The winter holiday has produced the usual slew of concerns about Accident and Emergency provision. There is too much demand; the numbers of people using the service are up again; waiting times are excessive; there are staff shortages. Something like this happens every year.
There are two different kinds of problem here. One is a reflection on the continuing problems of general practice. What’s supposed to happen in principle is that everyone is supposed to have a general practitioner, and when they’re ill they will receive treatment from the GP first. This doesn’t work as it should, because there are still large numbers of people (especially in London) who are not registered with a general practice, and because the reform of out of hours services has generated problems in its own right. The problems are not confined to A&E. A study of the demands made by unregistered patients in the Journal of Public Health found that the highest number of outpatient attendances were in genitourinary medicine, trauma and orthopaedics, while the highest costs were associated with trauma and orthopaedics, forensic psychiatry, mental health and general medicine. There is also some evidence that most of the people who go to A&E ‘inappropriately’ are people who are already registered with their GP, and who use their GP repeatedly – they have twice as many appointments, and make ten times as many out-of-hours phone calls as others. (It’s difficult to be certain what is an ‘appropriate’ call, because so much depends on what other services are available: an article in Family Practice reports estimates of inappropriateness that varied from 6% to 80%.)
There is however a further problem, and that problem lies in A&E itself. The system was mainly developed in the 1960s as part of the general philosophy that a medical service had to have comprehensive provision for when the need arose: a centralist dream, the same kind of rationale which insisted that all children had to be born in hospital. So we built a system that could cover general practice, casualty, unscheduled care and major trauma from a single service. It’s exhausting to operate. Because it has simultaneously to be decentralised and always open, and to offer highly specialised trauma care, we can’t train or maintain enough staff to provide the cover; and it guarantees that whenever there’s an outbreak of winter vomiting, sufferers will come together in one place to spread the disease. There are alternatives: to have a domiciliary response to minor injuries, community based hospitals for general practice and urgent attention, casualty units for accidents and major trauma centres with specialised resources for the most serious cases. Following the Kerr report, which argued for a schematic approach to unscheduled care, that’s the pattern developing over much of Scotland.
Neither of these problems would be addressed by the silly proposal to charge people for going to A&E services. The main people to be put off would be those who are already poorest and least well served.