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How GPs can help with urgent care: the application of logic and reason



David Cameron appeared on BBC breakfast the other week, in support of the Government’s £500m bailout for under-performing emergency departments (EDs).  The move has angered some ED consultants, who decry financial reward for failing standards.  So what’s all this got to do with the far-flung land of general practice?

Well.  Cameron went on to say (and, forgive me Dave, I paraphrase) that longer-term, hospitals have to work better with GPs, so that frail elderly patients stop bouncing in and out of hospital and clogging up corridors.  Indeed.

Forgive my paranoia, but hasn’t Dave just taken the scenic route to arrive at the rather spurious conclusion that EDs are failing because of GPs?  I know we earn far too much and we’re the fortuitous beneficiaries of an over-generous 2004 contract etc etc, but come on.  We’re all going insane chasing GPPAQs and briefly intervening; surely we can’t be blamed for the staggering increase in four-hour breaches (which, quite coincidentally, no longer carry a financial inducement)?  Let’s follow Dave’s thought process through, using an imaginary example, to see if it’s at all possible that he has made a few assumptions on his pootle through La La Land.

It’s 6.31pm on a Friday evening.  The local surgery has just closed for the evening, but the out-of-hours team are chomping at the bit.  At Bullingdon Residential Home, Ethel has had a fall.  She was only trying to stand from sitting, but the zimmer wobbled, and down she went.  There were no chest pain or dizziness, just a gentle mechanical fall, or a frame malfunction.  One of the support workers spots Ethel, helpless on the soup-stained carpet and gets her back on her feet, fully and painlessly weight bearing. In the absence of a senior (she’s popped out for a fag), 111 is bypassed and a paramedic is summoned.  No-one saw the zimmer wobbling, Ethel’s a bit shaken up, and suddenly she’s had a ‘collapse ?cause’. Off to A&E then. 

In the ED, a well-meaning but nervous FY2 greets Ethel, who’s clutching a dossett box of age-related medications.  So you’ve had a collapse Ethel?  Well, actually… she protests.  Her explanation (that it really was a wobble, not a collapse), falls flat and fades away as Dr Killing-Fields rampages through his doctor-centric consultation, sites his first cannula and requests a truckload of investigations.  These take an eon to return and eventually show nil conclusive.  Some bright spark spots that the collapsed Ethel takes warfarin for her AF and before she can say ‘I had a quick fall at tea, get me out of here,’ she is passed through a CT scanner.  There is no bleed.  As more trolleys back up to the ambulance bays, Ethel takes her spot on CDU, where she will unwittingly bed-block until the post-take ward round hours later.

Now Ethel doesn’t actually exist.  But her story is nowhere near as fantastical as Cameron’s coded accusation.  Even in pre-hospital utopia, these patients would still come into A&E, time and again.  What is seriously lacking is common sense in care homes, ambulance trusts and EDs.  I don’t blame care workers, paramedics or hospital doctors either, but a crazy cocktail of protocols, target obsessions and fear of litigation.

Imagine that Ethel’s fall happened hours earlier, at 12.31.  The local GP is called out, offers a few words of sympathy, quickly excludes fragility fracture and checks her obs.  Moments later he pats her on the shoulder and lets her get back to her lunch.

The services are already there.  GPs visit the frail and fallen in out-of-hours cars across the country.  I’ve done a shift recently and the service is not overstretched.  Don’t blame GPs Dave, just get punters (or their carers) to dial 111 (it can work very well) and apply some GP logic to ‘emergency care.’  After all, what’s actually best for Ethel in all this? 

Tom Gillham is a GP in Hertfordshire and Specialty Doctor in A&E. You can follow him @tjgillham.