Some may recall I raised this issue several months ago to a chorus of
indifference. The main driver for all these changes has of course been that
the GPs negotiated themselves a great package. Their mean salary is now
£106k (source http://news.bbc.co.uk/1/hi/health/6157219.stm) and they
forfeit £6k a year to abandon OOH care. Unsurprisingly, they did so in
droves and have largely handed their work over to co-operatives who have
made handsome profits over the past few years and now are being snapped up
by the big US conglomerates. They provide skeleton cover, and have 0845
numbers that are a lot less easy to remember than 999. In the last 24 hours
I have heard of an ambulance called to a young woman with a bleeding ear and
a mild exacerbation of long standing back pain in a patient seeing a
neurosurgeon in 7 days.

So we are seeing prioritisation software and advice desks appearing in
ambulance control rooms, and the rise of the Emergency Care Paramedic (ECP)
to treat in the community albeit rarely in the patient's home; in the best
systems such as Norwich the patient is encouraged to get to a treatment
centre. The pay differential between a paramedic and even an F2 is not lost
on the DoH either. And really we can't grumble when we are not emptying
waiting rooms of the backache and bleeding ear - they don't need our skills.


However, I also highlighted my concerns about training. I asked what we were
training our SpRs to do - work in urgent care centres as Consultants in
minor injuries?

I am now increasingly concerned about the training and experience of the SHO
level (F2) doctors. One of the advantages of the undifferentiated take of
the average 30 to 50k A&E department was the variety of patients that they
saw. I recognise that there was a pithy but unhelpful criticism of the
'sickest being seen by the thickest' but the plan of BAEM and FFAEM was to
increase the numbers of seniors to improve supervision around the clock -
and this was coming to fruition nicely. I need to ask where they will now
get that experience (particularly the General Practitioner trainees) if
everything minor that doesn't see a GP is being seen by ENPs and ECPs.

A separate but related issue is that we may be cutting the numbers of
emergency departments to such a small number that we may not find ourselves
with a viable specialty.

Nobody responded last time I asked these questions, but I believe that they
are the most pressing issues now facing us as a group and deserve debate.

Best wishes


Rowley.



-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Dunn Matthew Dr. (RJC) A &
E - SwarkHosp-TR
Sent: 06 December 2006 05:56
To: [log in to unmask]
Subject: Re: Emergency access - Clinical case for change: Report by Sir
George Alberti


I am also somewhat concerned by Sir George's comments that he would be happy
travelling across the country if critically ill and if he deteriorated in
the ambulance paramedics could sort it out; and that when he suggests all
suspected MIs and suspected strokes travelling potentially long distances to
get to specialised centres he does not seem to take account that this comes
to about 2 million cases a year in England (i.e. those who require
assessment by an experienced doctor rather than just those with a definite
diagnosis).


Matt Dunn
Warwick



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