If your A&E department is over-flowing with ailing but not expiring citizens who have had the nous to realise it is the one place in the whole of the NHS that is open in the evening or at weekends; who calculate that a 4 hour wait to see a junior doctor is better than a 2 hour wait just to get through on the phone to their GP receptionist during the week; who with the patience of Job and a small picnic packed by Nan are prepared to sit it out until seen: then ‘Something Must Be Done!’ Something, at the very least, must be done to separate the critically ill and injured wheat from the mildly dyspeptic chaff.
Nursing triage is now a standard place to start – though whether it is a good place to start is moot – an initial prioritising discussion of history, presenting signs and symptoms, and, one hopes and prays, having the ability to make an instant yet sound differential diagnosis between little Johnny’s runny nose and indications of possible meningitis: ‘Red’ for “Immediate threat to life. Treat now!”, down to ‘Grey’ for “Worried well. Let them stew.” That sort of thing. Nurse-led triage, though, can only be an effective tool when the totality of patients-in-waiting fits within the intended remit and flow of A&E, not when the rising headcount in the waiting area pushes it beyond its safe competence and capacity.
One response to pressure on triage is to increase its resourcing by number and by clinical experience and expertise, the evident risk being creating a secondary department within a department, which any half-decent systems theory would acknowledge as being inherently contrary to efficient and effective ‘flow’. Another option, now widely in operation, is the ‘Walk-In Clinic – located within A&E but a separated provision of GP-led primary care that can attend to the many for whom primary, not secondary, health services are all they really need and, in truth, want. The not unreasonable reasoning seeming to be: “They’ve come here to A&E only because they can’t access a GP out-of-hours, so let’s give them just that.”
Good thinking, maybe. But how does it work in practice, does it do what it says on the tin, or do we wretched patients kick the can all over the place until it is bent quite out of shape? First off, word soon gets around that here’s a GP resource for which you don’t have to phone to book an appointment days in advance: just pitch up when you fancy – with Nan’s sandwiches once more for the inevitable wait – and you will be seen eventually. Maybe just by a locum, but then you get seen by a different GP each time when you go to your registered practice so what the heck? It’s conveniently there in the evening when you get home from work, and if Sunday afternoon telly is particularly tedious you might as well go and be bored there as anywhere else: you’ve run short of the blue pills and if you can get home in time for X-Factor with your renewed prescription it’s a clear win-win.
So within days – hours – of opening your wonderful, new and problem-busting Walk-In Centre it is stuffed to the gills, not only with those people who would have been unnecessarily cluttering up A&E and whom you’ve been able to divert there, but also by a whole host of others who probably would have stayed at home but who now grab the chance to get sorted soonest.
Perhaps you’re beginning to feel like the Sorcerer’s Apprentice – just wishing you’d never started to mess with a system you don’t really understand and certainly are failing to control. What, though, are you going to do to attempt to manage demand for the ‘Walk-In Centre’? You’ve built a waiting area for 20, but now over 60 people at any one time are lining the corridor all the way back to the door off A&E.
Something, yet again, must be done! [This is, I hope you gather, a real example of a hospital on the edge of East London – and collapse – a few years ago.] So how do you stop people simply walking in to your Walk-In Centre? Why, easy! You introduce an appointments system! [I kid you not.] When people phone up to ask about the Walk-In Centre, you instruct your receptionist staff [true story] to tell them that they must make an appointment before coming down. This is both truth and lie: there is an appointments system because you’ve introduced one, but no one has to use it – if they know better – because both processes are running in parallel!
So now your corridor is stuffed half with people clutching a ticket for an imaginary timed appointment, and half with people who’ve just walked in off the street on the off chance. Both sets have, anyway, to queue in order to sign in with the Walk-In Centre receptionist, who can only tell everyone what she’s been told to say – people will be seen in strict order of arrival, no ifs or buts and if that’s tough then it’s just that – tough. (Fancy that job? No, nor I.)
The systems analyst has a decent metaphor for the situation: you’ve laid a carpet, but not flat: there’s a trapped bubble of air lifting one section. So you stamp on the bubble and, hey presto, it’s vanished. Or, rather, not. It’s simply moved somewhere else. Solution – lift the carpet and re-lay it flat second time around. Answer – lay it flat in the first place!
If too late now for the answer, what’s the solution? I don’t claim to know, though Jeremy Hunt does: it’s all GPs’ fault for abandoning out-of-hours care. The system having been dismantled under Labour is to be mantled (apologies to P G Wodehouse) under the Coalition. A review, with proposals of how to effect this volte-face is due at the end of the month. I, for one, am totally confident that the report will be replete with whole-systems thinking and proposals – fully acknowledging the challenges and complexities of reversing course – and will make it perfectly clear that whatever is done will have dire and unintended consequences if not designed, planned and delivered around the real world of how people and patients have learned to behave in order to make healthcare systems work for them. Has to happen one time I suppose.