Last Saturday, I cried for the entire journey home.
The day had been hugely stressful, the usual A&E combination of too many patients and not enough staff. It was largely my own fault – I had been hoping for a quiet shift in order to get some revision time in for an exam I was taking the following week. I did not stop from the time I entered the department until an hour after my shift finished when I finally dragged myself home. I had not had food, drink, or a wee for 12 hours. None of this was new. What was different on Saturday was that, for the first time since starting this job 4 months ago, I felt overwhelmed. Patients with non-urgent problems were saturating the department, and as a result there were too few of us to see the seriously ill patients that required immediate care.
The fact that our current Health Secretary has publicly stated that he takes his children to A&E because GP waiting times are too long, shows us that there is a complete lack of public education concerning appropriate places to seek medical help. There are very few things more frustrating than seeing a patient in A&E who is annoyed at having waited three hours, and then telling them that there is nothing that you can do for them. Sending people back to their GP is a vicious cycle – they most likely presented to A&E because it takes ages to get an appointment, and although their condition is not life threatening, they want it sorted. This is entirely understandable. What the public as a whole do not realise though, is that unless your condition is serious enough to require admission to hospital, or something that can be sorted with a one off course of antibiotics, A&E is the worst possible place to go.
Since the restructuring of the healthcare system, which has put commissioning and budgeting in the hands of GP surgeries, we are no longer able to refer into specialist clinics from A&E. If I see someone who has come with palpitations, I have to send them back to their GP for a referral into a cardiology clinic for monitoring. If I see someone with angina-type chest pain, the referral to the “rapid access chest pain” clinic no longer comes from A&E; it comes from the GP. The problem with this, of course, is that many people still present to us in the hope of circumventing the waiting time at their GP surgery, only to find out that they need to go back there for the necessary investigations.
It is hugely frustrating as an A&E doctor to see someone, know exactly what investigations they need, and essentially have no way of ensuring that they happen. Good GPs, of which there are many, will look at the discharge and arrange appropriate tests. Good A&E doctors will write letters to the GP, which the patient can take with them to explain what investigations have been done and what are outstanding. The frustrating aspect occurs when the GPs are slow, or the communication breaks down, and then the person gets lost out in the community until they have another, non-urgent problem, and present to us again.
We have just changed jobs, and last week was my final shift in A&E for a little while. A lady presented whom I had seen 7 weeks previously, and had discharged home. She was in her eighties, and had probable new onset dementia. When she had first presented, her husband and daughter, frustrated with the lack of access to their GP, brought her to A&E because they were worried about the decline in her cognition. After discussion, we agreed that she did not need admission to hospital; they were coping at home, but were keen for a diagnosis and some social support. We did a basic infection screen, and I wrote a three-page summary of her presentation and the family’s concerns. The husband took the letter to their GP the following day. The crux of situations like this is that you cannot get social support until there is a formal diagnosis of dementia. Until there is a diagnosis, families struggle on by themselves, with inadequate resources, and little understanding of what they are undertaking.
If the woman had an infection, or was dehydrated, or ill enough to require admission to hospital, the diagnosis of dementia would likely have taken a few days. However, she was able to go home, and things move at a much slower rate in primary care. Unfortunately, in the intervening weeks, none of the investigations happened; no support materialised, and as such the same family represented to A&E on my final shift, after the lady had attempted to assault her husband because she didn’t recognize him anymore, and he had to lock all the doors in the house to stop her running out into the cold.
So, the family is back, again with an inappropriate presentation to A&E, but a presentation out of desperation. By some cosmic cock-up, they are seen again by the very doctor who discharged them into the community last time, with the promise that this would be investigated and they would get the help that they so clearly needed. Again, this lady’s infection screen was normal, bloods were normal, and there was no clear indication to bring her into hospital. I found myself – a compassionate, sensible doctor, advising this family to essentially abandon their elderly relative in a busy A&E department, alone and confused, because then we would have a reason to admit her for investigation. There is so much wrong with that picture that I don’t know where to start. When we, as clinicians, are reduced to hoping for abandonment as an excuse to diagnose an elderly lady and give her home support, it is a glaring example of the failings of our healthcare system.
We need integration and communication between primary and secondary care. We need education for the general population on where to seek medical help. Lord knows there are enough YouTube videos around advising of where to go when you have the flu/need antibiotics/have run out of medication. I don’t know what the solution is, which is probably why I am not the Health Secretary, although he doesn’t seem to have this figured out either. All I know is that a system that leaves vulnerable people without support is not good enough. We are better than this.