Accident and Emergency (A&E) are back in the headlines again. Mortality rates are higher at weekends costing some 4,400 lives a year according to a dossier being prepared by NHS England. It is being suggested that this is because of:-

  1. Shortage of senior doctors at weekends
  2. Rising numbers of readmissions being caused by patients being discharged to early because of cuts in bed numbers
  3. Public confusion and lack of confidence in the new out of hours 111 non-emergency telephone line

The NHS regulator has said that emergency care is “out of control”.

 

Let us think this through.

  1. Senior doctors work during the week like most of the rest of us. They do this to fit in with their families and this means we don’t have to pay them for unsociable hours. During the week, they undertake planned surgery and other work and that makes sense. If we ask them to work weekends, there will be a knock-on effect on the rest of the NHS, both in terms of costs and a move from planned to unplanned work. So let us not jump to conclusions here.
  2. Weekend A&E departments are not like week day A&E departments, any A&E doctor will tell you that. We have crowds of people suffering from alcohol induced accidents and injuries just for starters. This puts pressure on the system and I have to assume that the NHS have made allowances for these differences in calculating their figures. Again, are we jumping to conclusions?
  3. There has been a rise in A&E admissions, which is partly why some argue that A&E units have become over run. But again, caution! The A&E statistics have been changed to include those walking into drop in centres, so the official statistics don’t give the true picture without more detailed analysis.

What should we do?

  1. We do need to focus on A&E to understand the demand on services. This is predictable in the main as there will be (within limits) a regular and predictable demand on A&E unless we change the system. But what about major motorway accidents or other rare events you say? Yes, but these are rare and we need (and most hospitals have) a trigger which calls in additional resources in the few instances where this happens. The demand on A&E should shape the resourcing levels, if the funds are available.
  2. But we can’t look at A&E in isolation. We need to look at the systems around A&E. How much pressure is being put on A&E because other systems aren’t working? The NHS 111 line is key to this. So is access to GPS during the week. Are we funding these sufficiently, they are cheaper options to admitted patients to A&E. Again we need to balance demand and resources.
  3. How do we allocate senior doctors’ time. May be we need more available or at least on call at the weekend. But we will need to model the effect of this. What will the impact be on mortalities – both in A&E and the general population who don’t get their scheduled treatments? What will be the effect on recruitment given that there are half the training posts unfilled for this area over the last two years? You can’t just force doctors to work weekends, you can bribe them, but we are back to resources again.

So I suspect that A&E figures are a symptom of what is happening in the NHS. Funding across the whole system including social care is at the real heart of the issue. We don’t have unlimited resources and we have to accept that. But given restricted resources we need to make the very best use of what we have.

We currently have big headlines but little analysis or informed debate.

Mike Bourne

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