Health news in the last few months has been dominated by the ‘Crisis in A&E departments’ as hospitals struggle to deal with an apparent flood of patients attempting to access emergency and outpatient services. The dominant cause identified by press, public and hospital authorities is a perceived difficulty accessing general practitioner surgeries which is creating tensions between primary and secondary health care providers. Yet these tensions are far from new – indeed they are as old as publicly accessible hospitals and frequently erupt into the public sphere.
At the root of this tension is resource allocation which, irrespective of the type of health care model operating in Britain, has tended to push the desperate, the complicated or the plain troublesome patient from the GP waiting room to the ever open doors of the hospital.
The outpatient problem became a public scandal in the last quarter of the nineteenth century when London’s voluntary hospitals – publicly accessible, charitable institutions, free to the sick poor and staffed by unpaid surgeons and physicians – noted a sharp rise in attendances in the casualty room and the outpatient waiting halls. General Practitioners and charity organisers cried foul, claiming many of these patients could afford to pay a private practitioner but were ‘abusing’ the voluntary hospitals’ generally lax approach to outpatient treatment. Abuse was conceived of in two ways – denying GPs their fees and taking advantage of the charitable (both donors and doctors) who gave their money and time to the deserving sick poor. Although these remained constant problems up to 1911 and the National Health Insurance Act (NHI), they were increasingly addressed by stricter policing of outpatients, more effective sorting of the casual patient and ultimately by the introduction of almoners.
The introduction of National Insurance did not solve the problem of too many people opting for secondary over primary consultation. Indeed there is some, admittedly contradictory, evidence that it may even have forced certainly groups not covered by the state system to use institutions as a place of first, rather than last, resort. It was certainly the case that patients and attendances in both casualty and outpatients (often unhelpfully mixed up categories) grew rapidly in the 1920s, especially in Leeds. This partly reflected a growing confidence in hospitals that fuelled the development of a ‘hospital habit’ among the general public. But changes in the structure of the medical profession also promoted specialist consultation over generalist knowledge. Moreover, some argued, National Insurance didn’t pay enough to keep difficult patients in the GPs surgery. The problem reached a head in Sheffield in mid-1932 when Moses Humberstone, chair of the Sheffield and District Association of Hospital Contributors, launched an attack on the growing number of patients who ‘have come to look upon the hospitals as their family doctor’.
Concerned by the increasing cost to the hospital of outpatient treatment, he blamed three factors for the ever-swelling numbers in the waiting and sorting rooms: a lax attitude among the hospital authorities who were too ready to accept any patient who turned up – especially if they were members of the Contributor scheme; doctors who, at the slightest hint of difficult patients were too ‘ready to tell them that he could do nothing further and they had better go to hospital’; and that ‘people seem to have lost a lot of confidence in their own doctors, and think that if they can be transferred to the hospital all will be well with them’. [Sheffield Daily Telegraph, 9 June 1932] Interestingly, Humberstone mused on the effects of the panel patient system introduced with National Health Insurance, asserting that ‘there does not seem to be the same sympathy between doctor and patient to-day as was the case twenty or thirty years ago, when the club doctor system was in operation.’ Plus ça change?
Sheffield Daily Telegraph, 9 June 1932
Much as today, tensions simmered between GPs and hospitals. Humberstone accused panel practitioners of not doing the job they were paid for and of treating ‘the hospitals as clearing houses for their own surgeries’. He urged GPs to ensure that if there was no need for a patient to go to hospital ‘even to see a consultant’ the person should be told so. Moreover, he urged practitioners to help ‘educate their patients to use the hospitals only on their advice, or, on the other hand, patients should realize that primarily the hospitals were established for accidents, urgent emergency cases and…not to be run to for every little ailment which requires attention.’
The GPs defended themselves by claiming it was the fault of the NHI for not including specialist consultation as a benefit within the system, though they assured the world they would punish doctors who were found to be passing on cases unnecessarily to the institutions. Attempting a middle way the consultants noted that most GPs were using a proper referral system but in another echo of contemporary concerns, Professor Naish pointed a finger at the patients, admitting ‘there is a certain type of person who really enjoys going to the out-patients’ department of a hospital. After they had been stopped and told there was no need for them to come again, they turned up some time later for some reason or other. (Laughter)’. [Sheffield Independent, 9 June 1932]
A General View of the Accident centre, 1959
Opening Brochure, South Tees Hospitals NHS Trust
One might think that the NHS would have put a stop to outpatient abuse but this was not the case – though the reasons for it were sometimes a little odd. In 1959 a new Accident and Emergency Department was opened in the Middlesbrough General Hospital. In the first year the unit was over run by thousands of people seeking attention, prompting the Health Authority to commission an investigation by Newcastle University academics. After comparing usage to other units in the region and considering the availability of GP services and the longer term culture of A&E use in a town with a number of dangerous trades, the researchers concluded the improbably large attendances were down to simple inquisitiveness on the part of the local population keen to experience the new service.
Whatever the causes of our contemporary crisis in A&E – lack of access to GPs, insufficient capacity, cuts to frontline hospitals services or a public battles over resource allocation – they have their roots in longer term tensions between primary and secondary health care. But they are also part of a much simpler concern – when people feel unwell they want treatment, and they will go to the place where they think that treatment will be found. In extremes that has always been A&E.