NHS primary care is still stuck in an earlier age

Long waits in A&E have to do not only with staff shortages, but with high demand

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The Independent Online

Members of Parliament yesterday added their voice to the growing chorus of concern about the National Health Service in general and Accident and Emergency provision in particular.

A report published by the Commons Health Select Committee sounded an alarm about the shortage of consultants in most A&E departments, and drew attention to the confusing range of alternatives which effectively encouraged people to “go where the lights are on” – in other words, to their local A&E. MPs also condemned what they saw as the lack of urgency on the part of the NHS in addressing the faults.

The most disturbing finding – although not one that will surprise many patients – is that only 17 per cent of emergency departments have a full roster of consultants for the 16 hours a day considered necessary. It might reasonably be asked whether 16 hours out of a 24-hour day – and this only during the working week – is itself enough for departments that are open around the clock. But with senior medical staff, especially consultants, already spread so thin, that is probably a question too far. Another pertinent point concerned the vast sums spent on hiring locums in an attempt to fill the gaps. 

Depressingly, the release of the report prompted a return to the recent bitter recriminations between ministers and the shadow Health Secretary, Andy Burnham. There was a conspicuous lack of remedies on offer and the timetable for any changes, as MPs themselves observed, seemed somewhat leisurely, even allowing for the time that the great ship NHS ordinarily takes to adjust its course. 

Despite warnings of a new crisis next winter, there also seemed a distressing absence of new thinking. As MPs noted, there was often a worrying level of disagreement among NHS leaders themselves even on the facts of the present situation, let alone where to look for answers. Yet some of the problems may themselves contain the seeds of solutions.

On the shortage of A&E consultants, most of the recommendations offered yesterday were for the obvious, unimaginative and expensive solution: (a lot) more money to compensate for the stress of emergency departments and the inconvenience of shift working. Yet shifts, as we and many others have long argued, should be a fact of life – and a condition of employment – in the NHS. If all consultants were required to work shifts, A&E would not be seen by potential recruits as necessarily more onerous – or “less attractive” – than other specialties.

Long waits and inefficiencies in A&E, however, have to do not only with staff shortages, but with growing demand. And a remedy here – as is widely agreed – would be to persuade more people to use the alternatives. If, as many argue, it is the inadequacies of many of these services – inflexible GP appointments systems, unsatisfactory out-of-hours provision, a shortage of council-provided social care and the rushed introduction of the 111 phone line – that are pushing ever more people to A&E, improving these services should be a priority.

But an NHS England survey of A&E usage in London also pointed to another explanation. The biggest increase in those using hospital A&E departments was not, as is often believed, among elderly people or those with chronic conditions, but among those between the ages of 20 and 40 who saw them as more convenient and predictable than the alternatives. Such people are mobile; they are probably working; as consumers, they are used to instant access to everything and see no reason why seeing a doctor should be any different. If the pressure is to be taken off A&E departments, the rest of primary care must be brought urgently into the modern age.