a pressing issue all the same).

I realise that this is a complex issue that will require time, money and patient education. What can we do as physicians? What can I do as a budding emergency medicine doctor? I suppose for now its patient education. Information empowers our patients and perhaps the next time we encounter a patient in the emergency room who you felt may have benefited from a visit to their general practitioner rather than the emergency room, inform them of this. There is no need to chastise patients but pointing out the resources available such as walk-in centres and out of hours GP services towards the end of the consultation may be worthwhile.

So from a foundation doctors perspective the above factor are what I belief are contributing to the current crisis however , what do you think? Are there other factors I have not considered? Does anyone have any remedies for this NHS ailment?

Yours comments and opinions are greatly appreciated.

Thanks for reading.

Aine Keating

 

References:

  1. BBC news article Nick Triggle (06/01/2015). A&E waiting is worst for a decade. UK
  2. Government document. (2007). Ageing population. Available: http://www.parliament.uk/documents/commons/lib/research/key_issues/Key-Issues-The-ageing-population2007.pdf. Last accessed 06/01/15.

 

 

 

Lauren Waterman on the value of an ED doctor.

10 Feb, 14 | by scarley

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

 

photo

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

 

 

References

 

  1. 1.       ‘Third of GPs back charging £10 to keep timewasters away from A&E units.’ http://www.independent.co.uk/life-style/health-and-families/health-news/charge-10-to-keep-timewasters-away-from-ae-units-say-gps-9035741.html
  2. 2.       ‘A&E timewasters cost NHS £27m’. http://www.express.co.uk/news/uk/208944/A-E-time-wasters-cost-NHS-27m

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