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During the last couple of weeks you will have heard many views on why emergency departments are overcrowded.
Some say winter pressures, and older people bed blocking have contributed to the problem. Then there is the effect of the mild winter weather with more viral infections and the flu outbreak. Some have suggested it’s the result of the back-to-back Christmas and new year holidays for community teams. Or perhaps it’s the result of austerity, a lack of investment in emergency departments, a lack of capacity in general practice, the effect of reductions in hospital beds, insufficient investment in community alternatives to secondary care, an ageing population and too much emphasis on simplistic target chasing.
Personally, I don’t think the problem is any of these: no one can dispute that the effect is borne by older people who seek admission to hospital in increasing numbers, but fundamentally I blame 40- to 45-year-olds.
It is they who own or rather disown their parents leaving them entirely dependent on the services of others. A generation ago society valued the older generation. They were an integral part of family lives, treated with respect for their wisdom and experience and looked after by their families in much the same way they had looked after their own parents and of course their children.
This is still the case in some cultures, but Western civilisation is now so firmly fixated on individualism that our responsibilities to others and particularly to our older people are now forgotten.
So for some, after granny has finished being used as a free babysitter, and evidently doesn’t have much disposable cash, her usefulness is spent, and she becomes a burden. She’ll live alone and forgotten in isolation and despair and when infirmity sets in there’s no one except the state left to support her.
Have you ever tried to discharge an 80-year-old in mid January?
‘She can’t go home because the care package isn’t sufficient.’ She’ll need home help to light a fire, a nurse to get her out of bed and washed, someone to give her her medicines, a meal delivered, an afternoon visit from a social worker, and overnight carers to keep an eye.
Previously a daughter or son would have done these things but because there’s no one left who really cares, no one will spot the early signs of deterioration until it’s too late to act, and she’ll bounce back into hospital in a fortnight with a complaint that she was sent home too early.
Until individuals in our society personally value their relatives, the difficulties of Western emergency medicine will never go away.
Charles Lamb is a consultant in emergency medicine. He writes under a pseudonym
How do you think the crisis in emergency medicine should be tackled?
Reply to Charles Lamb. I think there is some truth in this, for some individuals. However, I think the main issue is societal pressures & expectations, including financial ones. Women are pressurised to have jobs, particularly full-time jobs, leaving little time for elderly relatives. Often they have barely enough time for their own families, esp if they are on shift-work. Many of them do not enjoy their work. I am not against women's rights, just realistic & reacting to the individualism now prevalent in society. Doctors should beware of criticism because, as high earners, they do not face the pressures faced more heavily by poorer people.
7 day hospitals, so 7 day gp`s please!
I had to move away from living near my parents because of the NHS. I had already committed 4 years to training and at that time I was given no choice if I wanted to continue training in my specialty. Our family was always close. I'm telling my children to beware of a career in medicine.
I agree with anon who has put it rather gently
.....Generally speaking in the good old days , the older family members lived nearby .... if not in the same house and generally speaking , they expected to live with their family.
In Eastern Cultures, there "was" large extended families, the daughters/sisters/Aunts did not go out to work, so parents at home was just the norm, daytime company, they are not used as babysitters - they just are at home along with the neighbours and other elderly visitors and females who didn't work or go to school. Everyone knew their place and I suppose it worked ....it is now changing as my generation has gone to school and now commonly work ....tipping the previous balance ......still we have different generations of people in one house .. but still it is always the females who do the caring ....and I think the same could be said for "previously in Western countries"
Juggling single motherhood/fatherhood or even juggling with a healthy partner's needs , in your 40's with a young children (lets say we are lucky enough to have them healthy, who now needs to be dropped off at politically correct times , driven to classes, so they don't become obese, PTA meetings , afterschool club meetings, played with, timetables endlessly discussed ) ......food shopping .....washing.... ironing
with the guilt of not managing mother who by choice wants to remain independent and stay in the flat she has lived in all her life which is in most cases in another town ...country even
...and generally speaking .....it is females who live longer so generally speaking ...it is going to be 80 year old ladies who come to the hospital as no one ...even here in the U.K. would expect an 80 year old man to cope by himself ...so they would tend to have support mechanisms........
+ + a full time job (if you are lucky enough to have only one job that pays the bills , that is less than hours drive away from your house/school with its consequent appraisals, lack of security, survival of the fittest ethos)
I don't BLAME them ...rather in the same way that I view staff working in the NHS with time and financial constraints ...I applaud them .....
I would charge the people who attend A&E departments with alcohol-related injuries.
The 111 service should have more clinical input.
G.P.s should have surgeries running for ten hours a day via a rota system, but should not have to open all day at the weekend.
More money needs to be spent on dealing with the social problems of the elderly.
More resources in community in the District nurse team.More GPs
Employed Carers to be part of Community District nurse team. Carers need more support and supervision. They are supporting our most vulnerable citizens. Carers should have improved training and better pay .The elderly are charged double the amount the carer receives as a result some needy patients are refusing 'expensive' carers.Lack of supervision will result in next major scandals I fear Carers need more time to care .
Out of hours gp services to be based close to A+E departments to Triage walk-in patients .
In hospital more day assessment units for the elderly . Need access to speedy test results.. Their problems are multiple and complex.
I think there has to be some penalty if patients are drunk and abusive in A+ E department .This problem appears to be getting worse .
When you say 'previously a son or daughter would have done these things', you mean a daughter or daughters. Daughters who were local, and didn't work full-time.
A generation ago we had routine discrimination against women in the workplace, women were expected to prioritise care responsibilities (of both older and younger generations) above careers, and family groups were more often local. There were larger sibling groups. The 'elderly' were younger, dying in their 60s and 70s (rather than 80s and 90s), and had fewer care needs.
Now, a two income household is necessary, movement for jobs is very common, especially from rural areas, women (thankfully!) can pursue full-time paying careers, our elderly population live longer and have more needs. Caring often cannot be shared between 3 or siblings, as they don't exist. (My nan was one of 7, my mum an only child) Care work is now rightfully recognised as work, and those who do it are paid (though at a chronically low wage). These factors make it difficult to be the carer for your parents. We cannot expect one individual to get their parent up, washed and dressed, fed 3 meals a day, medicated at the right time, entertained and watched over at night while maintaining their own life, younger family and job.
For some, even providing some of that care for a stubborn/horrible elderly person they never got on with earlier in life seems ridiculous. I know a gay man who, having been disowned by his family as a teenager, finds the prospect of being forced to care for (or worse, live with) his mother abhorrent.
I feel that is is you, not those 40-somethings, who are individualistic. You place the responsibility and blame on individuals, when really it is a societal problem. Socialised responsibility for care, paid for by taxes, along with a decent respite system for those who are involved in their parents' care, would solve the problems of bed-blocking, granny dumping and insufficient care-packages.
As a former A&E doctor ( I left the speciality in 1993 when I couldn't get a senior registrar post - haven't times changed ) I have found myself, recently retired and living in South Yorkshire, about 5 hours from my 94-year old father in West Sussex. Forunately it is 10 years since his last hospital admission but the truth remains that it would be impossible to service his needs on a daily basis from here.
It is not only doctors who find find themselves at considerable distance form their aging parents. Few people now have much choice in their work and many have to travel, or move, long distances. Low salaries are now the norm, meaning all family members have to work. Meanwhile the social care budgets are being cut.
Western society has become accustomed to state funded care of the elderly. Now that this money has been reduced, front line services are taking the hit, and society is in no mood to look back.
Properly fund General Practice so that this work doesnt get there in the first place is my advice.Being seen by a GP who knows the elderly person -(and their relatives caring and otherwise ,and who usually has access to their telephone numbers too!) -adds huge value and heads off a lot off social issues and clinically needless A&E contacts and hospital admissions.
Too many people going to A&E and WICs etcetera because our Open-Access Appointments in GPs Surgeries are now far too gummed up with our own generated Review Appointments for Chronic Disease Managemant and Secondary Prevention work for our patients, the huge agenda of which has strangled Open-Access GP Appointments over the last 10 years; the fact that now there are just no longer enough GPs and Primary Care Clinicans of all types to do all the work we can usefully do for our patients is the real and unspoken and unrecognised core of that issue. That is also why 7 day working in GP Land would be little extra value in the NHS system if we just spread the same number of appointments around from 5 days to 7 if there were no additional hands brought on board to see our patients more often when they felt they needed to be seen.
Also sad to say but Out of Hours -GP Surgery hours that is -when historically we GPs did our own on call the service to patients was much better and for example admissions from residential homes at night were few and far between as we knew the patients and the knee jerk admissions via A&E didn't happen. However doing our own on call as well as working 11-12 hour days the day before and after was no longer sustaianable and something had to give -the patients got awake doctors with energy is the daytime at least but paid the price for that.
Just fund GP land properly. If we were to be absolutely fully shredded down honest too -GP land has become such a struggle for survival day to day that sometimes corner cutting including dumping patients with problems presenting in numbers we can no longer cope with covering ourselves onto A&E and Secondary Care has become part of that sad survival strategy too .
If patients were triaged to the correct service at the beginning, they would get better care earlier. Wasting money, knowledge, on phone triages such as NHS 24 is simply a waste of time and compromises the safety of patients - who invariably (if they have bothered to phone) will have contact at some point with a healthcare worker - so it is an expensive resource wasting delaying tactic not a solution.
People are also bombarded in the media with adverts telling them of different symptoms to call an ambulance for. To us as doctors, it makes sense , but we cannot expect people/parents carers with no clinical training to differentiate between what is urgent and what is not.
By the time patient do get to A&E, they need help and it means there is nowhere else to go - whether they are having an acute anxiety attack, have taken an overdose, have been found with a head injury/epileptic fit, are elderly with a UTI, parent worried about a child's fever - at the end of the day once they are in A&E , that is where they have come for help. People without experience/training, genuinely cannot distinguish between what is urgent - to them at that moment it is real.
Cuts are not efficient in the long run - they are shortsighted - Some trusts have decide to stop employing/replacing admin staff - so the ones who are left get overstretched and leave....imposing more clerical work on already swamped charge nurses
What is happening now is a toxic circle - Cuts (in both social (day centres /support workers/ homeless coordinators/home helps and NHS) - staff not replaced - overstretching those who remain - decrease in life quality - stress in the experienced staff - they leave - and so it goes ...and then we all start looking for some one to blame
In answer to the question , I think
Social Services as well as GP practices/Mental Health services District nurses and arguably MOE consultants , should be well funded enough so there is enough permanent staff to give a 24 hr service without it becoming impossible for staff to have a life . If there are 30 full/ part time GPS working in a practice , it does become possible to give a 24 hr service and still manage to work 40hrs a week (night or day) and for everyone to do one night a week. Health care would be seen as a good job and help retention.
Stop Blaming... The young.. the old ...the parents.... the nurses... the doctors - this will not help any crisis to be resolved
Get data : Do an audit - Follow all the patients who came into your emergency department in your A&E area for a month - who are they? What happened to them - not just "were they admitted Yes/ No" ...but actually what happened next. Once you have that baseline data, you will be in a better position to argue what is needed as a priority for your specific population ....
I agree with the point about effective triage
GPs and skilled up members of our clinical teams are the best trained and most economical people to triage but if patients cannot get appointments when they have or they perceive that they have an acute problem this system breaks down. This takes investment -I refer back to my posting of 4/Feb ..........'Anonymous.Properly fund General Practice so that this work doesnt get there in the first place is my advice.Being seen by a GP who knows ........'.If GP land isnt funded properly -as applies now - the whole NHS system breaks down as AED's and Hospitals are inundated with work better done elsewhere by people who know their patients better and often best. 8.4% of the total NHS budget for a Primary Care service that still does about 90% of the health work for us Brits is crazy economic thinking and Lewis Carroll like fictional logic as what the knock-on costs are of that underinvestment I little factual idea beyond my clear impression that they are huge and growing.
Writer is a Retired GP: Dr Lamb is entirely wrong to blame one small group of people for the ''crisis'' (how overused that word is) in A&E. In fact no single group is to blame .In fact the word blame should not be used at all. People in middle age lead busy lives and they have jobs and mortgages to maintain as well as caring for thier own chlidren. They cannot drop everything to care for elderly relatives. A major factor in this problem is the change that has occurred in general practice since 2004. I started in 1971 and our comitment to practice was 24/7, meaning we were never off duty unless we had delegated responsibility to our patients to another GP. Today practice in measured in hours of duty, and hours off duty. I saw it as my job to keep patients out of hospital, and I would often visit the same patient three times in 24 hours or five times over a weekend. Mostly the crisis would resolve itself, and an elderly patient would not need admission. Latterly in my time in practice, elderly patients were in hospital for such a short time e.g. 2-3 days that they would be no better on discharge and sometimes in a worse state of health.
I am not ''blaming'' anyone for the current situation, neither the GPs, the relatives nor ''society''. I do not like the terms ''bed-blockers'' or ''time-wasters''. In some ways all patients are time-wasters, but so also are some doctors!
I enjoyed immensely my forty years in medical practice, and I had the advantage of having a wife who did not go out to work. I do not think that would in todays world
to behave more as a human
An over simplistic view of modern life is what this article offers.
1) Many families simply cannot afford to have someone cut hours or leave a job to care for elderly relatives
2)Many families don't live in the same area, they are spread over whole countries and even continents
3) Many older people don't have children to care for them
4)Many people have had to move away from family for reasons outwith their control (anyone in medical training should be able to appreciate this)
Frankly, the care crisis in the UK is multifactoral, finger pointing and scapegoating does nothing to solve this very complicated problem.
Society, government (local and national) and health/social services need to work together in finding solutions to this complex conundrum, rather than working out who is most to blame.