Abstract
Winter is coming. Our coldest months are reserved for newspaper headlines about chaos in the halls of emergency departments that teem with people desperate to seek care, warmth and, possibly, treatment. That will still happen, of course, but emergency care is almost a daily debate, the Jerry Springer Show of medicine, with each news story making a dramatic attempt to shock us more than the last. Emergency departments are inundated, we are told, crippled, even crushed. Patients are bypassing general practice, since a same day appointment is but a memory, and joining a stampede to their local hospital. The gatekeeper function of primary care is defunct. With general practice on its knees, a domino effect brings despair to emergency departments and hospitals. The system is broken. Where is the urgent fix?
Solutions become possible when we achieve clarity about the problems, especially if they happen to be informed by data. And that has been one of the issues with the emergency care debate, we don't seem to have a precise grasp of the challenges. Any change in the gatekeeper function of primary care has been difficult to pinpoint. In this issue, Thomas Cowling and colleagues bring us some much needed clarity. Their essay, with data analysis, maps out the time trends of how patients are using emergency care in England, and what this means for hospital admissions and general practice consultations. 1
The authors confirm some of the speculation. Emergency care is stretched. Hospital admissions via emergency departments are rising. Patients are indeed bypassing primary care. And the gatekeeper function of primary care is disintegrating. Our existing system of urgent and emergency care has been described as unaffordable, unsustainable and fragmented. These claims may have substance, and the time trends for England are echoed by similar findings in the United States. Answers may lie in improved urgent care in general practice and a better gatekeeping service provided by emergency departments. Solutions are required quickly and they must be evaluated before scale up, say the authors, to avoid further ad hoc service developments.
A stretched service may also raise issues of patient safety and quality control. Experts in patient safety have long acclaimed the approach to safety of other industries like aviation, railways and seafaring. Now, Carl Macrae and Charles Vincent go one step further by arguing for a nimble but effective independent safety investigation body in keeping with those that exist elsewhere, like the accident investigation branches of the transport industries in the UK. 2 In a statement that holds equally true for emergency care reform, the authors conclude that we must learn from the past to improve the future.