From Napoleon to drunks in the Royal. The messy state of Accident & Emergency Departments.

Korhomme is a retired medical consultant.

Pick up any newspaper these days, and you’re certain to find an article about the woes of A&E departments. Overrun with patients, the waiting time requirements have gone to pot. And here, in N Ireland, we are the leaders in the UK in terms of long waits, as described on Slugger here. The medics who work in A&Es aren’t happy, and neither would you be, for this story has an awful ring of truth to it. How did things get to this point, and more importantly, what can be done about it?

We could define an Accident and Emergency Department (A&E) as the front door of a hospital, where patients arrive, get triaged and treated. Patients might walk in off the streets, or be brought by ambulance. Triage comes from the French for sorting or sifting; and although we usually think of sorting into three categories, triage doesn’t actually imply this.

A&Es were originally called Casualties; a Casualty dealt with people who walked in without an appointment, people who were casuals; there were even areas in workhouses for such casuals. A casualty was initially a military term for someone wounded on the battle field, and who sought treatment.

The earliest recognisable A&Es were developed on the battlefield, and more than two centuries ago it was Baron Larrey, Napoleon’s chief surgeon, who brought together the idea of a central clearing and treatment area, with the injured brought there by horse drawn carriages called ambulances volantes. You could say that they were the forerunners of the American MASH—the Mobile Army Surgical Hospital. (And if you don’t know about Hotlips, Radar, Hawkeye and the rest of them, then look up the film and TV series, or better, read the book.)

The impetus to develop an organised service in the UK came with the blitz during WW2; this Emergency Medical Service was incorporated into the NHS when this was founded. The earliest Casualties were shabby places, and the medics who worked there were those who couldn’t achieve anything better than such a ’dead-end’ job. Simultaneously, patients who needed hospital treatment and investigation could be admitted to the wards directly by their GPs. Consultants recognised that the majority of GPs were sensible and reliable, but that some were chancers, who were incapable of any real diagnosis, and wanted to admit patients as an easy cop-out. The patients from such GPs were then asked to go to Casualty first, to be assessed, to see if they merited admission. Thus was modern A&E born.

Modern A&E departments serve several roles; they manage and treat the injured, and they triage, or sort, the ill, those who don’t need admission and those who do. And, of course, as part of a service that is ‘free at the point of delivery’ they are open to abuse; people these days ‘know their rights’, don’t they? Freebies are always open to abuse, even though TANSTAAFL (there ain’t no such thing as a free lunch).

How are things managed elsewhere? Look to the European continent; there’s no single model or comparison, but what many places have is a mixture of public and private provision. There, private practice isn’t seen as a ‘dirty word’, as many see it here. The two are competitors, and they have to tailor their services to the expectations of their customers. There, if you think you need to see a specialist, you can make an appointment directly, and expect to be seen within a few days. You don’t need to be referred by your GP; you don’t, in a technical/legalistic sense, need to be referred to a private specialist by your GP in the UK, but it is expected. So, you can be managed, diagnosed, treated quickly; and if you need inpatient treatment, you can be offered a choice of public or private providers. You certainly don’t need to go to an A&E department with your bad back (or whatever), demanding that something has to be done.

Perhaps you’ve overeaten at Christmas, and then had a severe bellyache. You see the GP, you get a scan a day or two later, and you’re told you have gallstones and need an operation. You agree to this, and it’s done within a week or two. But here, you wait and wait for the scan; you have several hospital admissions for pain relief, and when you eventually get the operation, your gallbladder is a hideously inflamed bloody mess. What should have been a simple (laparoscopic) procedure turns into a difficult, dangerous major performance, both for you and for the surgeon.

Perhaps you’re blotto, totally wasted and the cops have found you face down on the street. They’re not going to take you to the cells to sober up, for every now and then such a drunk will have had a serious head injury, and be found dead the next day. No, they are going to take you to a designated ‘place of safety’, an A&E department.

So, what can we do? Perhaps A&E departments should concentrate on what they’re really for, and what they are really good at; the management of major injuries and serious illnesses such as heart attacks. It’s all about changing the culture, and about education. Education of the patients, the realisation of what A&E departments can do, and what they aren’t really for. The present model clearly isn’t working, throwing money or resources at it is only a short term solution. Suggestions for change include:

Raising the price of alcohol, and changing the booze culture. It’s well recognised that binge drinking is dangerous, and that the price of alcohol has much to do with this. Tightening drink-driving limits is long overdue.

Regard private practice as a sensible service provision, rather than a way for unscrupulous consultants to coin in on long waiting lists.

Charge patients for attending A&E. This goes totally against the mantra, the sacred cow of the NHS being ‘free at the point of service’. Any fee needs to be high enough to deter the time-wasters, and low enough (and refundable, perhaps) not to put those off who really need the service.

Any other suggestions? Leave them in the comments below.

And if you’re totally depressed reading this—and you should be—there are occasional good new stories about A&E in the UK. Take this, for example; an American gynaecologist visiting London takes her son who’s got something in his eye to St Thomas’s. He’s treated promptly, there’s no bill; she blogs about it, and gets 800 comments, almost all of them supportive of the NHS.

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