Accident & Emergency - self fulfilling problems?

As Pat and I left our house on Sunday morning we saw an elderly local lady who had missed her footing and fallen heavily onto the pavement whilst walking to church. She was sitting there looking dazed while another lady was trying to help her to her feet. The fall had obviously shaken her up – a badly cut lip, various other grazes and a particularly nasty sliced cut to her hand were the wounds we could see, but I suspect she would have also been rather shaky for a few days as a result of her fall. We helped her to her feet, gathered up her belongings – including her walking stick - and discussed what to do next. Fortunately, another neighbour came along who knew the lady and said he would make sure that she got home safely. “I’ll have to put a plaster on that cut on my hand” the lady said. Clearly something had to be done with it and although it wasn’t bleeding too much it was in desperate need of cleaning and I suspect needed a couple of stitches. “You might need to see a doctor” we agreed but her reply was “Well it’s Sunday, and the doctors aren’t open today”. It never occurred to her that it might be necessary to go to the local A&E department at the hospital – for older people that is often the case, they don’t want to bother emergency services with what they see as a trivial complaint.

Within that short conversation was highlighted one of the problematic  issues confronting our medical services in this country – the ability of the health service to meet demand and listening to the old lady made me think.

Sister Jen Du Prat whose humour and down to earth
way of managing patients have made her a
real celebrity. She comes over as the sort of person
you would want on your side when in difficulties!

A week never goes by without there being some media coverage in the UK about the health services available. It will be a brave government who considers abolishing the National Health Service – I have absolutely no doubts that it would bring any government down. It is widely praised and rightly revered. Equally, however, it can never meet demand and expectation – understandably when we or our loved ones are sick we want the very best treatment available – and instantly. In fact, the NHS is an almost no win situation; on the one hand revered and to virtually the whole population an almost sacred institution whilst at the same time vilified by those same people  when something goes wrong. When a hospital, nurse or doctor fails to respond in what the tabloids see as the way it should then the dogs of war are set loose. When a particular form of treatment is deemed too expensive or of dubious worth the “faceless bureaucrats” of hospital management are blamed. When necessary economies are suggested then “bureaucratic fat cats” are blamed for their salaries taking all the funds that should be put into patient care!

No system, I believe, can ever meet modern expectations, there will always be something else wanted. In our modern world, an ageing population, the costs of high tech medicine and drugs, the economic balancing of books, the availability and expense of highly qualified staff and all the rest mean that whatever system is used there are always going to be disappointed people and huge pressures built up. In the UK our “free” health service provides unquestioning care to all and in doing that is facing higher and higher costs as more and more people expect more and more. Because of my heart condition I visit the doctor occasionally for check-ups, blood tests and the like -  my every need taken care of. Each time I sit in the waiting room or pick up my repeat prescription I am amazed that all this comes “for free” – I would have no problem with making a regular donation towards the costs. I also sit there and reflect, when I read the notices in the waiting room, on the wide range of services that, in this modern day and age, are expected by the public and offered by the service.......... and I reflect, too, on  the necessary bureaucracy that this must cause.In short these things don’t just happen by magic!  I often think of the old village doctor we had for many years – Dr MacLaren.  He was of the “old school”. He ran his surgery with an iron rod,  no-one got past the dragon like receptionist unless they really were ill. The good doctor  was held in the highest esteem within the locality but, I have absolutely no doubts that he would not have survived today with the demands being put upon those involved in the modern service. And it all costs money.

 Many people take out private health insurance to help them access facilities quicker or to ensure what they perceive as better provision. There may be many ethical questions about that but even private companies face the same problems of too much demand – they however can resolve this by putting up fees or limiting the service unless people pay up front. In the end, it all comes down to money. There are as many views about what should be done to ensure the future of the NHS as there are people – we all have an opinion. Many politicians see some form of privatisation and outsourcing as a solution – others see greater investment as the way forward. Different involved parties have different viewpoints – doctors, nurses, patients, relatives, economists, politicians and the rest all argue their position and I am sure that all have some validity. But in the end these are only temporary solutions, in my view the pressures to some degree will always be there in some form or another. We are not unique on the UK – in America for several years President Obama has been battling to get his health care legislation through. When we look at other nations the grass might appear greener, but all, to some degree or other, face the same sorts of problems – too many people want better and better care which costs more and more. It is as simple as that and there are no easy solutions.

The many options and perceived solutions to the problems of health provision were again put into focus last week when a former government health minister commented that in his view the current health service would begin to critically fail within the next five years – something, he suggested had to be done and done quickly. Of course he had his solutions – as I am sure that we all have – but his comments were quickly followed up by an entirely separate item of news that said that attendance at A&E departments throughout the country were at an all time high and that they were having increasing difficulty in coping with the demand. For a variety of reasons people increasingly see A&E as a quick fix solution to their health problems. The situation seems to have got worse in recent years because allegedly it is now often difficult to get to see the local doctor within a few hours or days – sometimes one might have to wait for a week or more for an appointment. So, in “desperation” people turn up at A&E for immediate help.

As we drove away from the old lady, who was by now hobbling to her house on the arm of our neighbour, something else occurred to me that was new in my thoughts. It never occurred to her that her injuries were serious enough to warrant going to A&E at the local hospital – and, as I noted above, this is typical of older people. And whilst the problems of funding and resourcing the health service in general and the increasing demands made upon A&E services in particular are clearly complex and costly, I just wondered whether, in fact, we are unknowingly making things very much worse because of one small trend in recent years which is making the whole thing a self fulfilling prophecy.

In the UK today you can turn on the TV any night of the week and be almost guaranteed to see at least one hospital based programme. I don’t mean fictional series, although they are there in abundance, but “fly on the wall” documentaries. They all follow the same general format – the exciting, dedicated and tiring lives of the doctors, nurses and ambulance staff; the fact that no matter what your problem you will never be turned away; the vast majority of patients are successfully treated; only it seems those that you might expect to die (the aged and the very seriously ill) die, and those only very infrequently. The vast remainder, often against all odds, are successfully treated.  It is unashamedly  ”feel good TV” reminding us of the success of our system, the innate goodness of those who are there to care for us at times of distress and the fact that no-one is ever ”let down” by this system. I have absolutely no doubts that an advertising executive wanting to sell a product could not better the media coverage given to these situations – the overwhelming message is “come and you will be helped, no questions asked”. It’s an advertising executives dream! And it works – people do come in vast numbers – the local A&E department is something that nearly everyone wants to buy into!!!!!!

Of all such programmes none reflects this better that the hugely successful Channel 4  programme  “24 hours in A&E” – of almost cult status, it has had numerous series with more planned. Centred on King’s College Hospital in London it has made household names and given almost celebrity status to the various staff who we see each week overcoming the odds, giving of themselves and quite unintentionally sending the hidden message “Come, we are open for business and all who come will find succour – you will find kindness, a welcoming smile and the best treatment that money can buy”. And one sees a whole range of people who come – the old, the very young, and everything in between. They come with injuries ranging from the truly horrific and life threatening to the banal and unimportant – and, whatever, they are all given the same generous treatment. Just as it should be.

Dr Firas Sa'adedin - one of the A&E consultants whose
skills, calmness and commitment ensure success.

Much of the success of the programme is based, I believe, in the fact that it is indeed true to life – anyone who has experienced a busy A&E department will recognise that and in so doing it again reinforces the feeling that this is real life. It is what “real people” do both as patients and carers: when we are seriously injured in a road accident and our life is slipping away then we will be rushed into a department such as this and people will work to the limits to try to save us. Equally, however, when we feel a little “off colour”, or when our child has had a tummy upset for a few hours and won’t stop crying or, when we have, in the early hours, got drunk in a night club and fallen from the table on which we were dancing (and sprained our ankle) then we, too, can also turn up and expect the same support, kindness and help – whether we actually really need it or not – for we have seen others do it on TV each week. People just like us! Week after week we see elderly people brought in apologising profusely for being there when in reality it is manifestly obvious they are in serious need of assistance but at the same time we see younger people dropping in for the most trivial of conditions. As we watch many of the patients sitting in the waiting room passing the time in a myriad of ways: chatting, texting on their mobile phones, playing games, telling jokes, complaining because the coffee machine isn’t working properly or because  there is only a certain kind of sandwich available it is difficult not to conclude that the service is perhaps at the very least misunderstood and all too often being misused. It all begs the questions when is an accident and accident and when is an emergency a true emergency.

Waiting for our treatment - but are we all real emergencies?

The staff, of course, are quite correct to act as they do – they are bound by their professions and indeed, probably by their own code of ethics and beliefs to act as they do – not to discriminate, certainly not when the person needs help. They must be Good Samaritans, ever willing and able to help without fear or favour.  It is the very basis upon which our health service is founded and no-one would want to change that. But I do wonder if in portraying on TV the essential “goodness” of the facility and its associated hidden message that all will be treated without question just for a bit of exciting and feel good TV is not rather counter-productive. It legitimises casual use and in doing so somehow diminishes it. Accident and Emergency Departments are, I believe, for the cases which are by their very nature extreme, or thought to be extreme. They are not, nor should they be warm cuddly places which can be viewed as a soft option. This does not mean they should change their approach and become brutal or harsh places – the staff should carry on just as they are doing, providing a caring and warm atmosphere to all who come needing help. But equally, as the old lady who fell down in my street knew they should be viewed as a place of last resort which, undeniably, for many in modern Britain they are not. Rather, they are the first port of call for many – especially the young -  and the daily TV programmes displaying their very many benefits and kindnesses  are not helpful in ensuring that only those in there are indeed real emergencies and their needs the result of real accidents, not simply, every day events. Just, maybe, fewer TV programmes of this type might make these places a little more remote from peoples’  minds and experience and in doing so reduce the unnecessary use of them and thus free up personnel and resources for other important uses.