Former NHS Nurse and manager now contemplating the NHS from outside

That seems to be the question which is currently challenging health politicians and the media. Of course it is not a new question for those working in healthcare, since it is perfectly possible to track each and every attendance and episode of care that takes place. Even before I stopped being a commissioner at the end of 2011, senior managers were scratching their heads about the increase in ‘unplanned care’ and trying various methods of ‘managing activity’.

There is no doubt that attendance in emergency / unplanned care has increased, but why? The analysis we are given doesn’t tell us about when people attend, but in trying to answer the question, they point to changes in GP out of hours services. That suggests that there are no problems with the availability of GP services ‘in hours’. However, when a new Urgent Care Centre was opened in this County, it was discovered that faced with the chance to attend and be seen immediately rather than wait for an appointment at some of the less well run GP practices, people chose the former. It wasn’t all about out of hours services at all.

The lack of ownership by GPs in out of hours care is also blamed, but many out of hours services are literally owned by GPs as well as provided by them (it just isn’t obvious since they are contracted out). Of course, if you contact these services you are unlikely to see your own GP, therefore you might as well go to an urgent care facility. When you get there though, you might find yourself triaged into a GP service, where the same doctors providing out of hours care are also based. Funny how that isn’t mentioned.

Patients and their individual needs, are quite rightly being recognised as central to health provision. But with that recognition comes the realisation that people will use those services in the way that feels right for them. That might mean accessing emergency care for things that they perceive as needing attention now, even if those providing the care don’t think that is what is needed. If you feel you need to see a health professional and you know you have to plan to need it to attend your own GP surgery what will you do? Probably access a place you know is always ready to take you.

Then there are the telephone advice services – first NHS Direct and now 111. In deciding to change the focus of these services, a decision was made to completely dismantle the former in order to start up the latter. As NHS Direct ran down, then more people were referred to A&E. Everyone knows that assessment and triage of the patient are the most important parts of deciding what is wrong with someone, who is best placed to help them and what should be done. The more experienced the person doing this is (on the phone or in person), then the more effectively that problem will be dealt with. It stands to reason then that if you get rid of qualified staff before the new system is in place you are asking for problems.

Finally something that no one has mentioned. Children are some of the biggest users of emergency care. They become ill quickly, in an unplanned way. Parents rightly worry that they need attention right now and take them to A&E. We know that the birth rate has been rising steeply, we know school places are under massive pressure. I wonder if some of the increase in attendance relates to the increased number of under 5′s?

Like most issues in healthcare, this is complex. I doubt there is no easy answer nor a single cause. The propensity of politicians to blame in turn the previous government or GPs is simplistic and plainly wrong!

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Comments on: "Why are more people going to A&E?" (8)

  1. Dear Life in the NHS, really good post as ever – would you mind if we re-posted it with attribution on our site for frontline bloggers http://www.guerillapolicy.org or contact us via Twitter @guerillapolicy or email info@guerillapolicy.org – thanks in advance.

  2. “The propensity of politicians to blame in turn the previous government or GPs is simplistic and plainly wrong!” A case of “It’s not me gov” situation. When will the Political Numpties get it through their ignoble heads that it is more often than not their fault? They are the progenitors of this mish-mash-amateurish health policy. So who on earth do they think is to blame apart from them? I mean, really, bunch of dozey plonkers the whole lot of them. I would not employ any of the current leaders and heads of departments who have the luck to be in government. And only a few of the so called ordinary MPs. Scary.

    • I am afraid that is the reality of politics in 2013. Hunt in particular seems best at placing his foot in his mouth!

  3. Hi Julie,

    ” I doubt there is no easy answer nor a single cause.”

    Actually there is. I work in Tayside and we use what has become known as the Tayside model.
    Any patient who attends A&E with a primary care problem a problem that they have had for 3 or more days or something which they have already seen their GP for are put into what we call “The three day rule.”

    This means that they are seen at triage by one of the senior doctors and usually referred back to their GP. Obviously there are exceptions to this and some patients need to be seen in A&E which is why they are seen by the senior. Also as the triage nurse can make a decision in obvious cases.
    Gp’s do not send patients to A&E, they send them directly to the correct speciality without touching A&E. If a GP wants to refer to A&E they phone us and talk to a senior doctor. We do not do big fancy tests in A&E unless it is going to change the management of the patient.

    Yes it takes a lot of work, and yes we have to be consistent but we meet the 4 hour target about 99%. Patients now complain if they have to wait for 2 hours on a Sunday to be seen (our busiest day). We have been doing this for so long now that the message is getting through and the population now knows about the 3 day rule. Even one of our local radio people mentioned it on his show – although he was trying to make it into a complaint but that is the media.

    NHS24 (NHS Direct or NHS111 Scottish equivalent) cannot just send patients to us, they have to phone and discuss borderline cases unless it is a barndoor A&E patient.

    Obviously it is not as simple as that and there are other things in place; good out of hours availability, GP’s on board and we have also made the 4 hour target a hospital problem not just an A&E problem.

    If you go to

    http://www.shiftingthebalance.scot.nhs.uk/initiatives/sbc-initiatives/emergency-access-delivery-programme/good-practice-and-research/#Whole%20Systems%20Working

    Look under unscheduled care and find 2 documents about 3 day rule it explains it quite well.

  4. Thanks Euan, I will certainly take a look. You know it sounds so similar to how things were here before the internal market took hold and people stopped being able to contact each other directly.

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