24 hours in A+E: the Guardian version

You couldn't really expect me to pass up the opportunity to blog on this, could you? Grauniad journo Denis Campbell spends a day at Bradford A+E:

"People have come with period pains, ingrowing toenails and wanting sets of false fingernails removed," said [head of Bradford A+E] Wilson. "I once even had a young woman arrive – by ambulance – asking for a pregnancy test when she could have just got one in Boots."

I'd like to invite the audience to imagine how this arose. You're a Generation Y member, moved out from your parents' house and living in a basement flat with no Significant Other in residence. On Friday morning your toe starts to hurt a little, and by Friday evening it's really quite painful. Obvious answer: go and see your GP. Surprise! There's little to no chance of seeing the GP until Monday morning (and even then it's random luck if you get a slot, if it's anything like my previous GP surgery). You have no idea what an NHS walk-in centre is. Easy choice: A+E.

It's all very well for Dr. Wilson to get excised about the undoubted lack of stoicism of the modern public:

Three hundred and fifty million years of evolution means the human body has learned to deal pretty well with most ailments. Yet no one is willing to give things time to get better. They access emergency practitioners for advice when all they really need is two or three days, or a week, to get better

but the reality is that with the parlous state of the job market they often can't afford to take the time off. Even if they did, staying at home for several days to try to recuperate and hope their injury or illness gets better, who would look after them? And what of the people who aren't sure whether their rash and aversion to bright light is just another bug or potentially fatal meningitis? Who makes that call?

People coming to A+E with minor ailments is undoubtedly a serious issue, tying up very scarce resources. The simple way to deal with that is to make GPs more accessible, but the Labour government really screwed the pooch on that one:

The current situation "isn't sustainable", she warns. "We need changes, like GPs being available 24/7," she adds.

Yes, we do. GPs have settled into a very comfortable 5 day week with regular hours, and retained really high pay for this. There are many GPs who go above and beyond for their patients out of hours, but unfortunately way too many who are quite happy to take the cash and do the minimum. My personal experience is that about 50% of GPs earn their money (or deserve more), and 50% are massively overpaid for what they do.

Spencer is also keen to introduce some GPs into their A&E, to handle those with less serious illness.

Now this is a good idea, if they can make it work, get triaging right, and actually find a source of GPs who will do this work without demanding vast sums of cash for the privilege. I wish Sandy Spencer luck, she's going to need it.

That's not the sole problem that A+E faces - even once it has deflected the minor injuries, there are still way too many people who need to be admitted, and not enough beds:

"More patients are more medically complex. People are living longer and therefore older people present with a higher incidence of illness", explains Halstead. "There's now no age discrimination. Previously you'd have said: 'Oh he's 75, that's a good innings, there's nothing more we can do for him.' Whereas these days everybody is treated with whatever is available to relieve their condition, no matter what age they are."

And with a health system with finite resources, the tens of thousands of pounds needed to give an 85 year old an angioplasty rather than letting him or her die will be money that can't be spent e.g. employing more care assistants to ensure adequate coverage on a geriatric ward. Now that may be a trade off that we should be making - or it may not - but no-one seems to want to have that debate for some strange reason.

The NHS has to decide what it wants to do about A+E and how it's going to ration the treatment and budget available against the unbounded demands of the public. If you want healthcare to continue to be free at the point of demand, you're going to find it quite surprising how expensive it can be to supply it. There are hard choices to be made, and we do not ask the Government to make them perfectly; they must, however, make them.