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.

12 thoughts on “For God’s sake stop blaming patients for turning up at A&E

  1. Nice one George,
    The one that gets me is when I’m told by the CCG that 6% of patients DNA at GP surgeries.
    OK so 94% do, tell me Mr CCG what other target do you achieve with a 94% success rate – no answer!

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      • DNA is another aspect of “blame the patient”. Tell you what really matters, the DNO rate. That is the % of patients who are told by their GP receptionists, “Sorry, nothing left, call back another time”. It happens over 100,000 times every day in the UK. DNO? Did Not Offer.
        Now get the CCG to measure that. Nationally it’s 11%, according to RCGP. Rather higher than DNAs.

        Liked by 1 person

  2. George, I’m indebted and ever so slightly blushing.
    Thank you for your darn good sense on why people go to A&E, why it’s not a deluge, tsunami or earthquake of demand, and what to do about it.

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  3. Pingback: For God’s sake stop blaming patients for turning up at A&E | Two Old Chairs

  4. Thank you – Brilliant article and I solidly agree with it.

    And at least half the problem (At least here in Leeds THT) is that the urgent care centres aren’t open all the time, and that their usual response to anything other than a straightforward burn or twisted ankle is “Oooh, bugger, better get you to A+E then…” – They can’t provide much in the way of medication, they don’t have x-ray facilities, they usually don’t have any consultants on-hand.

    From the point of view of a disabled, basically housebound, person there are two levels of care; “Well enough to wait three weeks and get a taxi to the GP for a ten-minute appointment with no examination” or “Needs to be seen now, thus I need an ambulance at the door and a houseful of paramedics” – This being basically the result of DNOs from the GP’s surgery; If I say “I think I just need a house call” or “I need an appointment today, for what’s basically a long-term condition but has suddenly flared-up and won’t flare-down without treatment” all I get it a tutting from the receptionist and told that I should really have phoned first thing in the morning, and that they don’t do house-calls.

    So, presenting with (for example) a dislocated clavicle that’s an 8 on the pain scale but basically just needs old-fashioned cottage hospital treatment (“Here’s a faceful of painkillers and muscle relaxants, the nurse will be along in half an hour to see if it’s slid back into process. In the meantime, has anyone been feeding you and would you like a cup of tea?”) means instead going to A+E, because there’s no midle-of-the-road service. Ask your GP to actually lay hands on an injury? They panic and start phoning for the paramedics immediately. Show the walk-in clinic a full dislocation? They will have you in an ambulance, running red lights all the way to the trauma centre.

    But, A+E doesn’t feel like the “right” answer, it’s just the one that everyone and everything seems to point to.

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  5. DNO -Did not offer. Is the answer to create some slack with GP appointments? I understand that 30% of GP consultations are musculoskeletal related – if this is so surely the answer is self-referral to a Physiotherapist by-passing the GP, who would get a report from the Physio? There must be other conditions where self-referral could be used eg ear syringing.

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  6. George,

    Don’t forget that we now have CCGs with a high GP input at Board level. The solution to any problem will always be GP related in their opinion – even if that is totally the wrong direction.

    Given that GPs are in fact small businesses with a vested interest they are not going to consider anything that allows the patient to reduce their control by self -referral it could end up reducing their income

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