View from the ground, by Dr Steve Brown

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I was chatting to my squash buddy John, after yet another defeat, and the subject turned to his elderly parents. They are just about coping in their own home with dementia and arthritis but recently his father was taken to his local A&E after a fall and concerns about possible sepsis. He spent 24 hours on a trolley before a bed was found for him. John said that his father was not bothered about this as he was being treated and the staff were great. John could see his father was not distressed and was conscious of the bigger picture of the current NHS situation. I was pleased he did not get on any number of hobby horses.

This got me thinking about the recent comments from politicians that GPs who are not offering enough appointments are causing more patients to go to A&E. However, even if this was true these are not the patients we see on our news bulletins who end up on trolleys; these patients are not true accidents or emergencies. We know that A&E departments situated near GP surgeries see more patients who are happy to wait 4 hours to be seen in A&E, rather than wait 2 days for a more appropriate (and better quality) appointment with their GP.

I don’t understand why A&E departments have a financial incentive to see patients whose problems would be better treated elsewhere. I think I am right in saying that even if a patient is triaged (and not treated) in A&E by a nurse, and told their problem is more appropriate for primary care, the trust still gets paid! Could there be a better incentive for A&E departments to signpost patients more appropriately?

Hospitals are under a huge amount of pressure and working closer with primary care can ease this problem.

Surely the time has come to be radical and unify the budget for A&E and out-of-hours services, and to build an incentive into the GP contract that rewards primary care for seeing those patients who inappropriately present to A&E. This would be financially prudent and mean that A&E departments can continue to do an excellent job of treating true accidents and emergencies. Primary and secondary care can then sing from the same hymn sheet.  

In primary care we often receive hospital letters saying things like ‘following the patient’s recent discharge we have organised an ultrasound scan/blood test/X-ray, please can the GP chase up the result,’ or ‘at the preoperative check we found that the patient had some renal impairment. Please refer to renal clinic’. These are more examples where primary and secondary care need to sing from the same hymn sheet. Secondary care sometimes do not realise that in primary care we may not have requested an ultrasound scan/blood test/X-ray so they are creating more work. They also don’t realise that the renal function in the preoperative patient is stable, as is their blood pressure and microalbumin. I send letters or emails now to request that secondary care do what I already do; if I have ordered the test, I follow it through. I don’t ask my partners to chase my results so secondary care should not ask primary care to do so. I always tell my GP registrars that they should not order a test unless they are going to act on it if it is abnormal. In a small way I am hoping to show secondary care how we think in primary care. It’s a slow process, but if more GPs did this on a regular basis then the message would get home. This could lead to more dialogue between primary and secondary care and better processes.

Over the last few weeks a number of patients have asked me during consultations about how I am and about how the surgery is coping. The media has made everybody aware of the current NHS pressures. After getting over the initial surprise that doctor–patient roles have been reversed, the concern that these patients are showing about my welfare feels very positive. What is my general answer? I could just say a quick ‘OK’ and move on with the consultation. However, in a roundabout way I find myself saying that I work with a great team of doctors, nurses, and admin staff. We are all working flat out but are trying to do our best.

Prior to 2004 at a time when I was doing evenings on call for the practice, I remember that I used to sometimes have an hour to go home at lunchtime. This used to help me to recharge my batteries ready for an evening shift. There is no time to nip home now; there are more prescriptions, path results, docman, phone calls, and emails to deal with! I have to finish this article now in case I forget to chase up that hospital scan!