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Will!

The Nhs As I See It - A Hospital Doctor's View

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Hi all

I'm writing an article for publication about the current state of the NHS. I thought it might be fun to post some of the drafts here and see what kind of feedback I get. I hope to cover quite a few major topics including the debate about healthcare in America, swine flu, public funding, doctor's training and the European Working Time Directive. If anyone has any other suggestions I'd very much like to hear them.

First a little about me. I'm an Accident & Emergency doctor working in a large hopital in the south of England. I've worked in quite a few places in England in a variety of medical and surgical specialties and also in Johannesburg in trauma surgery.

These are only first drafts. Some of the stuff I post here may get re-written, deleted or disowned entirely as I proceed. There may also be quite long delays between my posts - I haven't forgotten about this thread and I will get back to it.

Cheers

Will

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The Accident & Emergency Department

If you've sustained a significant injury or become seriously ill then you've probably been to an Accident & Emergency (A&E) department (or 'casualty' as it used to be called). Patients attending the department have a wide range of reasons for doing so but the one concern they all share is how long they'll have to wait and for many it seems like they wait a significant amount of time. There are a number of reasons for this.

When a patient attends the department they go through a process called 'triage'. The purpose of this is to establish who is the most ill and thus who needs to be seen first. If you've sprained your ankle it may really, really, really hurt but you're not very likely to lose your foot as a result of it and thus you'll wait until all the more seriously injured patients have been seen. Many patients see people who've arrived after them in the department being seen before them and to some this seems unfair. Triage saves lives and limbs but it doesn't do much for worn patience and frayed tempers.

There a number of things A&E staff do to try to counter this:

The first is explanation. We try to explain to people why they are waiting. Unfortunately this requires each patient to have a sense of perspective about the severity of their own injuries relative to the injuries of others. Of course, they don't know what those other injuries are. For some people their back pain or sore throat may be the most pain they've ever been in their lives and they simply can't imagine that there are other patients worse off than them.

The second is re-direction. A significant number of people who attend A&E have complaints that could be addressed more quickly by a pharmacist or GP. Some people believe that going to the *Emergency* Deparment will result in them being seen more quickly. Unfortunately the patient with a long-standing problem with itchy haemorrhoids that he has just decided needs to be sorted *right now* may well find himself waiting longer than if he'd gone to see his GP. Many patients who attend A&E say that they couldn't get an appointment to see their GP. All GP practices offer same-day emergency appointments, not necessarily with the patient's own GP but with a GP in that practice, and there is an out of hours GP service that offers appointments 24/7.

The third, and by far the most controversial, is education of the general public.

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How dare you come on this forum and speak sense? ;)

The thing that really annoys me whenever I've had to visit an A&E department is that some people bring along their entire flipping family, and do they ever give up their seats for those that have come in with sprained ankles or using crutches?

From my experience, no.

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How dare you come on this forum and speak sense? ;)

The thing that really annoys me whenever I've had to visit an A&E department is that some people bring along their entire flipping family, and do they ever give up their seats for those that have come in with sprained ankles or using crutches?

From my experience, no.

Some people don't have anyone they can leave other children with though and are so distressed that they can't think beyong what's happening to their own injured person, if you want a seat ask for it.

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The third, and by far the most controversial, is education of the general public.

This is the only interesting point since the rest of what you've written is pretty obvious common sense to anyone who does have any kind of education. FFIW, given the context of the current storm in a teapcup, I've had the pleasure of visiting both a UK A&E department and a US Emergency Room as a patient and the treatment, including the very short wait (no more than a couple of minutes in both cases), was pretty much identical right down to the attending doctor in both cases being Irish.

The big difference was after the ER where the American hospital wanted to know how I was going to pay before they'd move me to a general ward - I had very good company provided health cover so no problem there but, if I hadn't, I'd have been in real trouble at that point.

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I always find timing is key to heading to A & E - if you have nothing too serious !!

Try and get down there for 6-7am. Unless there is some big emergency on - you will probably be seen within minutes.

People head down at 11am on a Saturday morning during the school term - and wonder why the place is mobbed.Or at 11pm on a Saturday night. Not difficult to work out why !!

Am I right Will ?

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I always find timing is key to heading to A & E - if you have nothing too serious !!

Try and get down there for 6-7am. Unless there is some big emergency on - you will probably be seen within minutes.

People head down at 11am on a Saturday morning during the school term - and wonder why the place is mobbed.Or at 11pm on a Saturday night. Not difficult to work out why !!

Am I right Will ?

I've never been much good at scheduling my accidents or emergencies with such precision.

p-o-p

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Some people don't have anyone they can leave other children with though and are so distressed that they can't think beyong what's happening to their own injured person, if you want a seat ask for it.

Perhaps I should have delved a little deeper in my example. On the 4 or 5 times I've been to A&E in the past few years, I have seen families of 6/7 with children of an age that could be left at home, taking up too many chairs in the waiting area. They weren't there waiting for a family member tat had been in a car crash or fallen from a building site. No, chav dad had a nasty cough or had hurt his elbow whilst pished and couldn't be bothered waiting for the doctors surgery to open in the morning.

Someone so clearly injured as to be hobbling around on crutches should not need to ask anyone for a seat.

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Years ago - not that long ago - people would go to their local pharmacist or call out their family GP instead of going to A&E. Now, they have no choice but to go to A&E.

The GP would be known to the family and, more importantly, the GP would know the family - their medical history would be as well known to him as his own. Also, the GP would work on weekends and into the evening. If there was an emergency the GP would come out at 2, 3 or 4 in the morning.

This no longer happens and the public is less served as a result. I think GPs are 'less', in so many ways, as a result.

Likewise, the local chemist would often be run and owned by a pharmacist who pretty much mirrored the above GP. If you did not have a prescription but needed a medicine the pharmacist would often give you the medicine whilst waiting for you to get the script from your GP or would simply contact the GP him or herself.

Because you knew and trusted the pharmacist, and the pharmacist knew your family history, then you trusted them for advice and were happy to discuss confidential matters with him or her.

These days more and more chemists are run by chains who rota in and rota out pharmacists so that wonderful and important personal relationship between a pharmacist and the Public has more or less gone.

I think the medical community has a lot to blame themselves for - especially Doctors who have chased big bucks from the NHS. Yes, you guys are now incredibly wealthy - far too wealthy IMPO - and you all seem to have property portfolios or investments in wine bars... but you are not a patch on the GPs of 20 and 30 years ago, are less well respected generally I suspect and, although most of you do not realise it, I think you are 'less' as Doctors.

It is quite ironic that one of the few ITV hits at the moment is that Martin Clunes' drama where he plays a surgeon who moves to a fishing village in Cornwall to become a GP - he basically has become a GP of 30 years ago where everyone knows him and he knows everyone. In reality, that is less and less likely nowadays. Ironic huh?

p.s.

You writing style is too linear - you are starting at the beginning and working through your thoughts, in your writing, in a linear manner who is tiring and boring to the reader. No offence meant - just an observation.

Why not start at the end of begin with a good anecdotal? Why not remind people of what used to happen when you were sick, as a child, and how, I suspect, your family GP came out in the middle of the night to see you whereas, nowadays, you would be forced to go to A&E?

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I've never been much good at scheduling my accidents or emergencies with such precision.

p-o-p

That is why I said if it is nothing too serious. ;)

Most things could easily wait another couple of hours. Personally I would rather sit with a sprained ankle in the house for 6 hours - then be seen within minutes. Rather than head straight to the A & E at a busy time and sit in a waiting room for 6 hours. Just a personal preference.

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Guest AuntJess
Years ago - not that long ago - people would go to their local pharmacist or call out their family GP instead of going to A&E. Now, they have no choice but to go to A&E.

The GP would be known to the family and, more importantly, the GP would know the family - their medical history would be as well known to him as his own. Also, the GP would work on weekends and into the evening. If there was an emergency the GP would come out at 2, 3 or 4 in the morning.

This no longer happens and the public is less served as a result. I think GPs are 'less', in so many ways, as a result.

Likewise, the local chemist would often be run and owned by a pharmacist who pretty much mirrored the above GP. If you did not have a prescription but needed a medicine the pharmacist would often give you the medicine whilst waiting for you to get the script from your GP or would simply contact the GP him or herself.

Because you knew and trusted the pharmacist, and the pharmacist knew your family history, then you trusted them for advice and were happy to discuss confidential matters with him or her.

These days more and more chemists are run by chains who rota in and rota out pharmacists so that wonderful and important personal relationship between a pharmacist and the Public has more or less gone.

I think the medical community has a lot to blame themselves for - especially Doctors who have chased big bucks from the NHS. Yes, you guys are now incredibly wealthy - far too wealthy IMPO - and you all seem to have property portfolios or investments in wine bars... but you are not a patch on the GPs of 20 and 30 years ago, are less well respected generally I suspect and, although most of you do not realise it, I think you are 'less' as Doctors.

It is quite ironic that one of the few ITV hits at the moment is that Martin Clunes' drama where he plays a surgeon who moves to a fishing village in Cornwall to become a GP - he basically has become a GP of 30 years ago where everyone knows him and he knows everyone. In reality, that is less and less likely nowadays. Ironic huh?

p.s.

You writing style is too linear - you are starting at the beginning and working through your thoughts, in your writing, in a linear manner who is tiring and boring to the reader. No offence meant - just an observation.

Why not start at the end of begin with a good anecdotal? Why not remind people of what used to happen when you were sick, as a child, and how, I suspect, your family GP came out in the middle of the night to see you whereas, nowadays, you would be forced to go to A&E?

I would go along with the depersonalisation of medical services - to their detriment. GPs did small ops 40-odd years ago. I had a wart taken off the back of my hand at 15 years old - a scalpel, bit of antiseptic and it was all done and dusted within 10 minutes.

My daughter had similar problem with a wart on her leg. She had to make an appointment and wait weeks to go to outpatients, then waited ninety minutes :angry: in the waiting room, which would have been longer, if I had not torn a strip off the nurse on duty who seemed to feel entitled to let people go before us - because she knew them!

When she got in there they burn it off with nitric acid or summat equally drastic.

Much has deteriorated in the last 40-odd years in the NHS. Young sprogs barely out of short pants don't realise this, but some of us can remember the better service we got, and we miss it.

PS I know A&E can't guarantee when you'll be seen, as it is an unpredictable section, but WHY the loo-o-ong wait in outpatients ?

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When a patient attends the department they go through a process called 'triage'.

triage is the problem.

its a good system when dealing with a plane crash, but for normal A&E its not.

for a start the triage nurse doesnt do anything. just sat on his/her fat a$$ asking dumb questions.

what should happen - you get a bed straight away, triage nurse hooks you up to the heart monitor (oh sorry NHS doesnt have these do they) then starts asking the questions and decides if you need a doctor right now or if it can wait 10mins.

triage should not be done in the waiting room.

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My daughter had similar problem with a wart on her leg.

...

When she got in there they burn it off with nitric acid or summat equally drastic.

Liquid nitrogen?

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Actually, you'll see nitrogen dioxide, steam and oxygen released since nitric acid tends to decompose at 0 degrees or above if concentrated.

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I am a former nurse/ healthcare officer.

A+E would not need triage if people could stop making a drama out of a crisis, the waste of time for those coming in with scratches and minor ailments is ridiculous and hence the need to prioritise.

GP's should, as mine do have an open surgery where things can be assessed and referred if neccessary.

Fri/ Sat nights are hell with drunks falling all over the place and abusing staff, drugs too play a part in this and waste resources.

My recent experiences of the NHS are poor, very poor with underqualified staff forgetting about dignity and compassion.

Too much of ' it's not my job' going on, resources are needlessly wasted.

I have recently been really disturbed by lack of hygene, can anyone explain why a hospital cafe has cakes and pastries open on the counter top for everyone to sneeze all over during the threat of swine flu. There is a huge oncology ( cancer) dept in this hospital, food is poor so relatives try and get something appealing for their nearest and dearest. Those undergoing chemo are prone to infection with compromised immunity.

It just seems that common sense departed along with matrons and proper uniforms. I'm so insensed at seeing people in Sainsburys and similar in their scubs with stethescopes dangling in to the freezers.

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Ah, good to see you've progressed beyond 300+ year old treatments (chopping things off) for cancer then. Oh wait, I forgot how applying untargeted pharmaceuticals to the human body is wonderful :lol:

The NHS is technically completely free to me at the moment but I still wouldn't touch it with a bargepole in most instances. I'd trust them to patch me up after an accident and appreciate that, for the most part though I'm not impressed.

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I am a former nurse/ healthcare officer.

A+E would not need triage if people could stop making a drama out of a crisis, the waste of time for those coming in with scratches and minor ailments is ridiculous and hence the need to prioritise.

GP's should, as mine do have an open surgery where things can be assessed and referred if neccessary.

Fri/ Sat nights are hell with drunks falling all over the place and abusing staff, drugs too play a part in this and waste resources.

My recent experiences of the NHS are poor, very poor with underqualified staff forgetting about dignity and compassion.

Too much of ' it's not my job' going on, resources are needlessly wasted.

I have recently been really disturbed by lack of hygene, can anyone explain why a hospital cafe has cakes and pastries open on the counter top for everyone to sneeze all over during the threat of swine flu. There is a huge oncology ( cancer) dept in this hospital, food is poor so relatives try and get something appealing for their nearest and dearest. Those undergoing chemo are prone to infection with compromised immunity.

It just seems that common sense departed along with matrons and proper uniforms. I'm so insensed at seeing people in Sainsburys and similar in their scubs with stethescopes dangling in to the freezers.

So would you say people like myself who wait for the quiet times help matters ?

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Guest AuntJess
I am a former nurse/ healthcare officer.

A+E would not need triage if people could stop making a drama out of a crisis, the waste of time for those coming in with scratches and minor ailments is ridiculous and hence the need to prioritise.

GP's should, as mine do have an open surgery where things can be assessed and referred if neccessary.

Fri/ Sat nights are hell with drunks falling all over the place and abusing staff, drugs too play a part in this and waste resources.

My recent experiences of the NHS are poor, very poor with underqualified staff forgetting about dignity and compassion.

Too much of ' it's not my job' going on, resources are needlessly wasted.

I have recently been really disturbed by lack of hygene, can anyone explain why a hospital cafe has cakes and pastries open on the counter top for everyone to sneeze all over during the threat of swine flu. There is a huge oncology ( cancer) dept in this hospital, food is poor so relatives try and get something appealing for their nearest and dearest. Those undergoing chemo are prone to infection with compromised immunity.

It just seems that common sense departed along with matrons and proper uniforms. I'm so insensed at seeing people in Sainsburys and similar in their scubs with stethescopes dangling in to the freezers.

+1

We are short a few battle axes to wield power, instilling fear and dread into those who flout these essential rules.

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departed along with matrons and proper uniforms

Yes, bring back matrons and proper uniforms. I have no idea whether that would make any difference to the quality of care but the entertainment value would be immeasurable. I'd say bring back Hatti Jacques too if she wasn't, very sadly, dead.

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The third, and by far the most controversial, is education of the general public.

There is an aphorism in medicine that all A&E departments are abused by patients (as in used for conditions which would have been better treated elsewhere as opposed to verbal and physical of A&E staff - although more on that later) because A&E staff define what abuse is.

To understand the way the public see A&E it is necessary to look at the history of the NHS. The NHS was founded in 1948 with three core principles:

* that it meet the needs of everyone,

* that it be free at the point of delivery, and

* that it be based on clinical need, not ability to pay.

These principles are very much the product of assumptions that were shaped during WWII. Specifically they assume that people will use the service responsibly. During a war in which bombs were falling nightly and the nation's very existence in jeopardy that wasn't a difficult assumption to make. To call an ambulance because you'd stubbed your toe would be wasting a resource that you yourself might need very soon, and so self interest would dictate that you wouldn't do it.

As time passed a generation grew up who had never known a time when these assumptions were prevalent and who largely took the NHS for granted. Without that enforced meeting of social responsibility and self-interest produced by the extremity of war, many people saw the NHS as something that they paid for and therefore were entitled to use however they wanted.

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To call an ambulance because you'd stubbed your toe

How many people as a proportion of the total do that? Clearly there are high profile, often ludicrous, examples of morons calling 999 because they can't get the microwave to switch on but they don't provide any statistical evidence of how well or badly the service is used in general. Equally, as an A&E medic, you'll quite likely remember the extreme cases (in both directions) but do you have any hard facts to say x % of the people who turn up to A&E really shouldn't be there? A long time ago I had the joy of working on an IT helpdesk during a university vacation and I often found myself cursing the idiots that called up for wasting my time. However, when the boss went through a weeks worth of user issues with me to see what could be done to cut the number of stupid calls down, it became clear that at least 80% were genuine and reasonable, it's just that the stupid stuff stood out more.

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