‘If you fell in a puddle, you wouldn’t call the coastguard.’

This, apparently, is the caption displayed on the side of some ambulances in an attempt to persuade people to think twice before calling an ambulance. Throughout the Christmas period, there have been reports of ambulance services in all parts of the country being pushed to breaking point by escalating demand. And they are not alone – the news coverage repeatedly described A&E departments as being swamped, and of huge waits in out-of-hours (OOH) centres.

You wouldn't call the coastguard if you fell in a puddle... (on side of East Midlands ambulance)

Why has this been such a difficult holiday period? With Christmas on a Thursday, there were four consecutive days when GP surgeries were closed, but this is not particularly unusual – whenever Christmas falls on a Thursday, Friday, Saturday, Sunday or Monday, there will be a similar block of ‘closed’ days, so it actually happens more often than not. Nor has it been unusually cold, and there have been no major outbreaks of influenza, norovirus, etc. Some of the increased activity is probably a reflection of an ageing population, with more people living longer while still suffering from several debilitating medical conditions, but there are also other factors at work.

Who tried to access care?

A colleague who regularly does OOH work tells me that those attending fall into four almost equal groups. The first group consists of people who are genuinely ill, and who probably need to see a doctor urgently. The other three groups, i.e. about 75% of those who attend, should probably not be trying to contact a doctor out of hours at all.

Of these, some people require prescriptions for their usual medication. Many simply didn’t request their routine medication before the holiday, others are away from home and forgot their medication, and some have lost their prescription or their medication. There are mechanisms by which they can obtain an emergency supply of their medication directly from a pharmacist without a prescription, and the process is clearly described here. However, as this website states, the service is not free. In many cases, obtaining a replacement prescription from OOH and taking it to a pharmacy costs the patient nothing.

The next group of patients that my colleague identified had requests for items that could have waited until their GP surgery opened – for example, sick notes. In some cases, this might have involved the patient taking time off to see their GP, whereas they were on holiday over Christmas, so why not go to OOH and see if it can be sorted out there?

And the final group of patients – at least a quarter of all those attending OOH – had trivial minor illnesses that one might reasonably expect people to be able to manage without seeing a doctor at all.

The pattern of those attending A&E is not dissimilar. Some are genuine ‘accidents’ or ‘emergencies’, but many should either have gone to OOH, or waited until their GP was available, or simply looked after themselves. Instead, up and down the country, they attended A&E in their thousands.

And GPs have also been inundated with patients before and after the holiday season with minor, self-limiting conditions. ‘It’s a virus,’ GPs explain, ‘they’re very common at this time of year. And no, antibiotics will not make any difference.’ Colleagues have reported patients attending urgently because they felt too tired the previous evening to go out with their friends, even though they now feel fine, or because they get diarrhoea whenever they go out for a very spicy curry, or because they have had a sore throat for twelve hours.

No wonder the entire system is overloaded to the point of almost collapsing.

Nor is this a new phenomenon. This Christmas might have been particularly bad, but most doctors would agree that this trend has been developing for many years. The public has become increasingly unable to cope with minor illnesses, and expects to be seen immediately – after all, you can’t be too careful, can you?

Who is to blame?

There are probably many reasons for this change in behaviour. Some commentators have blamed the breakdown of traditional families, with older generations no longer available to give advice to younger family members. Whilst this has probably played a part, it is too simplistic to blame the entire change on this. There are other mechanisms at work.

Disempowerment by media and politicians

Firstly, there has been a steady process – deliberate or accidental – of disempowering people. Constant scare stories in the media result in people feeling that they need advice or treatment now, rather than waiting to see if their symptoms sort themselves out. There is also growing intolerance of illness – I’m too busy to be ill, or I’m going on holiday next week, and I need to be better, and there must be something that can be done. Attempts by doctors to explain that the vast majority of viruses remain untreatable are met with scepticism or downright disbelief. And politicians of all parties have encouraged people to treat access to healthcare like any consumer activity, valuing convenience as they might value late opening by their favourite shops, in a system with funding at a level barely enough to cater for people’s ‘needs’ and nowhere near enough to deal with all their ‘wants’.

Complicit doctors

Doctors, too, have played a part in this process. Looking through the documentation for patients who attended A&E and OOH over Christmas, I found many who had been given prescriptions for antibiotics for conditions that did not require any such treatment. In one case, the doctor who saw the patient had even recorded that he had prescribed antibiotics ‘because of the patient’s demands and health beliefs’. Similarly, a child who was seen in A&E and diagnosed with a viral infection nevertheless received antibiotics. I can understand stressed, overworked doctors giving in to pressure, but this doesn’t help. Indeed, it positively feeds the problem by affirming the patient’s belief that they need antibiotics for conditions that are entirely self-limiting. To return to the title, it tells people that they do need the coastguard every time they fall in a puddle.

The solution: tackle demand

What can be done about this? Doubtless there will be demands for GPs to open longer, more money for A&E, etc. But all of these solutions address only the supply side of the equation, and do nothing about demand, which appears to have grown out of all proportion.

Tackling demand means telling people they are using the service inappropriately, and this is not politically popular, particularly with an election looming, but unless it is done, the NHS simply cannot survive. Patients who attend A&E or OOH inappropriately need to be told to go away should be signposted to other services as appropriate.

If they need medication because they have forgotten it or lost it or not ordered it in time, they should be directed to pharmacies – the inconvenience of paying will hopefully make them more careful in future.

And doctors need to stop feeding the monster by giving in to inappropriate demands for medication. It may be hard, it may even trigger the occasional complaint, but it most definitely needs to be done. The fear of complaints is something I often hear from colleagues, and this needs to be addressed. Doctors need to show greater self-belief in dealing with any such trivial complaint, and they should be supported in this by the entire system.

Healthcare is everyone’s business

All of us, patients, politicians and clinicians alike, need to start taking responsibility for this problem. If we don’t, we face disaster – patients with genuine needs will suffer while the system is choked with trivia.

4 thoughts on “‘If you fell in a puddle, you wouldn’t call the coastguard.’

  1. While I have some sympathy for the frustration expressed here, we end up having to deal with people as they are, not as we would wish them to be.
    It seems strange, but the evidence is that there is no agreement about what an inappropriate attendance in A&E is – see for example http://www.ncbi.nlm.nih.gov/pubmed/16302940 and http://www.ncbi.nlm.nih.gov/pubmed/16633392
    Also, in trying to make A&E attendance more specific – ie those who attend all need to be there – we will also make it less sensitive – so many who should go won’t go because they are worried about being told they’re wasting their time, or they worry about being charged. I am sure I am not the only one who has seen patients in general practice after their chest pain who didn’t want to bother the good folks in A&E.
    It’s not that A&E is used inappropriately, or that we shouldn’t try to change the way people use the health system, it’s just that any system we create needs to take account of the fact that people will go to A&E for things they think they need to go for (http://www.ncbi.nlm.nih.gov/pubmed/21871188) and they do have a logical decision making process about whether to go or not (http://www.ncbi.nlm.nih.gov/pubmed/8708188) even though we might disagree with them.

  2. Well done for raising awareness of this important issue. When you are a patient, it can sometimes be really difficult to know when a cough is innocent or when it may be something more sinister. Even as a GP, it’s easy to become cynical after a full day’s work of seeing coughs and colds and think that last patient will be the same as the rest or could be something more serious. But what if we could empower patients and ourselves and our staff. Nelson Mandela once said “Education is the most powerful weapon which you can use to change the world”. We now need to work with patients, fellow staff – clinical and non-clinical and build a partnership that supports each others needs, raise awareness, improve health literacy and show people wha they can do to help themselves and us too. This will not happen overnight – it takes times and effort and resources to change the culture. But it is possible. Start to build today based on what we know from yesterday and make the future happen. Enabling patients to view the health record and helping them to understand it by signposting to trusted information that enhances our consultations will help so that we all understand better how to use the limited resources we have and they are not wasted on trivia or because patients forgot or for things A&E are clearly not equipped for. We have just published a review of our own experiences at Haughton Thornley Medical Centres where 31% of our patients now have access to their records and are encouraged to understand their healthcare better. It is still early days but we are seeing behaviour changes amongst patients and staff that may point to possible solutions as we improve health literacy in general and allow patients and their carers to choose to look after themselves better by signposting to trusted information that is accessible 24 hours a day 7 days a week from any internet-enabled device. Please see http://www.htmc.co.uk/pages/pv.asp?p=htmc0584 and share with others. This is about the art of showing what is possible today now for the majority of people if we learn to support them and they support us @amirhannan

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