I think you may be confusing several
different issues.
You refer to the well-known elastic wall
syndrome. We have all seen that, but as time has gone on it has become clear to
me that this has several causes. When the 4 hour target (now standard) was
first introduced, significant amounts of money were put into emergency
department resources – but mostly in human resources, what you and I
call colleagues. Few departments were expanded. When allied to improved flow
through these departments there was a significant fall in the number of
patients in ad hoc care spaces – Corridor Ward and such. However, the 4
hour standard has fallen victim to the same fallacy that Nye Bevan convinced
himself of when he set up the NHS. He thought that once all illness was cured
the need for medical care would diminish dramatically. In the same way, it was
felt that a single change to working methods that the 4 hour standard prompted
would allow hospital bed numbers to be cut and stay cut. Unfortunately, attendances
have risen by 8 to 10% per annum in our department since and I suspect we are
not alone. This means that unless a vast and increasing number of people get
sent home the number requiring admission at any time also rises. There has been
a gradual resilting of the admission wards in our Trust and we are back to square
one. How many of Mark’s patients make it past his department straight
into a bed? He mightn’t have to deploy resources to look after speciality
patients in his department but his nurse manager sure does and that will slow
care for his patients. So already his team are doing someone else’s work.
There are some occasions on which bypass
of an ED does work; for example, all our acute cardiac work now goes straight
to the cath lab. This is clearly better for patient care and I support it. I am
yet to be convinced that this is the case for other patient groups.
Mark’s problems may well be
alleviated by getting together with his acute physician colleagues, pooling
resources and sharing the load. It’s not a cop-out – it’s
doing patient care better. Any PCT managers reading this – you do need to
think how you are going to deal with this as the patient numbers are continuing
to increase, and the patient population attending EDs, particularly by
ambulance, is increasingly unwell.
BW
R
From:
Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Prescott Mark (RLZ)
Sent: 11 March 2010 11:32
To: [log in to unmask]
Subject: Re: GP referrals to
specialities
So once again the ED is expected to have
rubber walls and unlimited resource to manage everyone’s problems!!
– nice cop-out for everyone else!
As you can tell – I am dead against
us duplicating someone else’s work – it pisses off me, the patient,
the GP and the managers – is there anyone who is not upset by this?
I am not a megalomaniac who wants to take
over the whole of medicine!
If a GP has seen and assessed a patient
and refers, for a specialist admission, to a speciality team - then neither
they nor their patient have any business in my department unless the patient is
unstable and needs resuscitation – which we will do better than any other
speciality
Yours grumpy!
Mark P
From:
Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Rowley Cottingham
Sent: 11 March 2010 09:52
To: [log in to unmask]
Subject: Re: GP referrals to
specialities
Not dyspeptic at all, Vic. In fact you
have supported my argument most cogently. GPs have a vital role to play in
admission avoidance and as you say seniority helps immensely. GPs can’t
contact specialties for all sorts of reasons. Sadly, while it may be better
that a patient goes directly from bed to bed I’m afraid that is the
exception rather than the rule. It is ridiculous to set up parallel access
systems as well as expensive in terms of staff and resources. Published data
shows that patients get investigated more quickly and treated earlier if they
come to EDs. There is no evidence that in house teams are any better at
determining whether a patient goes home or comes into hospital, and maybe that
is because of seniority issues.
The urgent care centres are proving, where
they work well, to support this system very successfully. I’m pleased to
say that our own joint venture was described as a potential future model in the
long awaited Primary Care Foundation report (page 37) http://www.collemergencymed.ac.uk/CEM/About%20the%20College/Current%20Issues%20and%20Statements/Primary%20Care%20and%20Emergency%20Departments
. Power to your elbow in this work, but don’t bother referring to
specialties.
BW
R
From:
Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Victor Calland
Sent: 11 March 2010 08:40
To: [log in to unmask]
Subject: Re: GP referrals to
specialities
I think Specialists are archaic ;-)
Come on Rowley, I hope you took some Rennies and got over your
dyspepsia!
Working at the Urgent Care Centre in Ambulance Control at the moment I
am coming across situations where the GP is either not referring to a specialty
because they can't get to talk to the admitting doctor because they are in a
phone queue or the bleep is unanswered, or they ask the family or nursing home
to call the ambulance - so it goes to A&E. It is clearly better if a frail
patient is transferred from bed to bed and does not have four hours on a
trolley. It takes the pressure of the Emergency team. Unfortunately the whole
system is running at capacity and so everybody is looking at ways of dumping
the burden of unscheduled care simply because it hasn't been scheduled.
Part of what we do is to deflect 999 calls to the GP, part of it is to
upgrade where necessary - often admissions direct from a GP's surgery which
have been automatically downgraded because there is a defibrillator on site.
Initially I was profoundly sceptical of the project, but even at this early
stage I am becoming convinced of the need for someone with experience and
authority to direct where people go. Its amazing how professional staff are
more prepared to accept their responsibilities when they know the call is
recorded!
Vic Calland
On 10 March 2010 22:16, Rowley Cottingham <[log in to unmask]> wrote:
I think GP referrals to specialties are archaic and should be banned.
BW
R
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]]
On Behalf Of Redman Paul (
Hospital NHS Foundation Trust)
Sent: 10 March 2010 22:07
To: [log in to unmask]
Subject: GP referrals to specialities
I seem to be seeing a spate of referrals from GPs to the speciality
teams that are being batted sideways with a request from the
specialities that the GP send the patient to the ED and the speciality
SHO can be called by the ED staff if we are concerned. I eventually
lost my rag with the ortho sho today over this - it wouldn't have
arisen if the letter from the GP hadn't incriminated the sho in
question.
Is it our hospital or is it becoming more common? How have others
dealt with it? Are you ignoring it? It seems all specialities are
involved but obviously some personalities are more apparant than others.
Paul Redman
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