Emergency care systems: increasing pressures but little sustainability

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Emergency care has again been at the centre of healthcare news in many countries over the last few months. The ‘winter pressures’ are upon emergency clinicians in the northern hemisphere, and in the UK, process measures (e.g. the 4 h target) have been at all-time lows 1–5, questioning the sustainability of the service and the sustainability of emergency physicians 6,7. The seasonal influenza outbreak undoubtedly contributes to the demand on services, with spikes in acute respiratory illness occurring particularly in frail elderly patients. However, the influenza season does not explain everything – where I work, in Hong Kong, our flu season is significantly less pronounced than it was in 2016. So why is the situation so bad for some emergency care systems?
The media and politicians invariably focus on hospital emergency departments, as they are perceived to be the root cause of all problems. The reality could hardly be further from the truth. There are undoubtedly significant deficits in medical and nursing staffing at all levels of the emergency department 8, but the lack of hospital beds leads to access (or exit) block, which has a much more profound effect on emergency department throughput. This has a knock-on effect to prehospital services, when they cannot even offload their patients from an ambulance to the emergency department, which further risks emergency care capacity in the community.
The UK Chancellor (finance minister) has recently allocated no less than £100 million for 100 projects to place general practitioners in emergency departments to triage ‘inappropriate patients’ away from the emergency department setting (https://www.gov.uk/government/speeches/spring-budget-2017-philip-hammonds-speech), another great example of an evidence-free recommendation imposed by politicians. Yes, there are inappropriate attenders, but the vast majority of those attending an emergency department do so because they need to be there. General practitioners are already stretched to their limits to provide the care that they are trained for: it is illogical and wasteful to ask them to take on a role that they have not been trained for and that has never been shown to be effective. General practitioners should be given every encouragement to continue to do what they do best: excellent timely community-based primary care and chronic disease management.
The much more fundamental issue is the lack of downstream medical and surgical beds for frail elderly patients to be admitted to. Various sources have recently suggested that the UK has fewer beds per head of population than almost all other developed countries. With an increasingly ageing population, and ever-rising demands and standards, we are witnessing the disintegration of the UK National Health Service’s acute services due to a political unwillingness to stop the culling of hospital beds.
Efficiency by rationalization can go only so far, and then it becomes destructive. If patient care standards are to mean anything at all, we need to see a stop to acute bed closures, and in many areas more beds must be staffed and opened. We also need to see more emergency clinicians (doctors, nurses, and other healthcare workers) being trained 9 and added to the emergency care system. Failure to do so, rather than suggesting evidence-free interventions that will not work, will lead to the implosion of the UK emergency care system as we know it, and maybe others too.
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