Sunday Read: Where are the usual customers?
Another day with few patients except for those with COVID. Which all begs the questions: where are the usual customers?
Two patient groups of particular interest seem to have disappeared without a trace.
The first group is are patients with serious sounding symptoms or known serious diseases. This group includes patients with bowel obstruction, chest pain with known heart disease, head injuries in patients on blood thinners, and suspected fractured hips. These patients need to be expeditiously investigated on the day of presentation. Although many of these patients turn out to be not as serious as first thought, a good proportion need admission for observation, specialist opinions, and alterations to therapies. A sizeable number of these patients also require assessments for social care. Many patients will have significant medical interventions – coronary stents, hip prostheses, or the diagnosis of new cancers.
Some of these patients are still attending – after all you cannot walk on a fractured hip. However, there has been a distinct reduction in the number of these patients. Talking with others, we are slightly suspicious of the consequences of the stoicism that is often seen in these patients. They often say things like “we weren’t sure whether it was serious so didn’t want to bother you”. There is genuine concern that when normality returns we will find a number of patients who now have significant and irreversible impairments to their health – for instance, a cancer that has now spread, or coronary artery disease that has now caused a heart attack and actual scarring of the heart.
The other group we are talking about are the “worried well” who should normally see their GP about minor complaints including sore throats, skin rashes, constipation and such like. Many patients attend A&E instead of their GP because they do not have a GP or claim not to be able to get an appointment. Being seen within 4 hours in A&E is often preferred by patients of working age as they can attend out of hours and do not have to compete with elderly patients or children who will always tend to get priority at the GP, and who also have more flexibility to attend the GP. The availability of specialists, blood tests and imaging also means that patients get a relatively thorough workup.
Unfortunately, A&E doctors do not know these patients so must start from scratch for each patient. Many A&E doctors are also relatively junior so each attendance takes significantly longer than an experienced GP – often as long as 45 minutes to an hour.
The exact number of these patients is always a little contentious when I discuss them with my colleagues – although it is fair to say that even as few as 5% (1 in 20) adds a distinct burden in a system that is creaking. Because A&E departments do not routinely turn these patients away, and the doctors and nurses are (nearly) invariably polite, there is little to dissuade these patients from effectively bypassing the primary care system. Not all of these patients have malign motives for attending A&E – most simply don’t know what is serious and what is not, and everything feels serious in the middle of the night with only the wonderful interweb to create a further sense of panic.
When this crisis is over – if anyone is listening who deals with these things -it would be much appreciated if we could find a better mechanism for dealing with these attenders. They are ultimately a symptom of a deeper issue in the NHS: how do we fund patient care?
In simplistic terms, the current system uses a fixed budget as the starting point. Service obligations require the NHS to see all patients that turn up. Great idea if the budget matches the demand - the Government gets to set a consistent budget and also claim politically that it has paid for the healthcare that voters have asked for.
Reality is somewhat more complex. The budgets are not matched to demand.
Some of the problem is demographic. We have a population that is both growing but also ageing. There has been little recognition that costs will rise much faster than the rate of inflation. Moreover, not all health costs are fixed costs. Many costs scale with the number of patient care episodes – for instance each hip operation requires an expensive prosthesis. NHS trusts have no option but to go into deficit since they are not allowed to deny patients care, even if it is simply impossible to provide it for the money that is being given. Although there are likely to be NHS trusts that are not well managed, the majority of deficits are likely to be simply where budgets have not adequately allowed for the service provision demanded.
These fixed budgets are then cascaded down to the various healthcare providers. The current system effectively assumes that patients will choose the right care environment. Even with Google and the increasing number of diagnostic apps, it is more difficult than is readily appreciated to understand if symptoms are serious or not, or whether they should be seen by a GP or other service.
Ultimately the NHS is ‘free at the point of use’ but it is not free. We need to think again about how we resource health care. The answer is surely to make the costs of each patient care episode more transparent and effectively to move toward event driven reimbursement mechanisms. These are widely used across the globe and which give patients greater freedom to choose when and when they access healthcare. These mechanisms enable funds to follow the patient, no longer do we need to care whether we have been given the resources to deal adequately with demand.