Still “waiting” to “be seen”

There is a recurring story that appears in The Herald with dismal regularity.  It relates to “A & E waiting times” in Scottish hospitals.  If the numbers quoted vary each time this story comes up, the variations are not statistically significant; so the story is always essentially the same.  X% of patients were “not seen” within four hours.  The opposition parties at Holyrood make a tremendous fuss, saying that the statistics demonstrate conclusively that the government is destroying the NHS, and that therefore the Health Minister must “consider his position”.  They don’t really expect the Health Minister to resign, and they are not as aghast at the statistics as they purport to be; their outrage is faux-outrage.  They are merely doing what opposition political parties do – chipping away at the government in an attempt to topple it.  Whether or not they have a better idea as to how the NHS should be run is open to question, and indeed hardly seems to matter.

This issue came up again in The Herald last week and as usual I spluttered into my cornflakes before writing the following letter, which they published the following day:  


 I write to beg The Herald to stop referring to the time patients spend in the emergency department (ED) as a “waiting” time, or a time “to be seen” (“A & E targets record third worst week on record”, Herald, July 28).  These expressions are inaccurate, sloppy, and misleading.  The patient’s initial point of contact on entering the emergency department is, or should be, with the triage nurse, and triage, or rapid assessment of a patient’s emergency status is, or should be, immediate.  Most emergency departments then assign a time within which the patient must be seen by the emergency physician.  This might only be a few seconds, but in any case, all true emergency patients will be assessed within “the golden hour”. 

The medical consultation comprises history, examination, investigation, diagnosis, treatment, and disposition.  To describe this as a “waiting” process is quite wrong.  Of course there can be delays to disposition, notably access block to the ward, but this is beyond the control of the ED. 

A patient on the waiting list for a hip replacement might wait, truly wait, for years.  This rather puts the ED “time to disposition” (my preferred terminology) in perspective, and shows up the absurdity of turning ED “performance” into a political football.  It suits opposition politicians to talk about “waiting times” and “time to be seen”.  Annie Wells for the Scottish Conservatives said, “Over a fifth of patients are not seen within the SNP’s target time of four hours”, and Jackie Baillie for Scottish Labour said, “A & E waiting times are spiralling further and further out of control”.  Either they are ill-informed, or sleekit. 

Emergency physicians are not interested in the four hour rule.  Instead, they try to ensure the patients in the department are in a safe environment, and they do their best for the patient in front of them, however long it takes.  Politicians should stop trying to micromanage an environment they don’t necessarily understand.  They would be better to visit the ED staff, not to tell them what to do, but to ask them, “What do you need?”

Yours sincerely…

I was published verbatim, or nearly so.  They took out the word “sloppy”.  That’s fine; at least they kept “sleekit”, an expressive Scots word meaning sly, or cunning. 

Health Ministers come and go.  South of the border, there was Mr (now Baron) Lansley, then there was Mr Hunt, then Mr Hancock, and now Mr Javid.  I heard Mr Lansley speak a couple of times at the annual conference of the Royal College of General Practitioners.  It was all about “GP commissioning” but I was only listening with half an ear, since health is devolved.  The GPs were suspicious of the government of the time and thought they were trying to privatise the NHS by stealth.  Mr Hunt, I recall, got offside with the junior hospital doctors by trying to impose a contract on them, thus driving them to go on strike.  He got offside with the consultants by suggesting hospitals were dangerous places at the weekend.  Mr Hancock definitely got offside with me when he suggested that GP consultations should be, by default, online.  And already, Mr Javid has got offside with the public by telling them, with respect to Covid vaccination, not to “cower”.  Health Ministers, by and large, don’t know a great deal about medicine.  But why should they?  Baron Lansley studied politics, and Mr Javid politics and economics, both at Exeter, Mr Hunt and Mr Hancock both studied PPE at Oxford.  If I were a Health Secretary with a background like that, I don’t think I would wish to tell doctors and nurses how to do their job.  Instead, I hope I would represent them in Cabinet in order to get them a bigger budget, then I would hand it over to the professionals and tell them to get on with it.      

You can’t understand medicine until you practise it.  I started my first medical house job, in wards 29 and 30, Edinburgh Royal Infirmary, forty years ago yesterday.  I’m still trying to figure it out.                                     

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