Who’s to blame for overcrowding in accident and emergency departments?

• Download figure
• Open in new tab
• Download powerpoint

The health secretary Jeremy Hunt blames general practitioners (GPs) for the overcrowding crisis in UK emergency departments,1 because GPs gave up responsibility for out of hours care in 2004. Is this fair? Before 2004, GPs had 24 hour responsibility for patient care. General practice has always been hard work, but demand and expectation were increasing unsustainably in the 1990s. Middle aged GPs (without the protection of junior staff) were often up through the night yet working the next day. Compared with hospital colleagues, the pay and status were poor. GPs were hugely undervalued. General practice was in crisis, with talk of widespread professional burnout.⇑

As a consequence GPs started forming local cooperatives, sharing the burden of out of hours care. For many doctors, being on call just three or four sessions a month was a revolution in working, and eased the pressure. This model was inexpensive, worked well, and care was provided by locally accountable doctors. And many of us took pride in not referring patients to hospital, temporising until the patients were seen by their own GPs the next day.

But the Labour government offered to take all out of hours responsibility away from GPs. It introduced NHS Direct, offering telephone advice, and vetting out of hours requests for GPs. The intent was to reduce demand and costs. But telephone advice is fraught. NHS Direct became institutionally risk averse, addicted to clumsy clinical algorithms that often dispatched unnecessary ambulances. Access to GPs out of hours became bureaucratic, with distant call handlers and call backs taking hours. Many patients simply bypassed this mess and went straight to hospital emergency departments. NHS Direct’s costs spiralled.2

As for out of hours consultations, initially it was older, experienced GPs who continued to provide care, but eventually they stopped. Fewer younger GPs had the experience or mindset to work out of hours. Facing a recruitment crisis, GPs were shipped in at great expense from outside the area, this policy filling Daily Mail polemics. And doctors are never blamed for doing too much, so inexperienced and disconnected doctors have a much lower threshold for sending patients to hospital. Continuity, localism, and experience were lost. Lastly, society became more anxious about health, fuelled by the media peddling fear. These are the foundations of the overcrowding in emergency care.

How do we fix it? Keep it simple. Locate emergency departments in primary care centres, and make out of hours primary care available on a walk in basis. Pay GPs to take back out of hours telephone triage, and keep some morning slots open so that out of hours demand can be deferred. Monitor this. Finally, insist that emergency staff rotate through general practice, because overinvestigation in emergency care adds huge pressure on resources. Nobody wins in a blame game.