‘A tale of two patients – and one failing NHS’

From misplaced admissions to wasted ambulance hours, Dr Katie Musgrave argues that the NHS’s growing chaos is what happens when general practice is left to wither

As GPs we really do get a fascinating insight into the workings (and malfunctions) of the NHS. I sometimes think that the leadership of NHS England should be forced to listen to the anecdotes we hear in our surgeries. This time round, I wanted to write about a couple of patients I have seen in the past few weeks, who had difficult experiences with emergency care for very different reasons.

One patient had fallen down a flight of stairs at home in the middle of the night, and suffered extensive traumatic injuries. Several C and T-spine vertebrae were fractured, as were several ribs. They had also sustained a small sub-arachnoid haemorrhage.

Astonishingly, despite the extent of the patient’s injuries, they were not admitted to hospital. They reported having spent the night and most of the following day in an ambulance outside the A&E department, entering the hospital briefly for different scans, and finally for a five minute conversation with a neurosurgeon. They were discharged without analgesia, and booked in for a follow up outpatient appointment a week later.

Seeing this patient walk gingerly into my surgery, with extensive facial bruising, neck braced, and clearly in significant pain, I was flabbergasted that they hadn’t been admitted for at least a few days. How severely injured do you need to be? I found myself wondering.

The second patient was a 70-something year old booked in with me first thing on a Monday morning. The appointment notes reported a recurrence of the symptoms that had taken them to A&E over the weekend. It transpired that on the Saturday this patient had looked grey, felt dizzy and vomited. The family had called 111, and an ambulance was despatched. The subsequent tests – ECG, troponin and other bloods, had all been normal, but the patient had stayed in the ambulance overnight for monitoring, as their pulse was a little slow. Eventually they were allowed to leave with a reduction in beta-blocker dose.

When I saw the patient in my surgery, the history and examination were textbook for benign paroxysmal positional vertigo. I spent the appointment reassuring them that despite the emergency ambulance (and night spent waiting outside A&E), that a recurrence of the vertigo symptoms were not unduly concerning, and they didn’t need to be rushed back in. Surely, I thought, if the patient had seen an out of hours GP, the diagnosis would have been made without any need for A&E’s input. After all, there was no chest pain, cardiac history, or shortness of breath; just vertigo and an episode of vomiting. It seemed like a terrific waste of resources.

I have since found myself comparing the two anecdotes, and wondering about the relationship between them. One was a patient who – in my opinion – needed an urgent admission, and required hospital level care; but did not receive this, potentially putting them at risk of missed diagnoses or avoidable complications. The second was a patient who hadn’t needed to go to hospital, and the time spent in the ambulance was a waste of precious resources, which could have been used more effectively elsewhere. 

The lesson I have taken from these patients – and which I would dearly like NHS England to understand – is that dysfunction within the NHS comes about, in large part, from a misdistribution of resources. It is widely acknowledged that general practice and community care needs more investment. The above scenarios spell out the importance of well-staffed GP surgeries, and out of hours GP services. Day in and day out, GPs see complex, high risk situations, carefully identifying the few patients that need hospital admission, while managing the vast majority with community based care.

If you overwhelm general practice, making it impossible for GPs to perform their duties efficiently and effectively, the end result will be a never ending queue of ambulances outside an A&E department. One in 20 might contain someone with time-critical, life-changing health needs; but the hospital will always struggle to sort the wheat from the chaff. What they need is an experienced generalist upstream to manage demand. This is the only way to prevent the system from descending into chaos.

Dr Katie Musgrave is a GP in Devon