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Leader: The A&E crisis

Leader: The A&E crisis
23 February 2015

The chair of The Commissioning Review editorial board unpicks the cascade of events that led to the A&E crisis

The chair of The Commissioning Review editorial board unpicks the cascade of events that led to the A&E crisis

As we enter another year it is always good to reflect on the last and plan for the future. Sadly that concept is alien to the NHS system and the politicians who decide how much money the service gets given on an annual basis.  Every year there are four seasons. This has happened since records began. Yet every autumn there is a mad scramble to develop a winter plan and every organisation is charged with sending a representative to formulate that plan. When I was involved I used to exalt, “What! Winter again? I thought we had that last year?” I then would put forward a suggestion of doing a fact finding mission to the Bahama’s because for some reason they never suffer winter pressures. The irony was lost on several people who wondered if such a trip would be good use of taxpayers money!

The plans would be formulated and circulated, then the usual, “Who is going to pay for this?” question arises. The commissioners usually end up spot-purchasing extra capacity and when the inevitable A&E crisis hits, the golden baton of blame goes around.

The political solution is to throw money at the problem – £700 million this year! The issue is the money has to have business cases and bids approved before being released and this all takes until spring, when the crisis is over. Only those areas that are not coping and missing targets get the money. The efficient target- hitting areas are rewarded with nothing. The system competes for that funding on an annual basis so any scheme that is working has no recurrent funding to maintain it into the inevitable next winter crisis.

Those parts of the system on block contracts have no incentives – other than goodwill – to increase capacity. The payment-by-activity and punitive targets drive poor decision making, leading to more admissions and increasing stress in the system. Hospitals fill up and cannot get elective cases in and so cancel lists and break the political promises of no-one waiting more than four hours in A&E or 18 weeks for treatment.

The problem is we have forgotten to tell the patients about this winter thing. They have the audacity to get ill and interrupt the smooth running of the health service. As professional groups we give so many mixed messages to the public of how and when to access healthcare. The NHS England campaign, The earlier, the better that was launched last January (2014) said if you are old or young, catch it early and prevent hospital admissions.

“Can’t get a GP appointment? No problem, see the pharmacist.” “But you don’t pay for your prescription? Insist on a GP appointment for a script.” “A&E is always open and they test for everything and are ‘proper doctors’. The ambulance always goes there so it must be the right place.”

The issue is that the A&E doctors they see are usually the most inexperienced, doing part of a rota, and the senior doctors are specialised to do the heroic lifesaving, so coughs, rashes and earache leave them cold. Twenty years ago as an A&E registrar I sat behind the counter and prevented people registering if their problem was not an accident or emergency. I was quickly hauled into the hospital manager’s office (when did they become Chief Executives?) to be told to let them register and then send them away because I was affecting the hospital figures and therefore the funding.

Every year we prove Einstein’s theory of insanity by using the same tools to do the same job and then wonder why it doesn’t change. Until we commission for the patient not for the organisation, we will continue perpetuating the crisis.

The reality in a free-at-the-point-of-care service is that demand will always exceed supply. The political interfering to solve one problem, such as A&E waits, leads to a knock-on effect elsewhere in the system. The payment system and clinical governance risks need resolving so that patients are treated by the most appropriate person for the condition they have – or perceive they have. People logically choose the path of least resistance so we need to simplify the system. Two places to access face-to-face, A&E or the GP, 999 for emergencies and 111 one for everything else. Thank goodness for 111: now there is a new runner to hold the golden baton of blame! 

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