Tom Coffey On emergency performance

Published: 01/04/2004, Volume II4, No. 5899 Page 19

The success of the accident and emergency reforms can be measured by the lack of front-page stories of long trolley waits, patients lying in ambulances waiting to get into A&E, or frazzled consultants complaining about third-world medicine being practised.

March 2004 has been reached and an A&E crisis has not appeared. This is even more surprising when you consider that there has been a 10 per cent increase in A&E attendances matched by an increased number of departments that are able to treat and discharge or admit 90 per cent of their patients within four hours.

A&E is proving to be an area where targets have transformed delivery of care. I know of a number of A&E consultants who ridiculed and criticised the 90 per cent A&E target; most are now smiling quietly. They realise the target has produced a unique emphasis on A&E and also an increase in workforce investment. The changes in A&E are a classic example of investment and reform.

The improvements are exemplified by a complaint at a local hospital. A patient attended A&E and parked in the local hospital carpark. She put in money for four hours, having been told that is the maximum time she will have to wait to be seen and treated. She was then seen and treated within 75 minutes. She has written to the hospital chief executive asking for reimbursement.

The A&E reforms have focused on managing the patients who attend the department with the explicit assumption that if a patient seeks to be seen in A&E, then that is the right place for them to be seen and treated. This may prove unsustainable. The year-on-year increase of attenders may cause waiting times to creep up again.A number of departments are seeing patients returning for different problems, which should obviously have been dealt with elsewhere, because they only waited 30 minutes last time they attended A&E.

Only the deluded believe that the 98 per cent target for four-hour treatment is achievable, sustainable, clinically safe and not open to producing perverse clinical incentives. The agenda may now have to move onto demand management.

Australia has a very similar hospital and primary care-based system to the UK.However, if a patient attends A&E for a primary care clinical condition, they are diverted to one of the nearby 24hour urgent primary care centres. The advent of primary care trust responsibility for 24-hour primary care may allow this system to be developed in the UK. At present there is not a viable alternative to A&E in most places at 5 o'clock on a Sunday afternoon (many GPs, however, feel that these patients can wait until the next day and see their own doctor). PCTs may decide to work with their A&E departments to ensure that the provision of urgent out-of-hours primary care is linked, so that all urgent primary care attendees at A&E can either see their registered practice or be seen in an urgent primary care centre.

If a solution to delivering care to the increasing number of A&E attendees is not found, the great successes over the last few years will flounder.

Tom Coffey is a south London GP, professional executive committee chair for Wandsworth PCT and chair of the New Health Network.