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I usually make house calls on a Friday afternoon, seeing some of our older, housebound patients. Mr A is an insulin-dependent diabetic who has been unwell with vomiting and a urinary tract infection for a few days. He has been on antibiotics but is making slow progress. He is unable to keep fluids down and his blood sugar levels have been so low that I have cut down his insulin dose. When I see him at around three in the afternoon, he appears fatigued and dehydrated. His blood pressure is low and I decide that he needs intravenous drips, which, as a GP, I can't do.
I struggle to speak to someone in the hospital as the phone lines are busy. When I finally get through, I refer him for a medical admission, but there is no bed on the medical admissions ward, so he has to first go to A&E. I have no choice but to admit him to hospital. The nearest "safe haven" bed with nursing support and access to drips – set up to avoid admission to an acute hospital – is not available that evening. I know nursing home placements can take weeks or even months to organise. I explain all this to Mr A and his wife and they reluctantly get ready to go to hospital while I call the ambulance.
As GPs, our hospital referral rates are constantly being scrutinised. The aim is to avoid any "unnecessary" attendances. But though, in theory, it makes perfect sense for patients to receive their treatments in the familiar, and often more comfortable, surroundings of a GP surgery, it begs the question: is quality of care being compromised to make NHS savings?
I agree that, unless it is an "accident" or an "emergency", no one should have to go to A&E. Waiting for hours to see clinicians who are working in pressured surroundings, often with no access to old medical notes, is not ideal.
Problems arise when illnesses that GPs class as minor – sore throats, coughs and minor urinary infections, which could be treated by us the next day – seem more serious to patients, who take themselves off to hospital. There are NHS initiatives to encourage patients to see their GPs first, but lack of GP appointments in overstretched areas, and even living close to an A&E, are cited as common reasons for attendance.
Mr A was discharged in the early hours of Saturday feeling much the same. Many NHS trusts have reduced the number of in-patient beds, and doctors are encouraged to promptly discharge patients. He received daily, close monitoring from GPs and community nurses for a week, but declined any further hospital admissions. He lost a lot of weight and remained very frail, so much so that he fell and fractured his hip a few weeks later. He is now on an orthopaedic ward awaiting surgery.
Mr A should either have been kept in hospital longer and treated when I referred him, or – if GPs are expected to plug the gap between hospital and community settings – more district nurses, community matrons, midwives and social workers are needed. Only then can Mr A and thousands like him start to cost the NHS less in the long term.
• Zara Aziz is a GP partner in a practice in north-east Bristol. She is part of the local GP consortia group
Comments
19 June 2012 3:28PM
I think in fairness there are also some GPs who refer unnecessarily. I know in my wife's practice (she runs it despite being a salaried GP as the sole partner is 'retired' but still a partner) they have a newly qualified GP who refers loads of cases she shouldn't through a combination of 'wanting to be on the safe side' and not wanting to tell a patient that they don't need a referral.
With coaching and by growing in confidence she is now referring a lot less cases.
Patients using A&E when they shouldn't is a different matter altogether.
20 June 2012 11:45AM
Would it not be simpler to ask "the authorities" to allow GPs to rig up a saline drip in the patient's home?
20 June 2012 11:47AM
Thanks for this. For Mr A, as well as the community roles you mention, I wonder if the diabetes consultants and nurse specialists, who usually work on wards and outpatients, should be 'virtual' members of community teams, and come out to prevent conditions deteriorating.
When people have dementia, the balance is shifted further in favour of treatment at home, by the disorientating effect of new surroundings - whether in hospital or a community bed. And even more important to manage acute conditions early. There might not be the understanding and tolerance of, and co-operation with, being on a drip.
20 June 2012 11:49AM
It isn't rocket science
20 June 2012 6:38PM
Re "If GPs are expected to plug the gap between hospital and community settings – more district nurses, community matrons, midwives and social workers are needed".......correct, apart from social workers, who aren't of much practical use, apart from filling in various forms.
20 June 2012 8:28PM
In our ageing population sometimes it is just one minor thing that tips the balance and they are unable to safely manage their medical problems at home. Lack of hospital beds is not just compounded by more referrals, but also long term inpatients who are unable to be discharged because they are waiting for placements in residential homes or for social care packages, hence the need for robust social services. I think healthcare staff in hospitals are working increasingly harder because of all these pressures.
21 June 2012 11:53AM
Couldn't agree more with the article.
With an increasingly ageing population, it will only get worse and changes need to be made now to sort it out.