I was recently part of a team of GPs who audited the hospital notes of patients who had been admitted to hospital. The particular group of patients we were looking at were those who had been admitted but then discharged in under 24 hours. The intent of the audit was to look at what was happening to these patients and whether they really needed to be admitted at all, or whether they could just have been sent home without the need for a hospital bed.
I want to describe a not-untypical scenario I saw happening.
I rremember talking to one of my GP colleagues at the time, asking her how she would have managed a similar presentation in General Practice. The patient was in their 50s (although could have been any age) presenting with a cough and feeling breathless, they have had the cough for several days and they are worried they might have a chest infection, or even pneumonia. On examination they have normal blood pressure, normal pulse rate, normal chest examination (ie no signs on examination of a chest infection), normal pulse oximetry (a measure oxygen levels in your blood), normal temperature, normal breathing rate. I pause at this point and ask my colleague what she would have done. Confidently (because this is exactly the kind of thing GPs see all the time) she replied that she would have reassured the patient and sent them home. In A&E, the patient also had blood tests, a chest X-ray and blood-gases (a sample of blood taken from the artery to determine oxygen levels more accurately). At some point during this process they were admitted to hospital, before then being reassured and sent home.
If the patient had attended their GP, it would have taken a 10 minute consultation. They were in the hospital for several hours. If the patient had attended their GP, it would have cost the NHS around £35, instead it cost the NHS several hundred pounds.
Most people I speak to, including my patients, do not enjoy a trip to A&E. Most people I speak to think we should be using tight NHS resources as efficiently as possible. Despite this, there are many people every day turning up in A&E who don’t need to be there. Last week our local hospital was in the newspapers with this article about increasing numbers of people attending A&E. I saw it first on FaceBook, and many of the comments suggest that people are attending A&E because they can’t get to see their GP. This is unfortunate, and I suspect largely untrue. I know a lot of GPs in my area and I am pretty confident that all of them would say they would see patients on the same day, where appropriate, if they had an urgent need that could not wait. You may well be asked to wait a couple of weeks for something routine and I don’t think that is unreasonable, but all GP surgeries have provision for emergency patients on the day. Many of the local surgeries in the Central Cheshire area have also been part of the The Prime Minister’s GP Access Fund. This has provided an additional 32,645 GP appointments across the area in the last year, just on weekdays. There have also been an additional 7,691 GP appointments at weekends. On top of that there have been nurse and physio appointments too.
40,000 extra GP appointments in a year. That’s an average of 3,361 extra appointments per month. (If you read the newspaper article above it mentions that the hospital had an extra 1,600 A&E attendances over a 3 month period. I’m not sure how that is newsworthy, and this isn’t?)
So, there are more GP appointments, including at weekends, as well as GPs making provision for urgent appointments. There are also Out Of Hours services available if your GP surgery is closed (call 111 to access these), yet still people are choosing to attend A&E for conditions their GP is more that qualified to manage. Do we understand why this is? I’m not sure we completely do. One thing I can be sure of, is that demand appears to be going up. Increased demand to GPs will result in an increase going to A&E.
I have a few ideas about why demand is going up.
I think as a society we have become less tolerant of ill health. We are no longer prepared to wait it out. I see people attending with coughs, sore throats, sticky eyes and other self-limiting conditions on the day they start. We are unhappy living with the symptoms and want an immediate cure.
I think as a society we have a greater sense of entitlement. Rather than gratitude for the NHS, and a view that we need to carefully use the precious service which is available for free, we all feel that the NHS is there for us, and that we are entitled to it. This drives increasing use.
I think as a society we have ever increasing expectations. “You’re telling me that we can put a man on the moon, but you can’t cure my cough?” Well, quite possibly not, and if you’ve only had it for 3 days I’m probably not going to try to unless my examination of you suggests otherwise (or unless you have some other reason why I would need to, like COPD as an underlying condition).
I think as doctors we can do so much more that we used to. Medicine has moved in. We are actively treating conditions today that a couple of decades ago we were not. Management of chronic, long term conditions has taken over a large chunk of the GPs time. Heart disease, kidney disease, COPD, heart failure, hypertension and more. All being treated and keeping us all living for longer and longer. This is good, but all adds to the ongoing demand. Our local hospital tells us that they are seeing patients with increasing complexity and acuity. In other words, they are sicker, and have multiple medical complaints.
I think that as a society we are much more litigious. We also tend to think “better safe than sorry”, and seek out advice and reassurance much more than we used to. Schools, nurseries and employers increasingly send people to the GP to check up on things. Gyms stop people from joining until they have a medical certificate saying that it is safe to exercise (it almost always will be) and it has led to a culture requesting that you “Get a note from your doctor”. It also results in doctors behaving more defensively, requesting more tests, and bringing people back more often, none of which are necessarily a good thing. This might account for why in A&E, where you are likely to be seen by a doctor less experienced and confident than your GP, that you are more likely to have more tests (that you might not need), and find yourself unnecessarily in a hospital bed. (There is a side issue here about patients being classed and charged as admissions when they never get as far as a ward, or even a bed, and we need to sort that out too).
You may well be thinking that not all of these things should impact particularly on A&E, but suffice to say that if you increase the work going to GPs, some will spill out and have an impact on A&E.
We all, collectively need to work out how to tackle this. GPs do sometimes need to look at their access issues and their telephone lines, but I hope you can see from this that GPs are working very hard, offering huge numbers of extra appointments over the last year, and doing what they can to meet the need. I get very frustrated and disappointed when I see them being accused of being the underlying problem behind the A&E crisis. A quick point here – the Prime Minister’s GP Access Fund locally runs out of money within the next 6-8 weeks. We have heard that additional monies are to be made available from the Government, but we have been hearing that for a while and have not seen anything in writing. We are concerned that there will be no money to continue this scheme. The CCG does not have any spare money to fund this. We could only find the money by taking it out of the local hospital. If the money is not forthcoming, those 3,361 extra appointments per month are all going to disappear.
I started my last paragraph says that we all need to tackle this together, and I really do mean all. This is as much a society problem as a GP or hospital one. We all need to do our bit. We need to choose well when we need care, and stop and think if we may initially need to help ourselves before seeking other services. We need a greater tolerance and understanding of risk, and to be less quick to pass all risk onto others. We need to acknowledge that self limiting conditions really are self limiting, and to be patient patients while we wait for them to resolve.
It’s time to rethink how we use and access NHS services. This can be done. Let’s do it together.
Dr Jonathan is a GP at Swanlow Practice in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group.
Follow Jonathan on Twitter @DrJonGriffiths