How to solve the A&E crisis? Self-care may hold the key...
Patients should be encouraged to use their judgement when it comes to seeking help for health problems, argues Dr Simon Fradd
Call me old and grumpy, but I am becoming more and more irritated by GPs being blamed for the ever-increasing demand by the public to be seen in A&E departments. What really makes my blood boil is when politicians and hospital doctors alike say these people (I deliberately will not call them patients) should be at their GP surgery. No, they shouldn’t. They should be looking after their own minor ailments.
I used to run a triage service at the front end of an A&E department. We regularly steered 60% of people away to self-care. Over Christmas and the New Year this increased to just short of 80%. Interestingly, the hospital concerned did not like this and took the service in-house - and that figure halved.
Demand on A&E and inpatient hospital services is not just a problem of increasing numbers it is also one of increasing medical acuity of an ageing population. General practice is being asked to take on more and more: integrated care pathways, secondary to primary care shift, looking after the terminally ill at home, as well as coping with increasingly complex medical problems. All these are to be welcomed as putting the patient at the heart of the NHS but at the same time, funding for general practice is being slashed. Where is the capacity to deliver to come from?
I am the first to admit that waste in the NHS is endemic. We over-investigate, fail to communicate well and regularly duplicate work. We treat patients inappropriately largely because we fail to involve them in the decision-making process. However, the main driver is individual lack of comprehension and anxiety, it certainly is not a desire to destroy the NHS
For years I have been banging the drum about public education and support. The Doctor Patient Partnership campaign played an important role for a decade through health promotion initiatives such as working with the Samaritans to identify people at risk, and explaining the problems of delivering NHS services. In 2004 the Government also sponsored Making Sense of Health, a schools’ health education project for all children from seven- to 16-year-olds. The Open University gave an entirely positive evaluation but the Government then declined to fund the rollout in the national curriculum.
Much has been done to support self-care. The MHRA is at the cutting edge of switching prescription medicines to over-the-counter so that they are available without prescription. When he was a minister for health, Paul Burstow set up the national Self Care Forum (still going strong). The RCGP introduced an online self-care course for healthcare professionals, again still running.
But over 57 million GP consultations a year continue to be used for minor ailments, making up some 20% of our workload.
This problem is worldwide and the solution is also perceived to be international. Last year China launched a Self Care Day on 24 July to be run every year, with the intention of making it an international event.
I hope that together we can find ways to bring about a groundswell of change in both public behavior and support by healthcare professionals for self-care. I believe there are four blocks to change which we need to solve:
- The first is public anxiety, or at its worst, fear. This is particularly around childhood illnesses. The solution is education, not just information. The prime target needs to be children in schools - and it needs Government funding.
- The second is patients’ ignorance of basic care. We cannot simply say to the public: ‘Go away’. We have to say where and what to do. For example: ‘You have a headache, go home and take paracetamol or ibuprofen.’
- The third is the inconsistency of health messages, which leaves the public confused and worried. We can all line up behind the 14 commonest self-limiting conditions presenting in general practice and tell the public to self-care in the first instance.
- The fourth is a feeling of being short-changed - but self-care is better care. It empowers the individual not only to look after themselves, but also to recognize red flags for when issues need to be escalated. It improves access to services. It enables the public to recognize poor quality care and demand it is improved.
Recently a survey from www.nhsmanagers.net showed nearly 100% of respondents agreeing that GPs should do more on self care using the QOF points on reduction of A&E attendances, but as a GP I know it also needs Government commitment. So, Mr Hunt: I will accept my responsibilities, but I am fed up with you washing your hands of yours.