Letter: NHS under strain

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Sir: This week British hospitals will be groaning with medical patients. Paradoxically, the problem is not that too many have been admitted, it is that too few have been discharged.

Admitting a patient is easy, but discharging a patient is often quite difficult. Discharge involves making the correct diagnosis after relevant investigations, assessing response to treatment, and organising social and medical follow-up.

From 5pm on 24 December until 9am on 4 January, NHS hospitals in England and Wales will have had 232 hours of medical "on call" cover, but only 24 hours of "normal" working - 9am to 5pm last Tuesday, Wednesday and Thursday. Whilst medical "on call" cover is usually excellent for life- threatening emergencies, it does almost nothing to achieve the discharge of more routine admissions. This is because each "on call" junior doctor is not only covering his or her own patients, but also those of four other junior doctors. Routine investigations - X-ray, endoscopy, ultrasound etc - are unavailable when "on call".

On Monday 4 January, medical firms will reassemble to find their patients spread across all medical wards, as well as in surgical and gynaecological beds. There will be such a backlog of work that there will be delays for almost all investigations; social workers will have closed their casebooks etc. It may take weeks to get back to normal.

What can be done? Firstly, NHS hospitals must maintain a full service in all areas of the hospital from 8am to 8pm every day of the year. Secondly, medical firms must be based on a hospital's geographical areas, so that the "on call" doctor has a clear idea of the patients who are under his or her care.

Let's get ready for the millennium: whatever is difficult this year will be much worse in a year's time. Re-organising emergency medicine in the NHS would be an excellent way of celebrating the event.

ROY POUNDER

(Professor of Medicine Royal Free Hospital, London)

Richmond, Surrey

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