Question Time Extra Extra Time

On Question Time from Torquay (BBC 1, February 9th), the panel was asked, “If one of your elderly relatives was admitted to “A & E” tonight, how confident would you be that that person would get a bed, or stay on a stretcher?”  This pointed question soon promoted a general discussion about the parlous state of the NHS.  Owen Smith put that down to underfunding; Billy Bragg identified reducing hospital bed numbers as a cost-cutting exercise; Ann Widdecombe thought increased funding was not the answer; we needed a “grown-up” debate, on how to fund Health – but she didn’t actually say how she thought Health should be funded.  Claire Perry agreed with Ann Widdecombe.  She thought the NHS shouldn’t be a “political football”; she also thought 30% of the patients attending emergency departments didn’t need to be there.  Peter Whittle thought Health and Social Care needed to be integrated, and that moneys could be redirected from the overseas aid budget in order to help with funding.  Even the chair had a view.  David Dimbleby considered the typical left-right political posturing as represented by the panel to be sterile.  The prevailing opinion from the floor was that the NHS was poorly managed by an inflated bureaucracy.

The whole debate seemed to generate more heat than light.  There was a general expression of apprehension and anxiety that one’s putative elderly relative might end up languishing for many hours on a stretcher.  But what I found remarkable about the discussion was that, while there was general consensus that the NHS is in trouble, not one single concrete initiative was proposed.  Not one.  If for example, you want to spend more money on the NHS, you might say precisely how much more you wish to spend, and what precisely you want to spend it on.  If on the other hand, you think the NHS needs reform, you might make a suggestion as to what a reformed NHS would look like.  If you think the NHS has to offer the public a different product, you might wish to describe what this new product would be.  You might even wish to scrap the NHS.  There was none of this.  In other words, it has to be said, the standard of debate was very poor.

But it’s hard to see how it could be otherwise.  You really can’t begin to organise a health service unless you know a bit of medicine.  The construction of an NHS is an act of integration.  You might ask, how do you manage a patient who presents with a headache?  You can’t begin to answer that unless you know about the epidemiology and pathophysiology of headache, what headaches are benign, what headaches are sinister, can we intervene, should we intervene, and so on.  Then you might ask, how do you manage a patient with chest pain, and again you have to go through all the different kinds of chest pain.  Then you do exactly the same for abdominal pain, back pain, nausea and vomiting, cough, shortness of breath, altered consciousness, auditory hallucinations, suicidal intent…  It’s a huge undertaking.  You can’t begin to make any sense of it unless you immerse yourself in it for a lifetime.  This is why there is some sense in the suggestion that people should indeed not make the NHS a political football.  It would surely be better if the politicians approached the doctors and nurses and said, “What do you need?”

The trouble is, they wouldn’t get a straight answer.  It has to be said, the medical profession lacks cohesion and leadership.  The specialties still operate within their own isolated silos.  Medicine is profoundly tribal.  Interestingly enough, this is most evident at the front door of the hospital.  Most members of the public are unaware of the fact that, for patients who are acutely unwell, there are two modes of admission to hospital – either via “Accident & Emergency” (“A & E”) or via the “Acute Assessment Unit” (“AAU”).  If you visit your GP with your headache and she decides you need urgent investigation, she will send you to the AAU.  If you front up to hospital directly with your headache, you will be seen in “A & E”.  Same patient, same presenting complaint, same diagnosis – different pathway.  Depending on which path you take, you will be assessed by one of two doctors with very different training backgrounds and career pathways.  If you arrive at AAU you will have with you an accompanying letter of referral from your GP.  It’s a kind of invitation or admission ticket.  If you front up to “A & E”, you are a gate-crasher and let’s face it you might be one of the 30% that Claire Perry (and indeed Westminster Health Secretary Jeremy Hunt) say shouldn’t be there.  You need to be disposed of ASAP (certainly within four hours).  AAU will happily keep you for 48 hours, if necessary.  The front door of the hospital operates a system of apartheid.  The public don’t know about this.

Why should this be so?  It’s historical.  There used to be an entity called “General Medicine” or “Internal Medicine”.  With the rise of specialties and super-specialties the general physician became a dying breed.  AAUs started springing up about 30 years ago and internal physicians morphed into “acute” physicians and a subspecialty of “Acute Medicine” was born.  So acute physicians have a college and a career pathway and an annual conference, and emergency physicians have a college and a career pathway and an annual conference, and a lot of the time they are discussing and researching and treating exactly the same conditions, in their isolated silos.  It’s completely potty.

I’ve accused the Question Time panellists of offering no solutions so the least I can do is make one concrete suggestion.  I’m not suggesting for a moment this would be any more than a start, but at least it’s a start at the front door where that elderly patient is languishing.  I think Acute Medicine and “A & E” should amalgamate to form a single specialty which runs a single department.  Call it the Department of Emergency Medicine.

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