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Dr Brian Patterson: 'Throwing money at A&Es is not going to resolve the problems'

Published 18/01/2016

Dr Brian Patterson says that a lot of general practices in Northern Ireland are struggling with the demands of increased workloads
Dr Brian Patterson says that a lot of general practices in Northern Ireland are struggling with the demands of increased workloads

GP Dr Brian Patterson talks to Lisa Smyth about the crisis in our health service and the need for courageous decisions to be taken to avert it collapsing under the strain it faces.

Q. What happened in our accident and emergency departments at the beginning of the year?

A. Clearly it was a holiday period and there are always difficulties over holiday periods.

They are predictable, they do happen every year, but it couldn't have been down to winter in terms of true winter pressures.

There were no flu epidemics, there were no huge frosts causing fractures, so clearly it was a reasonably normal situation where an increased number of people attended A&E.

My view is that the situation in A&E is basically a symptom of a condition affecting the entire health and social services, and that is being caused by a huge number of factors.

The pressure that each one of these generates results in the pressures at the front doors of hospitals, which are the A&Es, and in other services, although these are less visible.

Q. What would you say are the factors that contribute to the problems in A&Es?

A. We have an increasingly elderly population, and not only elderly people, but elderly and young people who have chronic, long-term conditions, and frequently more than one.

We are also living in a world where dementia is becoming increasingly prevalent, which complicates all long-term conditions.

We also have a population that has reasonably high expectations that are getting higher.

In Northern Ireland, we also have a unique thing called waiting lists for outpatients, for operations, day procedures, diagnostics, and they are huge.

You have people waiting for tests to find out whether they should go on a waiting list, but waiting is not a free gift.

People who are waiting deteriorate and get sicker, they are suffering, and their condition gets worse and harder to fix.

All of that costs money and while they're waiting, they frequently show up at the doors of their GP surgery or the A&E and that all costs money. We can't figure out why we can't deliver prompt care when we're spending a lot of money on waiting, which doesn't produce any benefits and just fights a fire while people are waiting.

Q. Can you give an example?

A. Take someone with gall bladder disease who needs an operation which costs £4,000 to £5,000 under UK tariff.

If they have to wait for the operation, they attend A&E, they get admitted, they have to have other procedures, endoscopies, that sort of thing.

They have to take time off work, they may need carers to come in to help them, they end up on benefits.

Then, at the end of all that, they end up having the procedure but it is frequently more difficult than it would have been in the first place, so you end up spending thousands on someone waiting for a very simple procedure.

Q. We hear a lot about people going to A&E when they don't need to be there. How big a problem is this?

A. I do think that this issue is frequently exaggerated.

In the Northern Trust, we have done pieces of work where we have actually put in GPs at the front doors of A&E departments to find these people who are attending inappropriately.

The idea was that the GPs would deal with the patients but we actually had to remove those GPs because they were under -utilised.

People don't go to A&E for the fun of it, and it is a very easy point, after you have done a lot of tests on someone, to say that they could have done without going to A&E.

However, sitting in the community, without the benefit of those tests, it can be difficult to judge, so inappropriateness is sometimes diagnosed after the event rather than before it.

Q. Statistics suggest six out of 10 attendances at A&Es are alcohol-related. How much of a role does this play in clogging up our hospitals?

A. Mental health and addiction issues can be a problem if they are not dealt with properly.

I had a paramedic tell me there was one patient who had been to A&E more than once a day for a whole year.

This paramedic was going backwards and forwards collecting them, and that was because no one was doing anything about the problem.

They were being discharged from A&E but coming straight back in again.

Something had to be done to help that patient and, while there are little pilot exercises being done to address these problems, we need them to become mainstream.

The problem is, there isn't the money to do this but it would save a lot of work and money.

It really is the chicken and the egg; you can't spend money making something mainstream when you're busy spending money on the expensive services.

Q. Do you think that a lack of resources in the community contributes to people going to A&E?

A. A big difficulty in the health service in Northern Ireland is that virtually 90%-plus of all new resources are put in to fighting problems in acute care.

You need to invest in social workers, domiciliary care packages, GP out-of-hours, who can all provide solutions to address the demand.

I have to declare an interest as the chair of Crossroads, which provides domiciliary care, but it is about to flounder because the people in charge of the purse strings are prepared to fund domiciliary care by the trusts at a much higher level than by the community and voluntary sector.

As a result, organisations like Crossroads are finding it harder and harder to deliver.

At a conservative estimate, it costs well over twice per hour for the trusts to deliver the service than it does the voluntary and charitable organisations.

Q. So, are you saying that charitable organisations are at risk of going under?

A. Massively. If you don't get enough resources, you can't retain staff; if you can't afford to pay staff then you can't afford to provide care.

Crossroads is finding it is getting harder to get by. For example, the trust is paid £20 for a service and we get £10.

The trusts say it costs them more money because they have a huge infrastructure.

It's sad because organisations like Crossroads could be a huge asset if we were equitably funded.

Q. Do you think people are going to A&E because they can't see their GP?

A. The evidence doesn't back that up, you just have to look at the GPs we put in A&Es in the Northern Trust to see that.

I would imagine it is the case in individual cases but it isn't a major pressure.

When we have drilled in to the figures in the past, we have found it isn't true that A&Es are being inundated with people who can't see their GP, but it makes a good soundbite.

It takes the pressure off and blames someone else when the reality is that in the last 10 years, GP consultations have gone from six million to 12 million.

That's six million more people who have found their way into the GPs and similar figures don't exist for A&Es.

At the same time, the number of GPs has not increased, in fact there are actually less in whole time equivalent terms than 10 years ago.

Q. How serious is the situation in the A&Es?

A. If you treat it as an issue that reflects the NHS in general, and I include social services in that, it should ring alarm bells.

But the solution is not ploughing more and more resources into A&E, the solution is addressing all the other things.

I also think we need to focus on what happens in A&E. If you watch news footage in A&Es, it is clear that most people spend their time, not with patients, but with computers.

I'm not blaming the people as it's what they have to do, but I would suggest there may be other people, not doctors and nurses, who would be better to stand and wait for results out of machines and then hand those to the clinicians.

There are also quotas which state how many patients junior doctors are allowed to see in a 12 hour shift, I don't know what they are, but I know they exist.

In my day you went from cubicle to cubicle and back again but that doesn't happen now.

It's the same in theatres; surgeons are only allowed to do maybe four hips on their list for safety reasons. The fact they can do nine in a private hospital, we won't go there.

I'm not saying anyone is standing around doing nothing, of course, but I do think we should be looking at how resources are used.

Q. Why do you think so much money goes into A&Es?

A. For some unknown reason, the health service is equated with hospitals and hospitals make the news.

Waiting for four weeks to get a rail outside your landing or bath so you don't fall over doesn't make the news, but wait for 12 hours in an A&E department and it is on the news.

However, someone falling due to the lack of a rail can end up waiting the 12 hours in A&E.

It's worth remembering that we've had numerous reviews which have all said we need to prioritise resources into the community.

We've had Developing Better Services, the John Appleby report, Hayes Review, Transforming Your Care and, most recently, Donaldson.

They've all said the same thing, to prioritise resources into the community, and we have done the exact opposite.

Q. Can you give an example?

A. Over £5m went into the trusts for A&E support last year and they did see an extra 1,000 patients.

That works out at about £5,000 per patient, but unfortunately the spin off from that is that about 800 elective procedures were cancelled.

So while we paid for more people to be seen in A&E, we spent less on elective care so waiting lists went up, and those people probably ended up in A&E, so it is a vicious circle.

What we need is to listen to all these reviews - basically courageous decisions are needed.

At the moment, the balance is wrong, but that takes courageous decisions and debate, such as do we have too many hospitals, are we spending money on buildings that we don't need?

I think that is what this new review is going to say, it would be the same as the previous reviews, that, yes, we do have too many hospitals.

The question is, what are going to do about this?

Q. Is there support for the change required?

A. I welcome the new review announced by the Health Minister but my concern is there is no commitment to do anything about it.

Donaldson said what needed to happen - he said he wanted external people to work on it, but our Executive decided against that. Not In My Back Yard is a problem, we're all guilty of it.

We're in favour of change as long as it isn't in our back yard, but it's actually in all of our interests to have a properly functioning health service.

It's no use having a local service that doesn't work rather than a centralised service, with fewer centres, that works better.

The issue is that no matter what service is affected you are always going to get a campaign to keep it open. I always say, focus on what the service does for you, not where it is.

Q. Has Transforming Your Care (TYC) had any effect?

A. TYC has not been allowed to deliver because of a lack of funding and political will.

I know there is a lot of good work going on but it is only the tip of the iceberg.

The problem is there have only been tiny little attempts, and we need to get the concept across the health service in Northern Ireland.

TYC said there are two options: we either do it in a planned, agreed and resourced way, or wait for the health service to fall apart.

We aren't doing it in a planned, agreed and resourced way at the moment.

Q. How close are things to falling apart?

A. Well, you see what is happening to A&E, to domiciliary care, you see what is happening in GP surgeries and what is happening with doctors and nurses emigrating.

Q. How bad are things in general practice at the minute?

A A lot of practices are struggling to cope with increased workload. The workload has doubled over 10 years.

There are a lot of practices vulnerable to collapse, with a lot of older GPs coming to retirement age and no younger GPs to replace them.

Q. It has been claimed that the GP out-of-hours service is unsafe. Do you agree?

A. It's not safe. You only have to look at litigation and the best key is what a medical defence organisation will charge you to cover you to work, and GP fees to work in OOH (Out Of Hours) are going up and up.

Q. Why isn't it safe?

A. The volume of patients, you are triaging extremely sick people from the not so sick.

It used to be an emergency only service and now it seems to be a general healthcare service 24 hours a day.

That's an expectation given to people by government.

Q. Do you think seriously ill patients are getting lost among those waiting to be seen by the Out Of Hours service?

A They do. When you have people who are waiting six or seven hours for a call back, doctors have to be very vigilant to pick out of that who they call back quickly.

When you have people waiting six, seven or eight hours when they are acutely ill, that can be fatal.

Q. Are you saying it is only a matter of time before someone dies?

A. There might already have been, I don't know, it's impossible to tell.

Although I'm not the best to say because I stopped doing OOH a lot time ago because I had concerns about safety.

My understanding is that things have got a lot worse since I stopped doing it.

Q. How frustrating is the current situation?

A. It's frustrating in that people see the only solution is to throw money at a crisis or sack the chief executive - look at the decision to get rid of the Health & Social Care Board.

If the car is broken, it won't be fixed by changing the driver - you need to look at why the car is broken.

We do have to keep it in perspective though.

I can produce thousands of people who have had a good experience in A&E when it matters.

Unfortunately, the less positive stories are becoming more and more frequent.

While they keep throwing money at A&E the problem is never going to resolve.

It just means there is less money for the things that need fixed.

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