There's good emergency service triage. And then there's the other kind

It came as a bit of a surprise when the French Emergency Department doctor (‘urgentiste’) I was talking to asked if we could postpone for a week the webinar we were planning.

‘You may have picked up that there’s a bit of a controversy in France around emergency services right now, and we’re even more crazily busy than usual.’

Well, I hadn’t picked that up. But two friends were with us from the glorious Eastern French city of Strasbourg where we used to live. One of them was a nurse, so I reckoned she’d know. Though actually both of them were fully up to date, and for a good reason.

‘Yes, a terrible scandal,’ they told me. 'In Strasbourg.’

The problem had arisen on a call to the emergency services. Rather than describe what happened, I’ll just translate the transcription of the call, between a frightened caller and a triage clerk:

‘Miss, I’m in pain…’

‘OK, so you phone a doctor, OK, got it? You understand, phone SOS Médecins [the primary doctor emergency service].'

‘I can’t.’

‘You can’t? Oh, really, you can phone the ambulance service but you can’t…’

‘I’m going to die.’

‘Yes, you’re going to die, without a doubt, some day, like everyone else… Ring SOS Médecins, OK?’

‘Please, help me, Miss.’

‘I can’t help you. I don’t know what’s wrong with you.’

‘It hurts, it hurts…’

It’s hard to disagree with the Enquiry finding that the clerk’s tone was harsh.

That was at 11:30. At 12:32, a relative rang again and, by sheer bad luck, was dealt with by the same clerk. Again, the call wasn’t put through to a physician, although two were available.

At 13:47, SOS Médecins itself called the emergency service. This time a different clerk answered. She put the call through to a physician who immediately sent an ambulance. It arrived at 13:58. Some two hours twenty minutes had been wasted by then, and that proved critical: although the patient was immediately hospitalised, she died at 17:30.

She was 22.

This tragic litany proved career-limiting for the first triage clerk, who has been suspended pending dismissal. It did no good to the emergency service director either, with the report of the Enquiry recommending that his resignation, already offered, be accepted.

It’s a classic case of rare – or hopefully rare – ineptitude. A fine object lesson in how not to run triage. Triage is the process by which healthcare staff decide what level of care a patient might need. Clearly, it failed in this case.

However, that there’s one other aspect of these events which casts a still deeper shadow over them. The woman who died was called Naomi Musenga. As my French friends point out, even on the telephone, her accent would have revealed her sub-Saharan African roots.

Naomi Musenga, in a photo from franceouest.fr
Would she have been treated differently if she’d been white?

Would the clerk have reacted differently had the caller’s voice identified her as white? Who can say? But the way things are in the world today, how can we immediately rule it out?

At any rate, it’s no wonder my French ED physician was too busy for a webinar this week.

Austerity in the GP surgery

Curious.

We – my wife and I together – joined our current GP practice because the service was simply so much better than any other we’d known.

The practice is associated with a walk-in centre, which itself provided great support for patients: anyone needing care immediately but not urgently – in other words, patients who were sick or in pain but not obviously suffering from anything potentially life-threatening – could attend the centre and be seen, seven days a week, from early morning into the evening.

A generous service. But not one it pays to cut

That’s a relatively expensive service to provide. There is at large today, throughout the Western world, a view that such expense should be cut back wherever possible. I wrote the other day that it’s often in the little things that we see austerity economics at work, and our GP practice is no exception.

Today, Saturday, I tried to renew a prescription on-line. That didn’t work. I could log in to the system but the buttons thoughtfully provided to select a medication to renew simply didn’t react if I clicked on them (and, before I’m challenged as a computer illiterate, let me assure you that I tried on two machines, using tree different browsers between them).

I then phoned the surgery but was told that, while the walk-in centre was open, the surgery itself was not. Could I ring in again on Monday?

“Yes,” my wife told me, “we’ve had a couple of letters. Funding’s been reduced so that they can’t stay open at weekends any longer.”

Once more, I felt the glacial fingers of austerity gripping my innards.

If the GP practice is facing cutbacks, the walk-in centre won’t be far behind.

While the service it provides seems generous, it’s only those with the narrowest of account-book outlooks, entirely focused on the short term – in other words, Conservatives – who can persuade themselves that such a cutback makes sense. It’s true that shutting down a walk-in centre would save a lot more money than shutting any other kind of practice but, unfortunately, the patients who use it won’t go away. They still feel ill or in pain, so if they can’t find care from a GP, they’ll go to the emergency department of the local hospital instead.

An emergency department is far more expensively equipped than any GP surgery. I’m not just talking about physical equipment, much of which is indeed costly: for instance, devices to provide a view of what’s happening inside a human body, whether by ultrasound, radiology, or some of the more powerful and sophisticated techniques now available such as CT or MRI scanning. However, even that fades into insignificance compared to cost of staff: medical and nursing staff on a wide hierarchical range, professional support such as pharmacists and various types of therapists, and even administrative staff.

The result is that while it may cost £50 to see a GP, it can cost £124 on average to attend an emergency department.

Cutting back on GP care is, therefore, a false economy.

There’s nothing unusual in that consequence of Conservative healthcare policy. All over England, hospitals are spending a fortune on agency or bank staff (“bank” is in effect overtime: existing staff doing additional hours on a far more expensive, hourly-paid basis). Why are they spending so much? Because they’re being denied the funds to take on more permanent staff, though that would be cheaper.

Of course, the false economy of shutting the walk-in centre would turn into a real one, if the patients denied treatment were unable to attend an emergency department instead. But for that to happen, our local hospital would have to close, or be replaced by a private one which only treated patients who could pay the full, economic cost of the care it provided.

I suspect a lot of people at the top of the Conservative Party would be perfectly easy about that happening.

However, I wonder if all their voters, further down the income range, would agree with them…