For God’s sake stop blaming patients for turning up at A&E

I’m trying to work out what is going on in A&E this winter.

Horrendous stories about excessive waiting times, patients on trolleys, ambulances queueing. Staff must be under awful and unsustainable stress.

Constant level threes, several level fours…how do they manage to keep going?

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Percentages are quoted all over the place about rises in attendances and admissions…

Blame is thrown around.

People are going to A&E when they don’t need to.

People don’t like waiting over the weekend or even overnight any longer; we all want instant access to everything. “It’s our right”.

People are sicker, with more long term conditions, co-morbidities. And of course older.

(Yeah? We do get older every year…get used to it.)

Flow through hospitals is blocked by fractured processes, unproductive (wasted) time, inadequate diagnostics and therapies, and patients ready for discharge but awaiting care arrangements to be sorted.

And inadequate numbers of staff.

What am I to believe?

The Kings Fund helpfully analysed A&E and delayed discharge data in a report last month. And I trust them to get it pretty well right.

http://www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters

Attendances at A&E rise in summer and fall in winter.

But admissions rise in winter because of increased complexity and multiple co-morbidities.

Elsewhere it has been suggested that admissions have been rising in recent years due to “junior” doctors having insufficient supervision and senior decision making from consultants, and understandably taking risk averse decisions to admit.

A&E attendance figures include patients attending minor injuries and urgent care centre units, which Kings Fund say have increased in line with A&E numbers.

Attendance at A&E in Q1-3 2015-16 was down on previous years, but acuity this winter has been higher. Older people get sicker and are less resilient. And we are all getting older. And living longer. (Joy!)

13% of people showing up at A&E are sent on their way without need for advice or treatment. Are they wrong to attend? Not necessarily. They don’t know what they don’t know. (Ever in your debt Rumsfeld.)

Another 35% get advice and guidance but don’t need treatment. “Put a pack of frozen peas on your ankle.” “Use paracetamol”…

And the other 52% receive treatment and/or are admitted.

Is there confusion about where to go in an “emergency” or an urgent situation. It’s either 999 or drop down to A&E. Yes I’ll have to wait for hours, but I’ll get seen and reassured or treated.

What’s that? Out of hours? Shropdoc? Oh, well, I’m only fifteen minutes away from the hospital.

It’s 2.30 in the afternoon and I’ve just twisted my ankle on a pavement edge. There might be a minor injury unit in my town? (We’ve got five and Shropshire). I get there and find the X-Ray facility shut at 2.00pm.

“You’ll have to go to Shrewsbury or come back tomorrow.”

Or I live in a village in nowhere land and decide to go to the hospital in Shrewsbury (or Telford). Good choice. MIU can’t help. And I need this ankle sorting out ASAP.

This isn’t confusion. It’s sensible choices based on what you know and where you live.

For heaven’s sake, why co-locate an urgent care centre or MIU with A&E and tell people not to attend? The idea is to channel people to the appropriate treatment. Durr.

And if you want people to use local MIUs, make them properly accessible, 8.00am to 8.00pm. X-ray and all.

Gordon Bennett. It ain’t brain surgery!

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So, hang on, let’s get back to numbers.

Have numbers attending A&E gone up by the often quoted 12-14% this winter?

Sounds horrendous, doesn’t it. Unbelievable. How can we cope? That’s doubling in seven years. We’ll need a new hospital.

Ah well, calm down dear. Between 13/14 and 14/15 attendance went up at A&E units and urgent care centres (eg Shrewsbury and Telford) by 3%.

3% increase.

And actually down in winter.

So what actually is going on?

I’m reminded of the wonderful Harry Longman who founded “GP Access” to enable GPs to eliminate patient waiting times by responding to demand.

Am I stupid or is it blindingly obvious that in winter you need more capacity to deal with patients with greater acuity and complexity?

And you need more capacity in the integrated discharge processes (and care economy) to get patients out of hospital when they are ready?

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And you need to smooth the flow through the hospital by having the right people available at the right time I’m the right place. Blood tests in 1 hour instead of 24? Physiotherapy the same day? Consultant decision within an hour, day or night?

Flex your resources. Move staff around where and when you need them.

Flex your leadership. And allow staff to solve their problems. They know.

I have read of hundreds of relatively simple, inspired, practical solutions on the Academy of Fabulous NHS Stuff. It’s happening all over the place.

Take a leaf out of Harry Longman’s book.

Perhaps invite Virginia Mason to hold your hand.

Surely the combined brain power of a million employees can solve this problem.

But for God’s sake stop blaming patients for turning up. It’s what you’re there for.

Dementia is not mental

Right. Should dementia be classified within mental health or physical health?

And what difference does it make?

Memory services in this country diagnose, support and “treat” people living with dementia. And memory services are by and large provided by mental health trusts.

So dementia is mental health.

Dementia, on the other hand, results from disease of the brain, physical disease. It’s not about memory loss due to ageing or stress or medications or (usually) other conditions.

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Dementia results from physical disease.

“Memory” clinic as a name suggests dementia is just about memory. Wrong. Dementia is the generic name for difficulties with perception, physical capabilities like speech and swallowing, memory, recognition, understanding, word finding…

Memory is just one piece of the jigsaw, the one that most people know about.

So dementia is about living, about occupational therapy, about using your “facilities” as often as possible so you don’t lose them. And occupational therapy is provided by physical healthcare providers usually.

I looked at the Shropshire Health and Wellbeing Board’s priorities for the next year. And there, at number one, is improving mental health, including dementia.

Why does this matter?

Well, as most people know, mental health care has been underfunded since year dot. So, if dementia is classified as mental health, care for those living with dementia is likely to be underfunded.

And it is underfunded.

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Second, mental ill health has been regarded since year dot as something to be hidden away, in asylums, in the community, not talked about. Some languages and cultures have no word for dementia because it is a disgrace to the family. It is not spoken of. We are only a few steps ahead of this in most of Britain.

Severalls Lunatic Asylum

Third, because there is no cure and because the incidence of dementia is increasing as we live longer, (and possibly because our lifestyles become less healthy,) people are frightened of dementia.

It’s the new Cancer.

And, fourth, if it were cancer, or acute kidney injury, or heart disease, and was therefore classified as a physical health condition, it would receive the funding and priority support and treatment that cancer gets.

Which it does not.

But, no, dementia is put into the mental health category, so it can be underfunded, under-talked-about, and misunderstood.

And of course, while people living with dementia progressively need more support from health and occupational therapy experts hosted by different organisations, coordinating access to these people and services gets progressively more complex.

And where there are joins there are cracks.

And where there are cracks there are holes.

And where there are holes there are trips and falls.

Limestone grikes and clints of the Burren, Co. Clare, Ireland - pavements with crisscrossing cracks

People get lost in the holes. They don’t re-emerge intact. They lose their functions, their social contacts. They become isolated, lonely.

They die.

We really need to decide whether we value people sufficiently to want to provide them with the best support we can so they can live as well as possible in their communities.

Because at the moment we don’t.

And that, as I have said before, is a disgrace.