Carol Black On improving acute medicine

Published: 03/06/2004, Volume II4, No. 5908 Page 29

An elderly patient with a long-standing obstructive airways disease is taken ill at home with acute breathlessness. The patient's GP recognises the need for urgent care, not deliverable in the patient's home, and sends them to the nearest accident and emergency department.

On arrival the patient is delivered into the late-evening mix of people with broken limbs and the casualties of 'after hours' pub brawls and, despite the staff 's best endeavours, becomes increasingly distressed while waiting. Eventually the patient is made comfortable and admitted to a bed on a surgical ward (the only bed available) to await review by the respiratory team the following morning.

Now contrast this with admission of the same patient directly to an acute medicine unit where assessment, diagnosis and treatment of the problem takes place within minutes of arrival. Expert and timely attention results in an immediate reduction in anxiety. The process of rehabilitation is initiated almost immediately, thus hastening recovery and ultimately discharge.Monitoring and evaluation are continuous, allowing rapid response to even minor fluctuations in the patient's condition.

At present such care is not widely available to acutely ill patients, who tend to be treated on general medical wards by physicians who combine this work with other kinds of specialist care. This is not ideal.Acutely ill medical patients need, in the first 24-36 hours, the undivided attention of teams specialising in acute care - only truly available in acute medical or assessment units, delivered by specialist teams. The patient may then be discharged or triaged to another team.

The key is the right kind of care at the right time in the right place, and by the most appropriate staff mix. Appropriate care during the acute phase of a chronic illness will not only alleviate the burden of suffering, but is likely also to lead to the more efficient use of NHS resources, minimising in-patient stays and the difficulties around hospital discharge.

Is it possible to make specialist acute care the rule rather than the exception? The Royal College of Physicians certainly believes so, as our recent report on acute medicine points out (see main story).

But there are hurdles to jump. Not only will the NHS need to provide the right kind of physical resources; staffing them appropriately will be a significant challenge.

There must be the education, training and career progression for acute medicine to develop into a recognised specialty and to attract younger doctors who need to play a central part in shaping its progress.We need a strong academic and research base to support future advances.

But we also need to develop a wider understanding of the nature of acute medicine and its close relations with critical care, with acute work on hospital wards, and with A&E.We also need to make a distinction between acute medicine and non-acute work in outpatient clinics and on hospital wards.

Professor Carol Black is president of the Royal College of Physicians.