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A faulty production line

Of course GPs in A&E won't improve access

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Ah, don’t you just love it when that happens? ‘Patients will be able to see a GP "in every A&E" by next winter, says NHS boss’ v ‘GP appointment waiting times to be published under new access drive’.

Glorious. Both statements from the same department, each deeply flawed and the one at odds with the other.

So. The GP in every A&E thing. I really don’t think you need me to highlight the issues. But just in case: off the top of my head, we have the potentially eye-watering defence subs, the funding of £100m not buying that much for that long, the possible inadvertent encouragement of patients to attend A&E (to see a GP, yippee!) and the fact that a more logical but equally ambitious aspiration would actually be to have a general practitioner in every general practice.

And the GP appointment publication thing? Ho hum. For one thing, appointment access is a very complex issue - and you can bet that whatever instrument they end up using to measure it will be about as blunt as the weapon they beat us over the head with when that data is misappropriated by the likes of the CQC.

And for another, while I’m not even slightly surprised that NHS England’s line on the new investment is, ‘’s reasonable to expect, on the back of that, improved access,’ I don’t even slightly agree. That funding was needed just to cope with the workload dump, and I am running out of time, energy, will and space to magic up appointments. It might get us off our knees, but we’ll still be barely mobile.

Which leaves us with that delicious contradiction. Just to savour the absurdity of it, I would absolutely love to work in my local A&E just to triage one of my own patients back to an appointment with me at my own surgery which he won’t get because I’m triaging patients like him at A&E who are there because they can’t get an appointment with me.

Hilarious, but infuriating, too. By the time you read this blog, the typo made by Pulse about this ‘GP streaming’ will have been corrected. Shame. Because I think they had it right first time. GPs will be steaming, and so will their patients.

Dr Tony Copperfield is a GP in Essex. You can follow him on Twitter @DocCopperfield

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Readers' comments (16)

  • Hopefully with that sort of thinking the Tories will eventually all disappear up their own bums.

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  • Healthy Cynic

    This comment has been removed by the moderator

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  • Ivan Benett

    Actually, the idea is to reduce admissions. It won't do that either. By the time the sick-enough-to-admit turn up it's too late. If they turn up with a Primary Care problem it will get charged as an A&E attendance anyway.
    Extended hours has reduced Primary Care type attendances at A&E, but at a cost. I have argued that the cost is reasonable for opening a service 8-8 during the week and 3 hours Saturday & Sunday. I know others don't agree.

    But the main problem is the high acuity attendees at A&E who need admitting. When they attend it's too late to turn them away. Many of them have COPD, heart failure, diabetes, or are elderly frail people with dementia, or any combination of the above.
    For each of these there are evidence based interventions that prevent acute deterioration. They need interventions early in that deterioration e.g. Rescue packs for COPD, diuretics for heart failure, antibiotics s for UTI in dementia. All of these are Primary Care interventions. So we need GPs to be proactive and anticipatory with these interventions early.
    For that you need good same day access to the practice. Not an appointment in 3 weeks once you've got past the receptionists.

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  • "Rescue packs for COPD, diuretics for heart failure, antibiotics s for UTI in dementia" -
    BUT - antibiotic stewardship instructs us not to use antibiotics and we have to stop drugs that have the potential for acute kidney injury during acute illness - resulting in unintended consequences of more seriously ill patients presenting to A&E, as GPs are frozen into inaction by impracticable policies and guidelines.

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  • As a profession we have to move away from the us and them syndrome , GP v Consultant and integrate to streamline our approach to patient care especially in acute illness. Why do we need a GP in every A/E department? at a time when the severe shortage of Gp's are forcing GP surgeries to close.
    ~ Why are patients who do not require A/E attend and secondly why are they not simply turned away at the gate to the appropriate service? Gatekeeper Role
    My view is as follows:
    Access to GP services for patients with acute illness at the moment is appalling with patients waiting on average 3-4 days and longer and many patients so frustrated they don't even try to get an appointment. A constant backlog of missed opportunity to hear, see or treat. That is the root of the problem and will not be solved by putting even more GP's in A/E departments. This will further divert GP's to A/E and exacerbate the shortage of the GP workforce in the community, the official gatekeepers of patient care and appropriate hospital referrals for acute illness. Serious acute illness, excluding 999 cases which are clearly defined develops and early diagnosis / management is the key to preventing complications and significant poor outcomes. The sticky plaster approach to our failing NHS
    will never work and be honest Is not been addressed by the guardians of our services.

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  • Why do patients end up in A+E

    1) getting older
    2) 111 protocols
    3) public expectation
    4) fear of litigation
    5) lack of social care

    Very little can be done about this next year or the year after. Admissions will rise GP or no GP.

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  • Just think about the number of "borderline" cases you see every day. In the surgery you can say if it gets worse call back or go to A&E. They will usually go home rather than make the trek to A&E now. If you are in A&E many will decide to stay in hospital (be admitted) rather than go home possibly to go back again later. Human nature - path of least resistance.

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  • Othimalai Velusami

    Everyone is talking and commenting of NHS mostly in negative sense.All of them are about the service providers.Can any one say how the service user can help or use NHS the way it must be used? i.e. self sensible healthy living not to live in the world of "state will take care of me"

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  • Othimalai Velusami.

    You have hit the nail squarely on the head.

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  • Well said Copperfield!Rising older population=more admissions. It is the funding cuts that have caused this, not GPs or any flawed "innovations".

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  • Service users have a huge role in NHS collapse.

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  • to be honest its not about them vs us--neither hospital vs GP or Patient Vs Drs. Its about 1st world country giving 3rd world country service to patients.
    Why do we need GP's in AED. And why if someone has come to AED be refused Rx and sent back to GP when GP surgery is absolutely full and no appointments available.
    Why is the patient supposed to know if his left arm pain is muscular or heart attack or is a collapse due to ACS or NSTEMI or just a simple collapse. They are not medically educated and some are barely educated.
    We should be able to provide for them wherever they present, AED or OOH or GP and guide them appropriately after careful history taking and examination and necessary examination.
    Number of acute illness sent back from AED to gp as it appeared on simple triaging as nothing to worry about only turning out to be much more complex later in the day. Even 1 patient harmed is too many harmed.
    Provide more AED's rather than closing them. Get more staff drs and nurse both in 2ndry care and Community care. It will cost but that is bound to happen as we are saving more and more people and making their medical more and more complex due to this survival and ageing population and newer knowledge of SIRS/ACS/NSTEMI etc etc which were not even heard of in the past etc.
    No excuse for not funding both 2ndry and primary care and then blaming everyone from patients to Health care providers but the politicians who control the finance

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  • What A&E needs is more SHO and Registrars, not more GP's who worked in primary care being asked to replace SHOs and registrars( if they lucky to be found anywhere or forced to become like part of GP training). Trying to move GPs to A&E( I would personally never volunteer) exposed to high risk patients without joys of all blood tests etc which is indeed a risky professional proposition. If investigations are done it also encourages the patient behaviour to go to A&E expectation of all investigations in one day instead of seeing own GP. This creates false demand. So good luck to the GP's who work in A&E. Was in my own surgery where a board stated a excellent GP for leaving for Australia, not A&E.

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  • Completely agree with Sandy. we need more Drs and Nurses in AED and more beds in Hospital and more Drs and Nurses in Hospital as exemplified during winter trolley waiting time. Why make GP's take risks without investigations backing them to make some difficult acute decisions.
    and we need more GP's and Practice Nurses to decrease the pressure and improve patient access.
    This is all going to cost money no matter how you put it.
    Ultimately it is job of politicians to provide adequate finance to employ adequate workforce to be able to safely do their work and for patient safety which leads to safe Clinicians

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  • Until there is a financial cost to attending A&E and GP, there will always be too great demand and too little resource.

    Increasing resources is of course good - but will also mean more people will get things seen since the time lost is lowered.

    A system closer to that of Ireland where there are charges for accessing healthcare - albeit heavily subsidised - would help convince the family of 5 with the sniffles that there is no need to book an hour with the GP for the self-limiting illness.

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  • Another side to this is that GP's are voting with their patients feet, so to speak.
    Up and down the country more and more GP's are being more resilient and saying enough is enough, and directing more patients to walk in centres or casualty, as they're overwhelmed by their workloads of over 10-11 hour days.

    We used to take pride in providing comprehensive continuity of care. But it's no longer possible.
    Certainly NHSE's drive is towards fragmentation of care, and getting numbers of patients seen by any clinicians possible.

    It's about quantity of care and no longer quality of care.

    We also need to stand strong and repeatedly tell patients "we're not an emergency service, go to casualty", once our appointments are taken.

    It remains to be seen how strongly the BMA will push the idea of a maximum daily workload for a full time GP, and whether hair shirted and cardie wearing GP's will accept this.

    I hope they will, even if it means it is detrimental to patient care. It'll be positive for the GP's health. It might mean some of these GP's will have longer careers, and NHSE can't complain they weren't warned, as A&E is overrun with even more of what were Primary care patients.

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From: Copperfield

Dr Tony Copperfield is a jobbing GP in Essex with more than a few chips on his shoulder