It is essential that we divert as many people as possible from A&E
Imagine you run a boutique — a mix of fashionable clothes for fashionable people, and everyday clothes for more limited purses. Your shop window is dressed with mannequins and current offers, and there’s a large sign over the shop reading “Boutique”.
One day, a customer comes in and asks for an ice-cream. You’re surprised, but you politely direct them to the ice-cream parlour a little down the road. Later that day, another customer comes asking for ice-cream, then another, and another. After a week of this, you remain somewhat mystified, but you arrange for a smart freezer to be placed in the corner of your boutique — for the ice-cream parlour to supply you with a range of fashionable ice-cream for fashionable people, and everyday ice-cream for more limited purses. And you change your shop-sign to read “Boutique clothing — and ice-cream”.
What you don’t do is:
· Tell your customers off for their foolishness in coming to the wrong shop
· Start trying to make ice-cream yourself
· Take out full-page advertisements in the local paper telling people that boutiques are for clothes-purchasers only, and that ice-cream purchasers should please stay away
· Simply put up with the stream of ice-cream requests, and actually do nothing about it at all
Debates about the role of A&E too often sound reminiscent of this (admittedly fanciful) situation. If only we could get patients to go elsewhere! If only primary care were able to pick up more of the demand! If only people didn’t come to A&E with trivial problems…. How can we educate people to use our services better, in the way we designed them to be used? Why won’t patients just use the NHS properly?
But what if that isn’t really possible? Rising demand for A&E, over many years, certainly suggests that it’s a long way from easy to divert enough people from A&E to bring capacity and demand into balance.
And what if it isn’t really desirable anyway? A situation where a large number of patients are willing to travel to a single central location, and then to wait (if needs be) for several hours to be seen should surely not of itself be seen as a problem — arguably it’s a community voluntarily organising itself in a way which permits a healthcare provider to offer an extremely efficient response. Certainly a more efficient response than trying to offer a large series of finely graded services in a wide variety of locations. The problem only arises when the services provided via A&E are insufficiently flexible in that one location — or simply too small — to match the numbers and needs coming through the door.
So if people won’t go to primary care, bring primary care to A&E. If people won’t treat themselves with simple over-the-counter treatments, make them available (for sale) in a pharmacy/shop attached to A&E. If people with mental health needs but no physical problems repeatedly present to A&E, enable the psychiatric liaison service to lead meaningful care planning for those people. If many patients continue to regard A&E as the best front door to the NHS, work on what happens behind that front door, rather than trying to send people elsewhere.
There are always two sides to a capacity and demand problem. Maybe the pressures on A&E shouldn’t really be interpreted as a demand problem at all — if a community is wanting to engage with its health services in this way, perhaps we should accept this, rather than attempting processes of either diversion or re-education. Maybe the — potentially far simpler — approach of focussing capacity in the places patients actually want to come is a better way of balancing capacity and demand.
Written by Niche Health And Social Care Consulting
