28 September 2008


In the past 4 years according to Anna Walker of the Health Commission there has been a 20% increase in attendances at Accident and Emergency Departments. How odd. How very odd. Are people getting ill more often? Surely not. Perhaps there are fewer alternatives than there were. No. It can't be that. We now have NHS Direct and NHS Walk-in Centres. We never had those before. Or could it be that these new government initiatives make more work for A & E departments? Or could it be something to do with the new GP contract? Which is it Mr Brown? This is not something medical. There are no diseases that increase by 20% in 4 years. It must be something the government has done. So tell us, Gordon, what is it that your government has done that has made things so much worse? Dr Grumble would like to know. And could you undo what you have done please?


Jobbing Doctor said...

We can never return to the status quo ante.

Before 2004, GPs were responsible for out-of-hours care and delivered a high quality of care, at great personal damage to their health, but because of a sense of professionalism, and a feeling that their hard work was valued.

They have been so thoroughly undermined by the Government and media, that we cannot go back to JD trudging up the stairs of high rise blocks of flats at 3 am.

If you undermine and bully your workforce, then you will get little collaboration from them.

I wonder if Government have learnt from their mistakes? Or is it always somebody else's fault?

Dr Grumble said...

Blow. I thought it was Gordon posting a reply.

Dr G posted this as a puzzling set of questions because he thought that was the most powerful way to make the point. The answers are obvious to those in the know but it could just be that those in power are oblivious to the damage they have done.

It is a gross example of the unfounded mistrust the government, goaded by ignorant policy wonks, had in GPs. They made the selfsame mistake with consultants.

Of course, Jobbing Doctor, this is now undoable. Who knows if they have any realisation of just how they wreaked this havoc? I fear they are blundering on in blissful ignorance ready to impose their misguided ideas on some other victims.

Doing nothing would have been a better option. Doing nothing can be difficult in medicine. In politics it is even more difficult. But often it is the best option

Anonymous said...

I've no doubt both of you are right, just a thought though is binge drinking a factor and the current trend of failing illegal drug prices, would be nice to know what proportion of these are overdose related.

If these are factors look out for a big rise as the credit crunch bites but then also a rise because Mrs. Smith can't afford paracetamol for her kid so has to pop into A&E

Anonymous said...

Wanless puts the recent steep upturn in A&E attendance even higher: by a third in fact.
[see summary of "Our Future Health Secured", p7].

Meanwhile, ambulance call outs have doubled in a decade.

We are all tearing our hair out at work trying to achieve the impossible because:
*year on year increase in A&E attendances.
Despite this we are expected to sort out 98% of patients in under four hours - it can't be done: I have no doubt all departments are LYING about the real number of breaches [i.e. stays over 4 hours]

*bed reductions: medical & surgical beds are now routinely running at 95+% occupancy - the safe upper limit is said to be 85%.

*performance management by non-clinicians: they think by watching docs/nurses [clip board in hand] gives them a better take on how to look after patients. Not only they that, they have co-opted more and more senior doc/nurses into management roles, a sort of mini-me type phenomena.

*far too many member of the public [perhaps fuelled by a succession of media horror stories] now insist on an ambulance then at least two independent opinions after they have stubbed a toe.

Once upon a time I used to be a clinical nurse, trained in both psychiatry and general nursing, but I have now morphed into a city broker screaming down a phone all day, or tapping an endless stream of insecure data into the spine.

I have no doubt similar patterns of obsessive control are replicated in Education or the Police Force.
Relentless central control has become the hallmark of NuLabs style in my book - I can't wait for them to go.

Who is the worse Bliar [and Broon] or Thatch, now that's a question to tax even the creme de la creme.

Dr Grumble said...

Much of this data must be available and undoubtedly there is more than one factor involved. But the increase seems too big and over too short a time for it to be plausible that these other factors are major contributors.

Dr Grumble said...

The problem with a new government is that they will be advised by essentially the same misguided policy wonks. These are the people who drive policy. There is little real politics anymore. You can vote for the red team or the blue team or the yellow team but they are all essentially the same. Their worst unifying feature is that they do not know what they do not know. And they also do not realise that their advisors do not know what they are talking about.

Part of the problem has come from the way successive governments have weakened the civil service and instead taken advice from self-appointed outside experts and focus groups. You might as well ask for a show of hands in the local pub.

There is no evidence that the blue team or the yellow team will do any different.

Anonymous said...

I'm sure you've noticed as well that there's also been an increased in admissions under medicine since the 4 hour wait. If A and E can't sort it out within 4 hours then it goes to the medics. Or the Surgeons. A lot of people could go home if they had a bit more time in A and E.

I don't know how many of these we keep in and get the consultant to see, or just discharge ourselves.

But it depends on the A and E. I've worked in one where I swear every single chest pain seemed to be refered.ward, so we can put people on there if they just need observing for a few hours, or a 12 hour troponin check.

Anonymous said...

Ahh, the 12hr troponin.

How did anybody ever manage chest pain before the 12hr troponin.

Nifty tests beget consequences - such as risk aversion.

We now have healthy looking 30 year olds sitting on CDU pending a "trop".

Dr Grumble said...
This comment has been removed by the author.
Dr Grumble said...

Dr G has certainly noticed many more admissions of people who don't seem to have much wrong with them. It is easy for Dr Grumble because by the time these 'patients' are shown to him some time has passed. The passage of time is important. In the old days before troponins Dr Grumble used to delay seeing chest pains because he knew that the longer he left it before discharging the patient the safer it would be. This important waiting can no longer happen in a place of safety such as A&E so they get admitted. No wonder we look to have become much more efficient on the wards as our length of stay has plummeted.

PhD scientist said...

Isn't the MAU often acting as a kind of "A&E extension" for these purposes - the patient has to be turfed from A&E to avoid breaching 4 hrs, so they are moved up to the MAU for assessment.

Mrs PhD Sci used to run an MAU before she decided to quit acute medicine, so when she is awake I will have to ask her her how many of her punters were "awaiting discharge but had had to be removed from A&E".

Anonymous said...

Anyone who knows anything about GP out of hours services in most rural areas prior to the 2004 contract knows that the GPs were providing a gold standard service to rural patients for peanuts. The admin. costs of running GP co-operatives was just covered by the payments for out of hours services. And of course all the GPs did their shifts overnight and at weekends for free. Thats why it worked, and at comparatively little cost to the NHS.

The government used the option of not providing out of hours as a bribe to get GPs to sign up to their new bright and shiny contract. They ignored anyone who warned them what a fantastic service they would be throwing away. Perhaps they simply could not believe that so many GPs had really been working this hard for years, and for so little out of hours fees. They certainly seemed to have no notion of the incredible expense of providing such a service themselves.

Then they found out, by which time they had reviled GPs sufficiently that it would take more money than they are willing to offer for GPs to help them out of the hole of their own arrogant making. And no doctor with young children is going to put their families through what their older colleagues did in order to oblige a government who spat on the service they provided for years, and who deemed it so worthless.

I know - I am the wife of a rural GP who went out in all weathers at night and at weekends and then staggered into work the next morning to do a 10 hour day. His annual payment for this was frankly not worth having, but he had no choice. I had to stay in with young children every hour he was on call to answer the phone. At on-call weekends this meant we were tied to the house from 12.00 noon Saturday to 8.00am Monday, being woken frequently at night.

So when Nulabour regarded my husbands years of out of hours as practically worthless they insulted him, and they insulted me. Go back to out of hours? They can get stuffed.

Anonymous said...

It's interesting that the Govt. and media assume that the rise in A&E attendances must be due to changes in the GP OOH contract - just because they happened from approx 2004. What has also happened from 2004 with a vengeance is that the Govt. is positively encouraging the public to use the NHS willy nilly and not only that but that the public should expect to be seen quickly whenever they want. No-one checks on how much demand has increased for GPs over this period - from experience I can tell you that it is similar to increases seen elsewhere in the system. 10 years ago our (GP) workload for the day was pretty well set by late morning - most patients had rung in by then because they had watched and waited for a day or so and then decided they woulds like to see the dr and called in the morning. We often had unfilled appointments in the afternoon in midweeek in summer! Nowadays, in the same surgery with the same number of patients and Drs we have patients phoning in at any time and for anything. We even have had 12 year olds calling on their mobiles from school to say they have hurt their backs in the playground!! Basically the Govt has increased expectations and shouldn't be surprised when demand (not need) increases as a result.

Anonymous said...

I'll bet you're absolutely spot on, anonymous.

Wanless put the number of GP consultations at 250 million per year..........250 million [up by a third since 1980] the mind boggles at how much "sickness" exists in our society.

i have only ever seen a GP once in my adult life [after a spontaneous pneumothorax] if I wasn't such a burden the number would be 249,999,999 [I think].

Dr Grumble said...

What government in their right mind would have driven up expectations the way this one has? My GP colleagues tell me that patients used to present with one problem. Now they come with several. What has driven this change? The government presumably. They have also tried to increase the availability of GPs to working men most of whom, like Dr Grumble and A&E charge nurse, do not need to see a doctor. It's crackers.