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.
The 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:
- Emergency same day appointments and house calls delivered by GPs
- Primary Care Out of Hours services
- Emergency Departments/Minor Injury units
- Community pharmacy
- 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:
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?