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We were very grateful to Leaman for his contribution that forms the first part of this debate. He is voicing concerns of many on the front line of A&E feel and we acknowledge his forthright and courageous approach. Equally it can be easy to criticise but difficult to be constructive, especially in such an arduous task as improving the UK emergency care system. We therefore have invited responses to the issues raised in the hope of stimulating debate on these critical issues for emergency care in the UK. We thank all the authors in this section for their hard work and well argued contributions to this debate.
For anyone still uncertain about the concept, See and Treat is a process whereby patients with minor conditions are seen soon after they arrive in A&E by a senior clinician. Providing they have an appropriate problem such patients are given their definitive treatment straightaway and can then be discharged.
The Department of Health is very anxious that all A&E departments should adopt See and Treat and has organised a road show that has toured the UK spreading the word. Circulars and emails, arriving on an almost daily basis, have encouraged senior A&E staff to attend these meetings. One recent DoH letter even asked departments when, not whether, they would be introducing See and Treat.
The star turn at the See and Treat road show is the Kettering A&E Department. Kettering had its Eureka moment when it found that it’s throughput times were rising because all its cubicles (both major and minor) were blocked by patients waiting for admission. With the encouragement of its chief executive the A&E departments response was to employ its most senior doctors and nurses in offices close to the waiting room where they found they could See and Treat quite a lot of patients with minor problems. This improved their department’s deteriorating throughput times.
Many people might think that the proper response of the chief executive in this situation should have been to ask why his A&E department was being blocked by patients waiting for a bed. Furthermore, how representative is the A&E department in Kettering and are its solutions appropriate for more successful A&E departments? Is it appropriate for the most experienced A&E staff to see the patients with the least serious conditions?
The Department of Health’s uncritical promotion of the See and Treat concept is wrong and should be questioned by A&E specialists
These considerations do not seem to have bothered the DoH, which, impressed by a few months improving figures, has decided that all departments should adopt the Kettering model. There has been no critical analysis of See and Treat. Nor have its principles been appraised in print by a major journal. Such disregard for scientific assessment is unfortunately all too prevalent in government circles. It should not however prevent A&E specialists from questioning the See and Treat concept.
Interestingly, much of the present waiting time problem is due to another concept that was introduced with little evaluation—triage. In particular the Manchester Triage Scale, with its notorious category 5 (or “wait until everyone else has been seen”), has encouraged excessive waiting times for those with less serious complaints.
In addition, A&E as a specialty has only itself to blame if it is now being told by others how to run its affairs. It was apparent at least 10 years ago that the chaos in most A&E departments could not go on but senior A&E figures failed to tackle this serious problem.
Before See and Treat is more widely introduced those organisations representing A&E in the UK should demand more evidence. An interesting study at Kettering would be to give the A&E department back its minor cubicles and to get the senior clinicians to use these spaces to see patients in the usual way. Would this produce a similar improvement in waiting times?
More information is needed about Kettering and the other exemplar A&E departments. Were their waiting times originally worse than average? Do they have above average numbers of GP type attenders for whom See and Treat can be used? Can their improved times be sustained or do the senior clinicians “burn out”? What has been the impact on SHO training? Will See and Treat encourage patients with GP type problems to attend A&E?
If the DoH really wants to help A&E departments most would be greatly assisted by an end to trolleys being occupied by patients waiting for admission. Minimal delays for radiographs would also speed throughput. Queuing theory and other business concepts may have lessons for those running A&E departments. However, patients, even those with minor complaints, are not “units” and should not be treated in this way. Such an approach is contrary to the holistic and personalised care to which most A&E specialists aspire.
The Manchester triage category 5 should be abandoned. Such patients should be redirected to GP cooperatives, of which there are now many excellent examples. However, triage should not be completely abandoned. In addition to prioritisation, well trained triage nurses can start and complete many treatments, redirect GP type patients, and postpone minor A&E cases if waiting times become excessive.
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