We are walking up a steep path to see the Temple of the Golden Pavilion in Kyoto. Ahead on the path a young teenager walking with her family sways, rolls up her eyes and sinks to the ground. Her brother catches her by the back of her thick hoodie and tries to haul her upright whereupon she promptly loses consciousness again.
In 20℃ heat my immediate working diagnosis is of a simple faint for which the ideal management would be to let her lie down until she felt better. Not completely fluent in Japanese, I explain to the family by mime the homeostatic mechanisms involved in blood pressure control.
My charade is completely lost in translation. They thank me very politely for my concern and task brother to keep me distracted while someone smartphones an ambulance. A siren can be heard before the call has ended and my now recovered potential patient is whisked off to hospital.
It did start me thinking about urgent care and admission avoidance. We know there is a real problem with the flow of patients through the unscheduled care system in our hospitals. The visible, and measurable, manifestation of this is a failure to manage patients appropriately within four hours of their presentation to A&E.
Yet the good old four- hour target is not measuring the performance of the emergency department; it is a smoke alarm for the whole system gumming up. Failure to discharge, smoothly and efficiently, enough patients to make space for the expected emergency admissions results in a proportion of patients being boarded out on inappropriate wards or backed up in cubicles in A&E.
This in turn can lead to sub-optimal care, for example a cancer chemotherapy patient with neutropenic sepsis on a gynaecology ward and consultants who have to go off on safari ward rounds to try and find their patients. I think this is marginally better than being parked in a queue of ambulances waiting to get into the department in the first place.
While I worry about my own practice’s patients and the performance of my own hospitals, this is not a just local issue. Did you know the NHS as a whole has failed to meet its four hour target virtually every day for the last six months? You and I know, as jobbing GPs, that there is a multiplicity of factors at work here - from demographic changes driving complex co-morbidly with multiple long term conditions (and would you like increased expectations with that, sir?) to very real cuts in social care funding making it harder for patients to have domiciliary support that might either help them stay at home in the first place or get out of hospital faster.
But never mind us, what do the experts think? If you pick up the Daily Mail, Ian Birrell will tell you it’s our fault as GPs because we gave up 24/7 out of hours care for our patients. Nigel Edwards, blogging from The King’s Fund, wonders if we’ve cut our hospital bed numbers too much making them inflexible to variation in demand and - more importantly - run at very high levels of occupancy. He doesn’t think the problem is ours as GPs but points out there is good evidence that accessible primary care with continuity reduces unscheduled admissions.
So, not our fault, but we can help. I wonder if the Japanese have any lessons for us in primary care. Now, where’s that phrase book?
Dr Peter Weaving is the GP-clinical director for North Cumbria University Hospitals Trust and a GP partner in Carlisle. He has been writing the Diary series for Practical Commissioning magazine since 2007. You can read the archive of his posts here and send him a tweet via @PeterWeaving.
