Published: 02/12/2004, Volume II4, No. 5934 Page 19

One evening at around 7pm I called the GP surgery where I was registered. I was not so naive as to expect an actual human being to answer the phone at that unsocial hour. The city may never sleep, but this was rather late in the day to expect a light on in the surgery.

My hope was that the recorded message would end with a phone number, which I could then ring to speak to someone urgently.

Although this was before the days of the new general medical services contract, the GPs had clearly taken unilateral action on out-of-hours cover. Their message ended with 'ring NHS Direct'. Making a mental note to seek out a more responsive practice, I dialled it. A pleasant NHS Direct person answered, took some notes about the problem, and said someone would call me back.

Time passed. Then I recalled that a local hospital claimed to have a minor injuries unit. Perhaps that would be open. A rummage in the cupboard, a flick through Yellow Pages, and a number was found.

Another recorded message. 'The unit is staffed on Monday to Fridays between 8.30 and 5.30...' Sigh.

After 45 minutes of waiting for NHS Direct to ring back, I climbed into the car and drove to the local A&E. The problem was neither an accident nor emergency, but it was urgent and painful enough to demand attention and we were treated with courtesy, seen promptly and given effective treatment.

Antibiotics were supplied ungrudgingly. Even the parking was simple. If we had to fork out for some overpriced pain-killers at a late-night garage on the way home, it was a small price to pay for sleeping easily.

Why do I trouble you with this tale? Why do I risk being reported for 'inappropriate' use of a busy hospital casualty department? Partly because the process described above represents patient choice in action. I chose A&E rather than primary care because it was convenient, relatively quick, and because in practice trying to use the primary care alternative proved hopelessly cumbersome. And also because my personal episode seems to be part of a wider trend, with attendances at A&E increasing year by year.

There seem to be various reasons why patients are using A&E departments more. One is the counter-productive nature of access standards in primary care. A requirement of prompt access has bizarrely turned into a denial of care.

Ring at 8.30am (that is, try continually from 8.25am using the redial button until you eventually get through) and, if you're unsuccessful in securing one of today's appointments, better luck tomorrow. If you're working or otherwise engaged at 8.30am, tough. In some places it has perversely become so difficult to get a GP appointment at all that the trip to the hospital becomes simpler.

Another reason is the improvement that has taken place within A&E, not least through the impressive work of the emergency services collaborative, and motivated not a little by fear of breaching the four-hour maximum wait. Word is out that one can usually be seen quickly and without undue fuss.

But it also mirrors an international trend - that of consumerism. Especially in towns and cities, and particularly among younger age groups, people now expect their needs and desires - whether for a quart of fresh milk, a holiday booking or a visit to the doctor - to be satisfied at times convenient to them rather than the professional. If internet shopping is open all night and the hypermarket for most of it, why not the NHS?

A&E departments aspire to this, and usually boast what all shopping centre owners recognise as a key attraction: a large car park. Primary care cannot compete.

Now in economic terms, the A&E department is a sweetly efficient machine. The customers come to us.

They are willing to wait for hours if necessary. We can segment them into minors and majors, then triage them so that we can treat them in order of priority, using the optimum skill-mix. The staff do not grumble much about the 24-hour nature of the operation: they know it goes with the turf. We have years of experience of the system. It works.

So, a proposal. Let's subject the 'primary care-led' NHS ideology for unplanned care - which seems to imply that we must build communitybased alternatives to accident and emergency, and discourage 'inappropriate' A&E usage - to some gentle critical scrutiny.

Let's start with patient choice, and accept that if patients genuinely prefer A&E, the responsibility of NHS commissioners is to build up A&E departments, rather than pouring investment into competing alternatives. We may lack structured information on real patient preferences, but voting with one's feet always tells a compelling story.

Let's look at the practicalities of out-of-hours staffing. Hospitals usually cope, but some primary care organisations struggle to cover Friday afternoons! Let's look at location. Recent experience on the siting of minor injury units is that they are often most effective somewhere near the acute hospital.

And not least, let's acknowledge that GP practices have a material financial interest in the outcome of such scrutiny.

Could it be that if we were to take all the resources we currently sink into expensive out-of-hours cover arrangements, minor injuries units that we struggle to staff and roving paramedics and practitioners and reinvest them into general hospital accident and emergency departments, we would not only create first-class A&E services: we would also be offering our users what they want?

A brief postscript. It is 8pm last Tuesday, and I have just phoned the surgery where I am now registered, to see what has changed. A recorded message tells me the phone number of its out of hours service (hooray! ).

Then it warns that due to a high volume of calls it is extremely busy, and that I should only ring 'for urgent medical conditions that cannot wait until the surgery is open'. Sigh.

Noel Plumridge is a former NHS finance director.