It’s Groundhog Day on the apparently dismal “A & E Waiting Times”.  The Herald reported them on Friday, along with the opposition politicians’ calls that the Health Secretary be sacked.  I wrote a letter to The Herald, comme toujours, and was delighted to be published on Hogmanay under the banner headline Time to get clinicians, not politicians, to sort out the NHS.  Here it is:

“We were expecting this week’s A & E figures to be bad, but these are awful” (Analysis, The Herald, December 29th).  Here we go again.

In the 1990s when I was clinical head of the emergency department (ED) of Middlemore Hospital in Auckland, New Zealand, the then health minister, Bill English, shortly to become Prime Minister, dropped by, not to tell me how to run the department, but to ask me, “What do you need?”  I told him we needed to double the staff, a remark which at the time I didn’t think went down particularly well, yet, in the event, it happened.

Our politicians, throughout these islands, would do well to follow Mr English’s example.  I think the standard of political debate concerning the NHS is, frankly, pitiful.  You have been publishing the same story intermittently for years now, in language you might have used in 1948, concerning “A & E”, or “Casualty”, or “Cas” not “seeing casualties” within four hours.  For the record, this means that emergency departments are not discharging patients within four hours.  This seems to be a surrogate marker for catastrophe.  Opposition parties call for the health secretary to be sacked.  

Political point-scoring is useless in this context.  It would be better if a cross-party committee asked clinicians the Bill English question, “What do you need?”

Better funding and better staffing are obvious requirements.  Yet there are profound systemic problems within the NHS and it must be the clinicians who take a lead in outlining what they are, and how they should be tackled.  One example: few members of the public, least of all politicians, are aware of the turf war that exists between acute medicine and emergency medicine, and that has resulted in an apartheid system of patient care at hospital front doors.  Medical assessment units don’t implement a four hour rule. 

The medical assessment unit and the emergency department must amalgamate to form a true specialty of emergency medicine.  The entire delivery of hospital acute care would take place around the central hub of the ED, which would no longer function as a first aid outpost, like a dressing station inundated during the Battle of the Somme, but as an integral part of the hospital.  Emergency Department “waiting times” would cease to have any meaning.  


It’s not the first time I’ve written this letter, or something like it, but I suspect it might be the last.  I’m not in practice any more, and you lose currency in medicine very quickly.  It is said that there is nothing so “ex” as an ex-politician, and the same might be said of a doctor.  It hardly matters what I think.  It is the opinions of the health care workers in harness that matter.  The trouble is, they are so busy that they have no time to think. 

The last time I time I suggested in The Herald that the acute physicians and the emergency physicians merge, somebody wrote in with a gag, that the new college could be called something like the Scottish College Royal for Emergency and Acute Medicine, or SCREAM.  Well, I had to laugh.  Nevertheless, intentional or not, this was a put-down.  And I have no doubt that if, while I was clinical head at Middlemore, I had made this proposal to the elder statesmen of the Royal College of Physicians, it would have gone down like a lead balloon.   

Where did the specialty of Acute Medicine come from?  There used to be a species of consultant encountered in hospital known as the “general physician”.  In fact, most physicianly elder statesmen were general physicians “with a special interest”.  I think for example of a renowned chest physician at Edinburgh Royal Infirmary.  “Never let a patient die of an undiagnosed chest condition, without a trial of antitubercular therapy.”  He was famous the world over, yet he was still on call for his ward’s receiving night, and in the subsequent morning ward round would have to make clinical decisions about patients with all sorts of conditions not relating to the chest. 

But as medicine became more super-specialised, the general physician became an endangered species. In addition, the model of care whereby the acute management of ill patients rested solely with junior, sometimes very junior, doctors, could not be sustained.  So general medicine morphed into acute medicine.  Acute medicine has its own college, its annual conference, its research publications, its own department, the acute assessment unit (AAU), and its own textbook, the Oxford Handbook of Acute Medicine.  I’m holding it in my hand now, along with a companion volume, The Oxford Handbook of Emergency Medicine.  Of course the remit of the emergency physician is far wider than that of the acute physician, yet the acute handbook (third edition) runs to 869 pages, as compared to the emergency handbook’s (fourth edition) 749 pages.  The main topics of the acute handbook all appear in the emergency handbook, though not vice-versa.  If the acute and emergency physicians were to amalgamate, then it might be argued that while the acute physicians would need to increase the breadth of their knowledge, then the emergency physicians would need to increase their depth.  So, a challenge for all. 

It doesn’t make any sense to have two work forces operating in more or less independent silos seeing the same, or at least an overlapping, patient population.  Why not merge?  What is the impediment?  Traditions run deep.  Both disciplines would need to surrender a degree of sovereignty.  No doubt the emergency physicians would be frightened of becoming swallowed up by one of the ancient royal colleges, while the acute physicians would be frightened of opening their portals to a tsunami of undifferentiated humanity.     

There’s more bleak news in The Herald today.  “Patients turn to ‘DIY medicine’” and “Health chief warns 500 could be dying each week due to delays in emergency health care”.  One thing’s sure: the status quo is not an option.         

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