John Appleby: pressures on accident and emergency services

With all the comments on why the A&E departments are failing to meet the demand of too many patients no one has mentioned that many many A&E departments have been closed down completely or partially closed despite all the demonstrations by the public who could see this situation coming. Why does the Government continue to deny the problem?

Another 'elephant in the room' is the inability of provider GP's to radically change the way in which they do business. Surgeries have a prime gateway function to prevent patients pitching up in A&E unless they are very unwell. Patients will go where they will be seen at any time.

If you can't get through to your GP (how many have proper telephone queuing systems), if they do not open their surgery in off peak hours, (a couple of hours on a Saturday and one commuter clinic a week just won't cut it) if they do not work with other providers to take chargeof the design, monitoring and care systems for their LTC and EoL patients. Get involvedand stop whining about your busy caseloads. Instead be radicall think about what your patients need not what traditionally you have provided.

This government made a political decision to 'dismantle' NHS Direct and replace it with a 'privatised' 111 service. In 2009/10, NHS Direct handled 4.864M calls in it's OOH service and was able to 'treat' 75.7%, thus referring only 24.3% to A&E.
As part of their policy decision, they started reducing manning in NHS Direct and by 2012/13, had reduced it from 2576 in 2009/10 to 1597 in 2012/13, a reduction of 38%. It resulted in a substantial reduction in the numbers 'treated' with the numbers referred to A&E rising to about 36%.
The first consequence of this was to increase referrals to A&E by about 438K patients.
With the new 111 service predominately working with a 'cheaper' staff mix-ie more call handlers and fewer nurses/doctors, and may patients self referring themselves directly to A&E because of lack of 111 service,
compared to 2009/10, there would have been an extra 296K extra referrals to A&E.
So, in 2012/13, there would have been an extra 734K patients attending our A&E departments. This largely explains the problem of extra workloads in our A&E.
So, this problem has been created by this government and not anybody else. If the policy to dismantle NHS Direct is reversed, within a short period, this problem can be resolved.

The comment around 111 raises important questions and evidence about increased ED attendance, however, it is too simplistic. The types of patients sent to ED's by NHS direct are not always serious cases. In my experience, a key issue is the 'downstream' blocking in medical beds resulting in the backing up of already stretched ED's.

Add this to an ageing population, reduction in nurses in the thousands, increased social/population mobility, reduction in service provided by GP's, socio-economic factors and financial decline then the real story emerges.

The problem will not be solved by simply re-instating NHS direct, although I do fundamentally disagree that ANY medical advice or management can be given by clerical staff with no experience of health care and by following a script. It is a catastrophic decision to use this approach and should be reversed urgently.

Data so far shows that 111 directs 4-6% of callers to A&E and a further 6% end up in A&E via ambulance, significantly less than the 24% via NHS Direct. Despite the 6% via 999 the 999 workload remains stable, a decrease of 6% of calls direct to 999 against the same month last year, when we'd expect a 5% year on year increase. 111 is certainly changing the shape of urgent care, but the evidence doesn't show it increasing workload in A&E or 999. It should certainly be considered as one of the factor in an extremely complex system, alongside GP provision, walk in centre and UCC capacity, A& E closures, down stream system issues in acute and community beds and extended cold weather, to name a few

After spending two different days in the A and E emergency system with an elderly mother this week. From the point of view of the flow was really
very professionally done. The sticking point for us was the blood results we had to wait many hours. If this could have been done by a section just for A&E, rather than for all the hospital needs. i feel a lot of people would be able to go home earlier, freeing up trolly beds. For those who show not signs within the blood of anything, that could be treated by a stay in the hospital. We found that services for help at home came to the hospital to assist us, was a great feeling of support.

Some hospitals have policies that deliberately cut out GPs and force patients to go to A&E departments. I recently broke my wrist on holiday in Greece. Knowing the high cost of A&E I visited my GPs surgery, with my X-ray and a note in English from the Greek doctor who treated me. He wrote to the Fracture clinic at Chase Farm Hospital, but they refused to see me, saying that they do not accept GP referrals. So I had to spend 5 hours at their A&E, wasting the time of their receptionist, triage nurse, X-ray department, doctor and plasterer, only to be told what the Greek doctor had put on my notes and was shown on the Greek X-ray.

How can the NHS stop wasting money in this way?