Wednesday, 26 June 2013

Healthcare gatekeepers

Curious the similarities and dissimilarities between the US and Europe.

On both sides of the Atlantic, we live in societies that proclaim the sanctity of human rights, and which honour them except when some overriding factor, such as the race or creed of the individual, makes it more convenient to flout them.

Equally, our societies uphold the rule of law, except when governments feel that it’s too constricting and they think they can get away with circumventing it.

Finally, our nations are built on the principle that power is exercised by consent and that government can only rule with the support of the people, except on those occasions when ministers want, say, to wage a war and therefore need to ignore the pusillanimous refusal of voters to see that this is the right thing to do.

However, striking though the similarities are, there are also major transatlantic differences. For instance, a large majority in the US remains wedded to the retention of the death penalty, a view they apparently regard as justified by the astronomically high murder rate they enjoy.

Another significant difference is the approach to healthcare. A great many European nations feel that a person needing care should receive it without consideration of his or her ability to pay. Many in the US, on the other hand, see this idea as a dangerous concession to socialistic thinking, one that infringes the individual’s fundamental right to be kept waiting for treatment while finance staff check on insurance or, in the absence of cover, other means of paying for care.

It has to be said that the European model of treatment free, or nearly free, at the point of care, does make it difficult to limit demand on hospitals.

In Britain, the issue was addressed by asking General Practitioners to act as gatekeepers. Except for emergency patients, hospital care was only available on referral by a GP to a hospital physician.

That ‘except’ is the problem, of course. Because people who don’t want to go through their GP just recategorise themselves as emergencies and turn up at Accident and Emergency departments. A good article in today’s Guardian relates some horror stories from the Bradford Royal Infirmary: a patient in A&E to have a false nail removed, another for a pregnancy test she could have bought from a pharmacy…

But these are exceptional cases. What is clear is that there is mounting pressure on A&E departments, leaving them under a strain that is close to unbearable, and putting hospital budgets in jeopardy. There is, it seems, an increasing tendency in society to view a hospital A&E department as a first port of call in injury or sickness rather than a last; at the same time, in a society where more survive into frail old age, a greater number of people are showing up with serious problems requiring treatment.

A&E may sometimes look like a substitute for a GP surgery,
but it really, really isn't

Clearly the GP as gatekeeper system is failing. I saw this when I was working with my local hospital: A&E attendances were climbing inexorably, and emergency admissions growing with them, putting services under intolerable pressure. 

One attempt at a solution the hospital explored was to open a general practice inside the hospital, right by the main entrance. This seemed a good idea: patients would have the impression they were going to hospital but would be seen by general practice rather than far more expensive hospital staff. The sustained increase in A&E attendance showed, however, that it wasn’t working.

In my view, the scheme had one great flaw: the practice was to one side of the entrance to A&E.

What I’d like to see happen is the practice to be set up right in front of A&E so that only people arriving by ambulance would be able to access emergency services directly. Everybody else would have to pass through the GP practice, where they would be triaged: those absolutely requiring hospital services would be passed through, the others would be treated by practice staff.

That would make GPs truly gatekeepers to the service.

It strikes me that it’s an idea worth trying. Apart from anything else, it might help us preserve the specific characteristic of the British system, an idea I rather like, not just because I prefer not having to reach for a wallet at a time when I’m already seriously off colour, but because, funnily enough, our system costs little over half as much as the American model.

Which sounds like win-win to me.

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