> Can't see that happening. Physicians don't want to
> look after emergencies. They want to pursue their
> interests in OPD's, various 'oscopies etc. The SpR's
> coming through are even worse.

This is the problem for the patients- there seems to be pressure on using A
and E doctors for avoiding admissions (i.e. sieve, do the workup according
to someone else's protocols, do the out of hours and take responsibility for
inappropriate discharge) while the physicians etc take on the sicker
patients (unfortunately, although many physician consultants aren't
interested, they do like these patients to be under my juniors).
This emphasis on A and E consultants to keep down time in A and E suggests
that I may be left sieving the patients and passing on anyone ill to an SHO
at an early stage. Not good for personal enjoyment or patient mortality, but
as Mr Milburn says, what the public consider important when it comes to
electing politicians is the waiting time in A and E. The problem is that if
A and E consultants are seen as working as juniors to inpatient teams it
does the image of the speciality no good.

> I think it's up to us to make sure this doesn't happen. It's
> still more
> efficient for us to "sort a case" completely rather than refer to a
> specialist I feel. The agency is concerned about total
> patient transit,
> including bed occupancy, and not just about waiting times in
> A&E.
> So if I can sedate and suture a child rather than
> admit, or GA
> the occasional adult to avoid admission, I expect the agency will be
> supportive, even though this "takes me out" for up to one
> hour per case.
>
>

There is, unfortunately this 100% 4 hour target, which makes it rather
difficult to sort your more complex minors (makes GAs in A and E pretty much
impossible and most regional techniques fairly difficult). The easy way to
hit this target is to use your consultants for speed dealing with simple
minors and pass on any patient requiring admission or more complex problems
to other specialities so they get out of the 4 hour period asap. Properly
resuscitating septic shock, spending an hour suturing a face or using
regional anaesthesia takes you out of this. I have a genuine worry that we
are being pushed into having sick medical patients dealt with by medical
SHOs, manips done by orthopaedic SHOs etc.

> Training has to be considered too. If all our minors are
> being seen by staff
> grades and ENPs during the day, then are we going to expect
> our SHOs to see
> these cases, unsupervised, at night? This needs to be
> carefully considered
> by each unit implementing "see and treat". Either they've got
> to incorporate
> their SHOs into "see and treat", or else they need 24 hour resident
> *shopfloor* supervision.

You'd think so. But look at the examples of good practice being held up-
consultants being the see and treat doc during the daytime, unsupervised
SHOs at night. What we're asked to do is to implement 'see and treat' at our
busiest times, so schedule the consultant to be there at the busy times to
do it but no additional resources available for increased senior cover at
other times (doesn't matter if you're hitting the 4 hour target then). Next
stage may even be consultant called in to do see and treat if times exceed
150 minutes.
The only quality issue that seems to be considered is time spent in A and E.
The various departments that have used increased consultant cover to provide
seniors for suturing difficult cases, regional anaesthesia, follow up of
complex soft tissue problems/ post concussion syndrome, proper resuscitation
of seriously ill patient etc. are being ignored or even pressed towards
taking consultants out of these to do see and treat. Basically, the increase
in A and E consultants is viewed as a way of reducing waiting times without
extra resources rather than providing a better service to the patients
needing the most skilled doctors.
The moves seem to be not only pulling A and E consultants out of where we
are needed but making increased consultant appointments (unless as a
substitute for basic grade/ middle grade doctors) unnecessary.

> With the recent developments I can see A & E
> looking after the minor injuries.  Emergency Medicine will be
> hived off to Emergency Care Physicians who will cherry pick.
> At weekends, late at night or when the departments become
> saturated they will they revert back to A & E.

I agree with Danny here. Seen a few initiatives around where other
specialities bring in nurse led clinics etc. Anything happens out of hours
or they get busy, the scut work reverts to A and E. Maybe even bypass A and
E to the wards with ambulances and then any patient who may be fit for
discharge sent to A and E (this happened with trauma a few years back in one
West Midlands hospital).


Matt Dunn
Warwick


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