A Solution to Our Emergency Department Crisis – Lock the Doors of A & E

Writing exclusively for Slugger, the respected medic Dr George O’Neill gives his proposal to tackle the crisis in A & E. Dr George O’Neill qualified in 1971 and is a General Practitioner in practice in North & West Belfast for 40h years.He was for 6 years Chair of the Belfast Local Commissioning Group and he also Chairs Addiction NI.

Emergency_roomThe media are constantly carrying stories about overloaded emergency departments. Politicians are demanding action, patients are constantly complaining, managers are constantly interfering and staff are constantly stressed about our Emergency Departments. But none have suggested a solution. The following is one possible way of addressing the problem.

Currently there are 5 streams for people accessing emergency medical care services:

  1. Emergency same day appointments and house calls delivered by GPs
  2. Primary Care Out of Hours services
  3. Emergency Departments/Minor Injury units
  4. Community pharmacy
  5. Northern Ireland Ambulance Service

The demand is increasing and the resources are under strain.  Whilst health care professionals view a proportion of this demand to be inappropriate, the patients rightly or wrongly consider themselves in need of emergency care and this culture is unlikely to significantly change in the near future.  A radical rethink is required to ensure this demand is more effectively met within the resources available.

The present model of deliver of illness care was developed in a different century for a different population with a different demography, different treatments, different expectations and an almost exclusively male workforce. I suggest it is no longer fit for purpose.

At the beginning of my career Casualty consultants wanted as many people as possible to visit their Casualty Department. Their funding was linked to footfall: the more people through the doors the more funding for the Casualty Department. This is how we ended up in the situation of people being conditioned to go to Emergency Departments.

In addition the model of care and health professional training is based on the acute curative episodic model. This model is not appropriate to address the needs of patients with long-term chronic conditions which cannot be cured and gradually worsen.

When I first became a GP most of my consultations were one off. You came to me with a problem, I wrote you a prescription and you went away happy. Now a lot of my time is spent dealing with patients with chronic conditions – diabetes, COPD etc. These patients require long term care.

Why do we continue to innovate to sustain the status quo when only truly radical changes will result in lasting solutions that address the needs of our population and improve outcomes?

The management of the primary care entry point should be flexible, as should the workforce which will staff this service and will depend on local arrangements/needs.

GP’s are no longer responsible for out of hours care. If you ring your GP out of hours you will get a message telling you to ring your local out of hour’s service. The out of hours service will then give you advice over the phone, send out an on call doctor/ambulance to your home or advise you to visit your local out of hours service.

 

A proposed model for Belfast:

Mater_Infirmorum_Hospital

Time to close the Mater A & E?

One Emergency Department on the RVH site closed to the public with access only via a blue light ambulance or a letter from a doctor. There was a public outcry when the City Casualty was closed. I would go one step further and also close the ED at the Mater. Belfast simply does not need two ED units a mile from each other. The Mater ED is being kept open for political reasons, not clinical. ED staff are specifically trained to deal with trauma: they are there for car crashes, heart attacks, strokes etc. They are not there to stitch up your finger. Everyone in Northern Ireland wants a hospital near them, but this is just sentiment. The evidence clearly shows that your ambulance is better driving past your local unit and heading to a major trauma centre. If I take a heart attack I am more than happy to spend an extra 30mins in an ambulance if it means I will get seen by the best skilled doctors in Northern Ireland.

A single Out of Hours unit operating 24/7 adjacent to but separate from the single Emergency Department.  The 24/7 Out of Hours ideally should be the responsibility of a GP-operated and controlled Community Interest Company or Mutual. It should be integrated with other Out of Hours services (social work, mental health crisis response, community nursing, chronic disease, pharmacy etc.). This is where patients will walk into. If their condition is serious they will be transferred to the adjacent ED .

Encourage more use of Pharmacists. They are well trained professionals who can advise on a wide range of conditions and deal with a range of minor injuries. Why sit for 4 hours in A & E when you could pop into your local pharmacy? Already many pharmacies now offer flu shots and other treatments. This should be extended to other services.

Better use of paramedics. Hospital care is expensive. Bringing people to hospital should be the last resort. Due to advances in medicine many health problems can now be dealt with or stabilised by a paramedic in the person’s own home. Take for example the issue of urinary tract infections and falls. This is a very common conditions in older people. At the moment they are brought to hospital but there is no reason why a paramedic could not stabilise the person and they get a follow-up call the next day.

The problem is the Ambulance service is currently all about targets. In our example of the old lady with a urinary tract infection a paramedic might spend 2 hours dealing with that patient. The time spent by the paramedic means that the patient did not need to go to the hospital. The old lady did not need a hospital bed with all the care and expense that goes with it. Furthermore the lady is happy because she can stay at home. But under the current model where is it all about response time all that matters is that the paramedic was tied up for 2 hours. All the systems work in isolation. Paramedics should be given more responsibility to deal with patients on site thus saving a lot of time and money down the line.

These changes will result in a health service that is not only less expensive but gives better care to the patients.

Can the culture of Health and Social Care adapt to a service run for the benefit of those who use it and not for the benefit of those who work in it? Will politicians have the stomach to make the tough calls that are needed?

What are your views?

  • chrisjones2

    One of the best articles I have seen on Slugger>Professional,well argued and honest

    I bet it will get next to zero responses as it dosent play to the themuns /or oursuns meme

  • John Sykes

    Your solution is a sound one but one I fear that will be avoided by the politicians. The last 4 years and present stringent cuts are not the fault of Westminster but of our MLA’s at Stormont. Their primary interest is not to make systems efficient, cost effective and work – their interest is fully focused only on retaining power, whatever the cost. That means deluding their constituents that everything that is done is for the good of “all the people.” Unfortunately with this attitude to life, logic and good business sense will never prevail.

  • Ozzy

    As a paramedic I wholeheartedly agree with giving us more training and skills to treat certain categories of people at home. But considering paramedics presently get 21-27k per year to take life-critical decisions in the field with minimal training, support and equipment we would need to see an improved salary in recognition of becoming doctors on the cheap.

  • Brian O’Neill

    Ozzy can you send me an email to brian@sluggerotoole.com thanks.

  • Excellent piece, as a start. This only really deals with ED. Should go across entire system and work out why people end up in A&E, from difficulty in accessing GP services, unreasonable expectations, price of alcohol which means more accidents at home, and Health & Safety/Safeguarding regime which makes it the safe option to send for an ambulance rather than stick a plaster on it. The key point above seems to be that of a system for medicine today. Rather like the welfare system, medicine has moved on while the bureaucracies are slow to change.

  • Brian O’Neill

    This is the first in a series of articles from Dr George about health care. We appreciate any suggestions for topics to cover.

  • CPB

    Article makes a lot of sense! I went to the RVH A&E last week – had hurt my foot playing sport. I felt a little guilty going as it wasn’t an emergency but if I went to my doctor I would have been sent for an x-ray anyway. So in effect I cut out the middle man. I can only speak in the highest regard of all staff who dealt with me. In and out in less than an hour with the comfort of knowing my foot wasn’t broke. Excellent service. With the current system, I don’t think there was any other option. Wait for up to a week to go see my GP who would then send me to get an x-ray, beside A&E, all the while not knowing if I had a broken foot or not!

  • chrisjones2

    It would be good to have some startegic analysis on how to reform /better the system within the same cost envelope

    We never get that – its all zero sumdebate fromdeadbeat politicans chaing 20 votes here and there

  • honest joe

    The way things are going in NORNIRON i can see that the place is fast falling apart and i place the blame at the feet of our politicians. Close the A&E departments where you choose but get rid of the biggest money drain in the country and CLOSE STORMONT.

  • carl marks

    I sometimes work with the H,A,R,T team and have noticed that Paramedics are busier than ever. i don’t think there is enough slack in the system to take on what would be a lot of extra work.

  • Dan

    Added to the comments from the 352 clinic consultant on Nolan last night, we’ve finally started getting some sensible proposals from the medical professionals on the future of services here…..a welcome change from idiotic nonentity politicians and the same old failed set of favoured consultants dragged out for each and every review over the years,

  • Ozzy

    That’s my address sent Brian

  • Ozzy

    You’ve hit the nail on the head, we’re working to capacity most of the time, any increase in workload like major incidents or prolonged seasonal pressures disproportionately magnifies the problem

  • carl marks

    would it not be preferable to utilise Nurses in something simalar to the Barefoot Doctor scheme set up and working well in parts of Africa and Asia?

  • Zeno3

    If you close the doors of A&E you are going to need thousands of more Ambulances to cope with the demand. People are not going to suddenly gain some ability to diagnose their own illnesses and make radical choices. An awful lot will just phone an Ambulance.

  • Brian O’Neill

    Did you read the post?

    A single Out of Hours unit operating 24/7 adjacent to but separate from the single Emergency Department.

  • chrisjones2

    …and they have to be told no

  • hugh mccloy

    While I dont fully disagree with the content, its missing several factors into the provision of health and the use and training of medical staff and the effect that specialism in different areas has had on the ability of the health service to function without an army of doctors and consultants.

    For a doctor to state “If I take a heart attack I am more than happy to spend an extra 30 mins in an ambulance if it means I will get seen by the best skilled doctors in Northern Ireland.” is a bit of a worry, along with other emergency circulatory illnesses speed is off the essence, it reminds me of the senior emergency consultant Dr Dornan from Antrim A&E answer to removing services from Mid Ulster when question about it in Magherafelt Council buildings, when someone suffers a medical trauma all they need is someone to hold their hand and some water inside the golden hour for the ambulance to get there and get them to hospital, this was during explaining ambulance response and turnover times to car crashes.

    Also this statement is a slap in the face to some of the best consultants and doctors that this county has produced, when functional would i prefer a 1 hour drive to the Royal or a 10 minute drive to the once Mid Ulster hospital and have people like Dr Hunter, Piper, Hawe along with the back up staff there treating me, ask the author I am sure he would have not issue with these people caring for him in a local setting such as Mid Ulster.

    The effect of the above on an ambulance service that is already under funded, and under respected would be clinically dangerous, new bypass protocols would have to be introduced and again with the tracking system as we are already seeing now is that ambulances will be trapped in urban areas unable to serve the more rural ones where they could be based.

    The recommendations themselves are nothing to to health care and have already been discussed in 1999 during the acute hospital review, again in 2008 during the comprehensive spending review and again during Transforming Your Care, the very model I proposed for Mid Ulster in Transforming your care is a 24 hour integrated minor injury and out of hours to take pressures from the network A&E’s along with intermediate care beds and HDU for emergencies.

    The GMC and BMA have went backwards in the provision of health as the NHS is developing, the need to have a specialist in everything has starved the NHS of producing the caliber of doctors that I have already mentioned, I also have 2 newly qualified family members who are doctors who could not find the specialist work in Northern Ireland that they need to continue their training, cannot get the more general training as training places have dropped due to hospital closures, so they are now lost to others countries and we are dependent on doctors coming from other countries. A high usage of locums is in itself a danger and numerous cases here already with locum doctors being struck off the medical registrar is yet to registrar as a danger to the Health Board & Trust. And to note again both of these did not want to leave but were left with no option as there was no opportunity here to stay and work in local or acute facilities.

    In every acute hospital now A&E admissions are vetted, or alleged to be by consultants there are very few people passing through A&E and into the wards unless they really need to be there, and this is the crux of the problem.

    Once wards fill up with acutely ill patients A&E’s shut down, they dont shut down due to the amount of minor injuries going to them they shut down because we do not have the capacity to deal with the acutely ill patients.

    We really don’t ave to look to far to see what works in health, we had a operational system, reverse what was changed and stop blaming patients for breaking it.

    Break down all the different specialist units we have, gp lists to ratio of patients, admissions via A&E, direct GP admission to wards, what is good is that this article opens a ongoing debate in a more public arena

    Dr O’Neill was on the local commissioning group for health in Belfast, he had ample opportunities to bring these proposals forward in an arena where it mattered and where more importantly he could, so why now are we seeing these proposals along with a massive put it private advert in the middle of it ?

    We have seen the effects of centralizing health care into a massive hub, it has not worked as the system is not capable of working like that, the NHS has developed a network model, and one that worked effectively here until the “specialists” arrived.

  • hugh mccloy

    they still have to get there or will they be left laying at home thinking they might only have a minor injury when in fact they have an acute one ? Remembering that belfast is picking up the overspill from every other tusts

  • hugh mccloy

    352 regardless of his comments is in the business of staying in business first everything else is secondary, whole NHS clinics have shut to sustain 352 and others, a whole wing of the South West Hospital is rented out by 352, cheap at that then the trust pay 352 to take on NHS patients, why don’t the trust open up that wing to public services and run it themselves? or has it something to do with 40% of the equity of that hospital being own by the private sector?. Just like in residential care for the elderly statutory care homes closed to keep people going to the private ones in huge numbers. And he openly lied, he stated the costs are the same, they are not and not even close. Previous FOI’s from DHSSPS show its more expensive to carry out private than public. But as usual as no-one questions it everyone believes it .

  • Dan

    having had an elderly relative in a statutory care home, then a private one, I can tell you that the difference was night and day….. in terms of comfort, safety and professionalism, especially the dispensing of medication. it was an eye opener to find out that one didn’t have to be a nurse to be allowed to dish out anti-psychotic drugs in one of these sacred statutory homes. happily as I pass it these days, its boarded up.

  • Brian O’Neill

    It not clear what you mean. Are you saying the private home was better?

  • Brian O’Neill

    Do you have links to to foi requests about 352?

  • hugh mccloy

    If only the difference was night and day, your family member was in a home that was being run down to shut down by the government to push places int he private sector, you can cite problems with statutory care homes, and in every equal if not more measure I can cite problems with private care homes.

    Ask RQIA for their inspection reports and see who fairs better in the very long list of deaths and bad practice, private or statutory. A quick google search of Cherry Tree nursing home brings home the need for regulated services not a Cart Blanche to do what you want.

    Standards and regulations of care are far higher in statutory homes and they cannot bed the rules like private ones.

    I was personally involved with Westlands statutory residential homes in maintaining it and taking some of its residents to stormont, detailing the benefits of keeping statutory care homes versus the arguments used to try and shut them. Like several local hospitals statutory care homes were run down by Trusts, make it unstable in the public eye to give them an excuse to shut it.

    After all what good is a private home when tomorrow they all could end up like Southern Cross, and where will the elderly go then ?

  • Dan

    Yes, immeasurably better. Cleaner, more professional and most importantly, safer for my relative.

  • Dan

    When my family member was in the statutorily care home, there was no talk whatsoever of it being run down for closure. That came much later. They had a full house.

    As for RQIA….in my experience, their inspection reports are practically worthless.
    Everyone knows what happens on the few days prior to an announced inspection. The place is spruced up.

    I asked for an unannounced inspection at one stage, detailing my concerns.
    Next day, I received a call from the home manager and the district manager, ‘just by coincidence’, asking to meet me for a chat to see how things were going. Clearly they were tipped off.

  • MJ

    Ho Hum. Whilst I have a certain sympathy with the sentiment and agree that we as a population are astoundingly poor at properly accessing healthcare, I`m not sure making ED`s major trauma only, or doctors letter only would work. Certainly, an experienced GP at triage (making it real triage) directing people appropriately GPOOH/ED/minor injuries/wise up and go home…..would be useful, though unpopular.
    A co-located GPOOH or GP urgent care centre working 24/7 has been shown to work well in many centres.
    However, there is the wiff of the centralist who has spent too many hours in meetings with the great and the good here.
    There has never ever been a proper strategic plan for unscheduled care in NI.
    Thinking is Belfast based only , and the agenda has been hijacked by those whose primary aim is to close smaller hospitals leaving nothing in their place.
    Also, given the poor morale within GP (many younger GP`s are considering their future closely) and the almost daily media articles lambasting GP`s for being lazy and overpaid, I doubt many will be keen to have more pressure on them in hours, unless a lot of the pointless nonsense in QOF is removed.
    OOH GP is a cinderella service. Chronically underfunded and largely out of sight an out of mind (nearly 1 million patient contacts each year).
    We have an ambulance service that has to deal with a largely 40 year old road network , the monies having been squandered in the past to spend on security.
    Couple all of that with a governing party, the DUP, who seem to be out Torying the Tories, in their desire to strip the public sector and hand the cash to their mates in business.

    Nope Dr O`Neill……..the RVH cant cope with what it currently has to deal with.
    Remove more ED`s and you will save money, but dont for one moment think that such monies will be reinvested in new services to deal with the demand.
    It wont.
    The trolleys will be filled with increasing numbers of sick old folk with nowhere to go given our failing social care system, and no hospital beds to be admitted to, as we supposedly have too many in NI.
    All the oft quoted statistics ignore the fact that we are still, many years post ceasefire a high demand society.
    No service = cost saving, but it doesnt mean the demand will simply disappear.

  • Aidan

    You are wrong. Only nurses are allowed to give out drugs in nursing homes of any sort

  • Aidan

    anyone who says private nursing homes in NI are safer than trust residential homes is relying on gossip

  • Aidan

    The RQIA system of regulation works if enforced. RQIA have a legal duty to pass on your concerns to the nursing home and trust if you contact them. Was good practice that the home manager asked to meet you

  • emelle

    I agree. There is a reason why paramedics can’t deal with a patient and then carry out a follow up call the next day, and that is that they are overstretched as it is. NIAS staff are pushed far beyond what is reasonable at the best of times.

    On another note, I’m unimpressed with the declaration that there should be an ambulance accessed ED and a walk in 24hr Out of Hours centre close to each other. Surely that’s pretty much exactly the same as the current system, but just in a wasteful extra building?

  • emelle

    You shouldn’t feel guilty. If your foot had been broken, you may have done further damage walking on it and needed multiple complicated surgeries to repair which would put the health service under more strain. A broken bone is best dealt with at A&E. You did the right thing.

  • emelle

    That’s not something that can happen in the current system. At the moment, if a caller says they have a bad splinter and they need an ambulance, the operator cannot tell them to behave themselves, they have to send an ambulance. It’s ridiculous, but it’s true.

    On the flip side, although there are people who would call an ambulance for a sniffle, what about people who downplay their symptoms? They have a bit of a stomach ache, and thought they should phone an ambulance, just in case, but really their appendix is about to rupture? Surely only someone with a patient like that could make the call if they were ill or not. Is it sometimes too risky to tell someone they won’t be getting any help?

    Just something to think about.

  • Doreen Patton

    At last we have a suggestion about improving unscheduled care in Northern Ireland which is encouraging public interest for a change. I do not agree with all Dr O’Neill has suggested but there are many elements worth considering. There is insufficient space on the RVH site for a minors unit which would have all the support services sited 24/7. Also there would still be a small % of patients who attend the minors unit who may require a period of observation and require an inpatient bed. The closure of the Mater ED will never take place in the present NHS. Dr O’Neill did not offer any action the GPs could take to prevent unnecessary attendances at ED. I do agree that GPs would be the best medic to examine minor type conditions. Emergency Nurse Practitioners would be excellent support to such a a walk in Unit. Did Dr O’Neill miss the opportunity to make improvements during his time on the LCG? I do not think our ambulance personnel should be asked to fulfil such a role. Their training would have to be 3rd level and a large pay increase with further regulation. Since the closure of the ED at the Belfast City Hospital in November, 2011 the unscheduled care has deteriorated and sadly continues to deteriorate. Yet the number of Consultants has increased in line with the College of Emergency Medicine recommendations. I appreciate that the problem is a multi system problem but can such highly trained and experienced doctors not cut the waiting time for assessment of patients and highlight to Senior Management early if problems are developing. I hope Dr O’Neill continues with his proposals and Mr Wells finds some time in his busy life to speak with him.

  • Agree with most of what George says and his views mostly support the commissioning plan for Belfast LCG of which George was an excellent chair. This is the type of innovative thinking that will transform our health and social care service in Belfast, in this case in Urgent Care. That is why many of these things are in the LCG commissioning plan. Regarding the politicians and whether they have the “stomach” clearly they will need to provide informed leadership; currently among the politically elected this type of leadership is sadly lacking. To them I say “Listen to George”.

  • chrisjones2

    Go stand in casualty and look at them.

    About a quarter are just drunk and / or or have imagined injury – stubbed toe etc

    Its hgetting bthem out of the system that is key

  • chrisjones2

    That’s not something that can happen in the current system.

    Then change the system?

    But it wont happen – look at the outcry just this week over minor changes and our politicians are lying conniving wasters who will run for cover or jump on a bandwagon at every chance

  • hugh mccloy

    Still does not change the fact that A&E’s grind to a halt due to the inability of the system to admit acutely ill patients, who need direct admission into the correct type of ward for treatment.

    When the beds fill up the corridors fill up, when the corridors fill up the cubicles fill up and A&E services stop, ambulances are diverted elsewhere. Take into account Antrim, Royal, The Ulster all grind to a halt on a weekly basis on delivering care to acutely ill patients you can blame minor injury patients all you like but even if you open up a separate unit for minor injuries in Belfast that wont cure the problem.

  • Doreen Patton

    If these are also the views of the Belfast LCG why has unscheduled care been permitted to deteriorate to such a low level, staff on the edge of burn out etc etc or has the ethos of only tell the Health Minister and the public that all is going well in “our Trust”. Now is the time for improvement in the EDs and honesty and openness with the public

  • Doreen Patton

    Many of the minor injuries are seen by the Emergency Nurse Practitioners. The main cause of long waiting times is the lack of inpatient beds.