Book review: In Stitches by Dr Richard Edwards
An easy yet intriguing read, “In stitches” is an A&E testimonial of an accumulation of cases (not chronologically arranged) and how A&E departments run in conjunction with hospitals. Although, there are a lot on interesting cases denoted in the book, there is a pattern or common trope to patients presenting with an issue - the only thing that realistically changes is the patient itself. Therefore, I will be honing in on two points that stood out significantly which relate back to how the NHS is run.
Firstly, we all know of the four hour A&E target, where 98% of patients should be seen and treated within this rule to streamline the admission process. Although over the many years this system has brought along some efficiency, such as through the use of triage and specialist nurses so that doctors do not have to become involved, raw data fiddling still exists. In fact, the BMA and BAAEM presented that 31% of A&E doctors have admitted to working in departments where “data manipulation was used as an additional measure to meet emergency access targets”. This is to prevent the hospital being financially penalised by NHS managers when several breaches occur and lowering its ‘star performance score’ . Strategies embraced by departments to meet the 4 hour target include:
Patients being discharged on the computer before they have left A&E.
Patients being admitted to A&E by the computer but not physically as there are more beds on the system than there are in real life.
If patients appear with a referral from the GP, they are admitted to the admission ward, not A&E, so no target is assigned.
If a patient is referred to a specialist after being seen by an A&E doctor, they can be left waiting for hours since they are not assigned similarly to the 4 hour target.
On days when the target is being assessed, elective operations may be cancelled to free up beds and the hospital employs locum doctors and nurses to appear as if targets are being consistently met.
Have you ever wondered why you have to be referred by the GP to a specialist first and not directly by the hospital doctors, who may in fact know your case better? The reason being, and my second point in play, is that accountancy yet dominates clinical rules. A&E doctors cannot easily make referrals, instead they have to send the patient back to the GP for the referral too be made. Yes, the NHS still bears the weight of the cost, but referrals from the GP come from a different pot and the hospital instead is paid by the primary care trust. This comes at the expense of the patient, and in some cases may cause further damage; such as when a patient has a TIA (transient ischaemic attack), they should be seen in a TIA/prevention stroke clinic within two weeks according to evidence based medicine to prevent a stroke. But this is not always the case. Doctors are taught the gold standard of care but often due to management structures and rationing of resources leads to a realistic silver and bronze quality of care being delivered. The NHS in sectors is disjointed and separate parts work independently: accountancy here unfortunately wins.
“In stitches” and my short book review are just continuous arguments that the NHS needs more resources; that targets should not be solely made by politicians without the input of doctors working in the clinical environment and that hospitals should not be penalised for failure of not meeting these unrealistic targets as it only adds pressure to the already pressurised NHS.
