David Gilbert: “What would a patient led solution to the A+E crisis look like?”

david_gilbertLike many people who spout rhetoric about the NHS, I am guilty of indulging in the blame game. Some professionals and policy makers “blame” patients for “inappropriate attendance” at A&E and we have millions spent on campaigns to urge us to “choose wisely” when thinking about heading that way (assuming that we do not make rational choices).

Likewise, I can blame professionals for thoughtless and ineffective policies and practices. Or, I can point the finger at “the system” for being professionally-centric. Note that the notion of blaming “the system” is itself a neat trick that casts a blanket of blame over others, without requiring us to be more precise about where the problem lies. It is also a familiar tactic for the traditional patient movement through which we can maintain an “us and them” attitude and an adversarial posture towards improvement.

However, this recent NHS crisis, and calls for patients not to “waste time” by attending A&E unnecessarily vexes me. This is an opportunity to demonstrate the benefits of patient and public engagement like never before. If patients could step up to be partners for change and help foster improvement in this of all situations, then wouldn’t that be fantastic? Maybe we would then be taken more seriously at strategic level.

So, what would a patient-led solution to the A&E crisis look like?

As many of us know in the patient-led movement, it is not about me being “the expert.” Nor is it about me purporting that my solutions are the only ones. Nor does it mean basing any answer solely on my own personal experiences.

I think it is more about how I and we contribute towards a process that allows us (patients and other stakeholders) to come together towards a shared understanding of the issues to be tackled, helping to generate a wider set of options and contributing towards a shared vision of what those solutions might be.

In the context of the A&E debate then, why is it that policy and practice is directed (I would say mis-directed) towards demand management mode and diversion at the “entry gate?” This is a mindset that seems to patients more about saying “go away” then “welcome.” This in turn leads to developing more “alternative” services away from the hospital (111, better GP out of hours services, etc), communication efforts to send people to these services, and urging people to “choose wisely.” Though I find it hard not to get angry about these tactics, they are legitimate responses to the problem of a “pressurised” service that is finding it hard to cope with “demand.” Staff work extremely hard to cope, the service is struggling, and when people are struggling, there is a tendency to point the finger at those who are “doing the demanding” and to do something about those people “causing” the problem.

But it won’t work. Why? From a patient-led perspective, I think there are several reasons.

The “just in case” mind 

Firstly, there is a basic psychological error at the root of the A&E debate. When my child is ill, or when I am hurt, I am in pain and feel vulnerable. On top of that, I am uncertain about what may be causing it, and fearful of the consequences.

Moreover, when considering choices about where to go to get help, it is not that I do not know about 111, or the GP, or even the minor injury unit. It is because my primal mind switches to “just in case” mode. I will want things checked out “just in case” something serious is the matter with my child or me. I seek safety and certainty when I am feeling unsafe and unwell. I am not irrational or uneducated. I am hurt and scared.

If, in addition to that, I have had experience of 111, or my GP previously referring me to A&E. Or, if I have a hunch that when I eventually get advice, they could refer me on (just in case). Or, if I reckon that they have what I need at A&E (the x-rays, all the right staff for any event), then it makes sense to go to the place which will be safe, effective, and cost-effective (in terms of my time and resources). I am not irrational or uneducated. I am making a sensible decision based on circumstances and evidence.

If policy makers and healthcare staff really understood the “just in case” mentality (and many do, but are probably equally powerless in implementing improvements), then my guess is that different solutions, including co-location of services at A&E, would be the norm.

So, why isn’t this happening? Because patients are not partners for improvement and change.

When it comes to A&E, if the right people were in the room, then my guess is that the “just in case” mindset would be acknowledged, and efforts might be made towards different solutions. Co-location of services at A&E would be one option. Simon Stevens urges staff to “think like a patient, act like a citizen.” But you can’t do that if patients are not in the room, helping to co-design improvement activities and generate solutions.

If ever there was an opportunity for effective patient and public engagement and patients being partners for change, this is it. Anyone want to try?

David Gilbert, Patient Director, Sussex MSK Partnership (Central).
This blog was written in a personal capacity.
David writes at futurepatientblog.com and can be found on Twitter at @DavidGilbert43.