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The weekend effect. Part 1.

28 Oct, 16 | by scarley


Chris Moulton VP of the Royal College of Emergency Medicine and Ellen Weber discuss the weekend effect. This is well worth a listen to get behind the headlines and politics of a controversial meme in healthcare.

What is it? Is there an effect and what can we do about it?

Click on this link to read more about the paper on Chris Gray’s blog.





UK emergency department performance: Failure or Success.

14 May, 16 | by scarley


Recent figures suggest that UK emergency systems are failing to meet the 4-hour standard (aka the 4 hour target). At first glance this is true the data shows that 88.7% of patients are seen and discharged/admitted within 4 hours as compared to the target (I’m going to stick with target) of 95%.

This has been described as ‘worst ever month’ and if we look at simple percentages that’s true.

Sadly, comments such as failure and worst are demoralising for the teams who are working really hard to deliver emergency care in an overworked and stressed system. The key here is in the percentages, they underestimate the number of patients actually seen in a system that is seeing more patients every year.

It is perhaps worthy to note that in the last quarter figures there were 5,867,323 attendances at UK emergency departments. Of these 711,201 waited more than 4 hours.

In other words we managed 5.15 Million patients within the 4 hour target.

Well done all. This is not a failure, it’s an incredible achievement considering the current staffing, political and financial climate. Times are tough, the target may not be met, but let’s keep some perspective.

This is a huge achievement.



Further reading

BBC on worst ever results for UK Emergency care

RCEM response to figures

King’s fund response to latest statistics.

NHS emergency care statistics

Choosing Well vs. Choosing Wisely

10 Mar, 14 | by rradecki

In the United Kingdom, the NHS and Manchester publish “Choose Well” – a guide for patients in need, to help them find the healthcare resources correct for them.  The resources described include self-care, local general practitioner services, and advice regarding when to choose Urgent Care or Accident & Emergency services.  In a system where resources are Screenshot 2014-03-10 18.19.29understood to be finite, in order for all to have access to a reasonable level of healthcare, this is a prudent consumer-oriented approach.

The United States has a similarly-named system of choice – “Choosing Wisely”.  Published by the American Board of Internal Medicine Foundation, this initiative also focuses on making choices in healthcare.  However, rather than focusing primarily on helping patients make better choices, the true target of this initiative is an entirely different problem beguiling U.S. healthcare:  physicians behaving badly.  Screenshot 2014-03-10 18.19.49These initial lists, containing 5 or more items each, describe diagnostic tests and treatment modalities that ought to be re-examined – essentially, low-value candidates for expensive, harmful overuse that go further towards fattening physician and executive wallets, while providing uncertain patient-oriented benefit.

For Emergency Medicine in the U.S., the published list is prudent medicine – but hardly reflects the most costly & wasteful utilization of resources.  Several prominent academics and educators have critiqued this list informally, while others have systematically attempted to derive their own.  The important independent recommendations range from decreasing CT utilization, to mitigating over testing of low-risk chest pain, to avoiding costly hemostatic medications without clear indications.

Regardless, the point of distinction is clear – Choosing Well vs. Choosing Wisely.  Patients ought to be expected to benefit from educational programs to help improve their decision-making.  Physicians ought to be making high-value decisions every day – and we should be embarrassed our choices are so poor at baseline that an initiative such as Choosing Wisely even exists.


Ryan Radecki


Ryan Radecki

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



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’.

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