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Emergency Health Care – what do we really want?

There's yet another report today about emergency care, out of hours care, GP care... I've been sitting on my fingers resisting writing so long that my fingers are numb. So here goes.

I want to start with a little nostalgia for my childhood.

Back then there were 2 possibilities for accessing care directly: the GP and Casualty (and yes, it was Casualty, not A&E). But first you consulted Auntie. For some people Auntie might be replaced by Granny or Mrs Thing down the road. This was the person in the community who, having either years of experience (from having raised 9 or so children) or a little medical knowledge, provided what is now called Triage.

Casualty was for injuries. Your Mrs Thing would check some simple rules. Can you bend it? Then it's not broken (this isn't strictly true, but still provides a fair rule of triage as to whether you need medical care). Is the wound clean, free of foreign objects and not requiring stitches? Then clean it thoroughly with antiseptic and apply a dressing. A bump on the head? Did you lose consciousness or vomit? Is the patient alert and awake? Is there an external bump? Then a bit of careful monitoring (and don't sleep for a couple of hours) and you'll be fine (this was often accompanied by an application of butter, which I can only assume was a placebo as I can find no therapeutic value to it whatsoever!)

Every home had a first aid kit, containing antiseptic, wipes, dressings, an eye-bath, antihistamine cream (for bites and stings), burn cream, calamine lotion... you get the idea. For minor medical issues, we were self-sufficient.

For everything else, you saw your family doctor. Again applying some simple rules. Are you going to die before the surgery opens? Are you going to get significantly worse before the surgery opens? (The best way to establish this is to wait and see if you do start to get worse). If the answer to both is no, then you wait till the surgery opens. Of course, that assumed that you could count on seeing a doctor swiftly.

The doctor would make a house-call during surgery hours for rashes (though Mum, clutching her book on childhood illnesses had usually already diagnosed) and high fevers. Having the doctor call was a cause for great alarm (Mum always panicked about whether the house was clean enough for some reason). Fevers were treated with aspirin (seriously, for children!) and ice packs.

Out of hours visits were only if you were dying. I recall it happening exactly once in my entire life – the occasion I developed vaccination fever and did nearly die. I wasn't admitted to hospital even then, though. Treated with paracetemol and ice packs (which I recall eating, too).

So what has changed? Why is hour of hours/emergency care now so pressurised?

Several things.

The population has changed. More people live alone, offering less opportunity for short-term home nursing. We have a higher proportion of older people, who have greater health needs. This has placed a huge burden on GP services, resulting in pressure in some places for getting an appointment. People are turning up at A&E with non-urgent things that they know perfectly well they should have seen their GP for – but saying that “It would be a week before I can get an appointment” (I write this knowing I'm blessed with an excellent GP practice who will find me an appointment with a doctor or nurse prescriber at short notice, or booked to my convenience.) The very success of A&E wait time targets has aggravated this: when I was small, you avoided Casualty unless it was essential because it would mean a long wait time!

We have seen the demise of Mrs Thing. Whether because we no longer have 'granny's wisdom' in our society or because anyone with a little knowledge declines to give advice for fear of litigation, people are less willing/able to self triage and self care. Attempts have been made to replace this vital part of our community with the pharmacist, though she too is only available at certain times: if I have to travel to see an out of hours pharmacist I may as well go to hospital. The NHS helplines have had a different problem: the default response of NHS 24 is always “Go to A&E”. I can think of several occasions when I or others have been advised to go to hospital unnecessarily, but the risk of getting it wrong means someone at a distance diagnosing over the phone will always choose the less risky option if there is the slightest doubt. Not to mention the people who go to A&E despite being told by NHS 24 they don't need to. I see little evidence that the new phone lines will be any better.

People have come to expect routine care urgently. Our supermarkets are open 24/7. So are our pubs. So we have been encouraged (by walk-in centres and government rhetoric) to expect our routine healthcare to be available at our convenience. (Though not, strangely, our tax office, bank counter, road fund licence office, local council office...) Because some healthcare HAS to be available at all times, there's an expectation that ALL of it should. And then there's this concept of “At our convenience”. At whose convenience? When I was small, if you had a medical appointment, you were given time off work (or school). Now you're expected to fit that in 'out of hours'. Is that at my convenience or my employer's? The idea of waiting till the surgery is open has somehow dissolved into a notion of getting care when I think I need it. And that, I think more than anything, has caused the pressure build-up at A&E, which is the ultimate in 'walk-in' centres. People incur an injury, wait to see if it improves (all very good) then pop into A&E instead of seeing their doctor because … well, it's open.

So what to do? Well, here's my few suggestions for the DoH.

Increase the number of GPs and make more appointments available during normal surgery hours. Then the people turning up at A&E because it's easier than trying to get to see their own doctor will go where they can best be helped.

Provide proper governance for out of hours GP services. I live in an area where people have very little confidence in the out of hours GP provision, so prefer to go to A&E if they possibly can. I'm not advocating a return to local GP surgeries taking back the responsibility (for an excellent account of GP out of hours care and the changes to contracts, see here) though contracts awarded to large companies rather than GP collectives seem to inspire less confidence. (Understatement)

Teach first aid and basic medical awareness in schools. Not just CPR (though that's useful too) but how to wash a cut, bathe an eye and determine whether or not you need a doctor. Train up the next generation of Mrs Things who can make less risk-averse assessments of need for professional intervention.

Back pedal on the rhetoric of 24/7 medical availability. Start helping people to see that it's ok to be ill overnight and wait to see the doctor in the morning. By all means, encourage the truly urgent to get the care they need critically – but persuade the less urgent not to clog up the works (and make things harder for those with critical needs). Make 'time off for medical appointments' a basic workers' right. Do we really want sick people forced to work and only see a doctor when it doesn't get in the way of them 'being productive'?

Of course, I doubt the politicians will do any of these things. It's much easier to blame the GPs for everything, rant about how much they're spending on A&E and pretend things are getting better.

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That's really bad.

Not much better over here and I don't think it will improve with Obamacare. All that will mean is that while some new people will get care (perhaps, doctors are starting to revolt over it, with some going insurance-free only), for the rest of us, insurance will skyrocket. Ours already has. Don't get sick.

As for the work (or school) not wanting people to leave for appointments, I've always found that short-sighted. I remember one girl coming into the bank (where I worked) sick because that bank did not want you to miss days (and preferred you ate lunch at your desk - I made it a point of never doing that). Instead of taking 2 days off and coming back non-infectious, she never missed a day. The end result? In an office of around 18 people, all but two caught her crud and some of them had to take a day or two off. Lost productivity? Through the sky.

Penny wise and Pound foolish.

P.S. Doctors made housecalls in your lifetime? Wow! Over here, that went the way of the dodo before I was born.

Politicians are usually greedy powerhungry morons...

Docs still do housecalls here, every company of x amount of people needs to have someone who knows BHV which is first aid and firefighting, on most public buidlings there's an automated defibrilator which everyone with two braincells or more can use.

Healthcare has sobered a lot though, here some politicians do understand that you need to keep the people healthy (rare).

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