A&E Doctors Comment in Guardian

By Selector | 25 April 2013 1:19pm

I work in an A&E department as a frontline health care worker. Here is where I see the main issues on a daily basis, for log jamming:

a) inappropriate referrals by GPs to A&E. We have no idea the patient is on their way to hospital. Neither do the speciality team who should be “expecting” them. Instead of the patient waiting 30minutes in A&E to see a specialist, they wait 4hrs to see an A&E (whilst we’re trying to sort out the referral mess in the background) and then the A&E doctor refers them to a specialty. Total time in A&E = 5hrs – 6hrs approx.

We try to get the patient up to a bed before breach time (4hrs) but often, when the speciality catch up with them on the ward (not their fault), the patient is discharged. Ergo: the patient should have been in and gone on the correct pathway of treatment within 30minutes of arrival.

If this patient has co-morbidty, we have to start managing them in A&E, as a ward would, during that extensive 5-6hr wait in A&E: e.g. finding trolleys to avoid bed sores, catheters, medication, feeding, washing, supporting toileting needs, dressing and undressing, etc. Many things in A&E we shouldn’t be doing if the patient is supposed to only be here, in our department for 30minutes. Not 6hrs.

Increasing dramatically. When you phone GPs, often they don’t speak great English. It’s an uphill battle.

b) an ever increasing amount of people don’t want to wait for a GP appointment for minor illnesses. When I was young, I remember if I had ear ache, I’d be seen by the GP within 48hrs. If you told the receptionist that you had a bunion issue – she’d schedule you to see the GP sometime in the next 7-10days.

I don’t know why patients can’t wait for a GP appointment. Why has this changed over the years? Something needs to be done: an educational issue?

This is rocketing. The number of people without GP registration in London is massive and increasing at speed. Is it mostly with new comers? Yes, I think so. Could immigration and border control be doing more to educate people when they arrive, I think so.

c) many patients don’t have GPs and won’t register. But we still take them and see them. We see the same members of the public 4 or 5 times in the year coming to us for care. Why can’t the A&E doctors ‘red flag’ patients and turn them away if they systemically well, present with non ‘accident’ and non ’emergency’, non-life threatening illnesses (repeatedly), if they are not registering with local GPs?

This is climbing steadily. We need some kind of push-back mechanism so that the community based services or GPs ‘catch them’ and scoop them up/net them in.

d) council provided services have seen a dramatic drop in funding. Not enough home visits by carers or district nurses are being done for patients in the community. Very simply managed illnesses are reaching levels of gravitas whereby GPs on home visits are referring to A&E for those illnesses which have gone past the competence of their care. For example: the number of elderly people with reduced care packages, who are immobile, who gain easily avoidable community acquired infections – like UTIs – has rocketed. Dehydrated, increased confusion, their poor hygiene (hence, UTI) is coming, by ambulance, to A&E. Other widespread and avoidable presentations born in the community are: leg ulcers, falls, poor nutrition, hypertension, ingesting wrong meds, etc.

The only thing that is going to fix that is an overhaul of non-Turst, community based services. More money? More discipline? More GP authority? More council intervention/responsibility? I don’t know.

Recently, other than poor GP referrals, this is the second worst area of rocketing unnecessary admission to A&E.

e) we have seen NHS Direct do a fairly good job. On the whole, if potential patients have spoken to an RN or a nurse practitioner or a medic, if the patient still comes to A&E, it’s usually cause they really have to come in.

Not so, the 111 service. I have the feeling at the moment that non-trained, non-healthcare phone operators are sending ambulances to people’s homes for paper cuts. The 111 service and NHS Direct have to work more closely together.

f) Outpatients clinics at our hospital have a tendency to close at 5pm and ‘dump’ their charges of care to A&E, out of hours. This used to be a horrific burden. The Trust has now quashed this practice by working more closely with the specialist teams and clinics. Occasionally, we still get inappropriate 5pm referrals from clinic.

g) private GP out of hours services. Why are these private companies allowed to charge service users a £100 call-out fee, approximately another £150 for a consultation, but end up sending the patient to us anyway?

This has to stop. Why? Because the majority of referrals are for prescriptions, or, treatment that is not for acute conditions.

You should see the handwriting or lack of documentation that these private GP providers send into us with their patients. It’s next to useless.

My Reply

medifix | 26 April 2013 1:38pm

I worked in the hospital paediatric and intensive care for almost 20 years. In 2000, I moved to be a GP and this was the worst thing I have ever done in my life. As a paediatric Registrar in intensive and acute care I am used to going through the notes. As a GP this is a disaster because I could find so many mistakes and the notes filled in with information that no one earth could understand.

The worst thing happened when patients seen in walk-in-clinics and nurse-led practice turned up to see me on Monday morning. The nurses would have treated asthmatics as chest infection, infections not diagnosed, CCF treated as Asthma and so I started see ing minor and also serious complication. Please tell me, can you just dangle a stethoscope on a fully clothed person and diagnose chest infection? Yes this is the reason people have lost trust in Gps and so rush to see locum doctors or go to A&E.

As a doctors it was difficult for me because I felt complications could have been prevented. If the mistake was committed by a doctor, the GMC would have suspended the doctor. This is “Negligent care” and so un-ethica. As a doctor who identified problems, it is my duty to inform authorities and so I did, I did not instigate complaints and litigation. Result (like other Whistleblowers) I was ostracised. I forwarded all the documents to GMC and tey did not find any fault in me and am still registered to work in UK. I stopped working in this organisation as a clinician because we are forced directly or indirectly offer treatment that may be harmful to people.

To protect people I have produced a simple tool Maya and offered it to the PCT but they have not implemented this as it is available FREE. This is the only solution that can reduce access to A&E by 60%.
Please do not blame the patients because they are helpless. What can one do when they can’t get the help or reassurance from GPs and are unhappy?

I think you as a doctor must do what ever you can to alleviate suffering. I have destroyed my life defending patients, so please do not write comments in the media because you will be next in the line to be …..

My Reply 2

You are in a way correct, consultation and demand has increased and the primary care is monitored and managed by a group called CPAG. I noticed this group has more non-clinicians (social medical or preventive medicine) and dentists, physiotherapists, nurses and lay people as the members.

One director told me he has never examined or prescribed treatment. The people who mange NHS are not one who can understand patient psychology but insist on NICE Guidelines and BNF. If the guidelines was right, I would have been the first doctor to offer a computer that can do a better job than the doctors or nurses in primary care.

Our duty is to protect vulnerable people and I must not conceal the truth. If it is a fellow human who is suffering today, we will be in their shoe in a few years and so must speak out. You can watch some of my videos in the you tube and please leave your comments.

 

 

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  1. Pingback: How To Reduce A&E Pressures And Save The NHS? | Dr Sri

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