Three kinds of emergency care

The identification of healthcare as a business can be problematic. Mainly, I think, because of a sensitivity around the involvement of private firms in the NHS - an issue that has rarely been out of the news in England recently. But I am going to argue that we should think of it as a business, at least some of the time. For two very good reasons. Firstly, there can surely now be no argument that it helps to think of patients as clients we aim to please. Secondly, I'd like to argue that using a business framework helps us to see what we might do about probably the most pressing problem we currently face in healthcare - how to cope with the demand for emergency care. In this area I believe a consensus is starting to emerge on the way forward - that there are broadly three types of emergency care. At the moment all three types tend to pitch up in A&E together. We need to separate them, both conceptually and physically, and get really good at doing each of these three types of emergency care business. At the moment, we're not as good as we need to be.

The first type of emergency care business is honest-to-goodness, drop dead unless it's treated properly, Serious Illness. Heart attacks, Strokes, Meningitis, Punctured Lungs. That sort of thing. Modern medicine is good at this. People who would have died from conditions like this only a few years ago can now be returned to a normal, or near-normal, life in weeks. These are the conditions that encourage people to believe that they need an A&E as close to them as possible. And yet this is wrong. Unless they are unlucky, most people will rarely need this kind of care, and what matters most, provided the department is near enough (which probably means within about 90 minutes travel time), is what is waiting for you when you get there. Running too many emergency units means that senior decision-making is only on tap some of the time. That translates into longer than necessary hospital stays, as well as poorer outcomes. The jury is now returning a verdict on this kind of care - centralising it to fewer locations improves outcomes. And for improves outcomes, read Saves Lives. But it doesn't save money. In fact some investment in infrastructure is likely to be necessary to make it possible. In future only some hospitals, typically serving populations of around half a million people, and with senior specialists on duty around the clock, should do this type of business.

The second type of business is Minor Illness. Minor illness care can, and should, be delivered locally (specially trained nurses do it really well), and is practically limited by demand to anywhere tens of people are likely to turn up every day. But we need to think carefully as a society about how much minor illness care we want to pay for, because when cash is limited there is money to be saved here if we modify our collective behaviour. For instance: if people in urban areas accessed minor illness services at the same rate as their rural cousins we would save millions of pounds every year, just in Wales. And that's not because rural folk are healthier (although some of them might be). They are just more self sufficient. And it might be controversial to suggest it, but how about promoting a bit of personal responsibility in this area? All A&Es are full of drunks every Saturday night. Is that really where we want to see our healthcare pounds spent?

The third kind of emergency care business is arguably the most important of all - care for Older People. Older people have special healthcare needs. Their physiology is fragile. They go off their legs and become confused when challenged by illnesses (typically chest or urinary tract infections) that younger people shrug off. They frequently have several conditions, all of which require monitoring and treatment modification. And they often need social as well as health care. Older people need to avoid hospital where that's possible, and, when it isn't, they need to get out again quickly before they develop 'hospital syndrome'. And yet this is the very group where demand is growing, and where care is currently often delayed, imperfect, and, in the worst circumstances, scandalously poor. Older people were the ones who suffered the most in Stafford Hospital, and older people were the ones who died prematurely. Not because they didn't get high tech interventions, but because they didn't get the simple ones - like rehydration. Sometimes, of course, older people will need to visit a Serious Illness centre. But then they need to get back home, or to their local hospital, as soon as possible. Local hospitals need to get really good at providing care for older people, so they get rapid assessment and multidisciplinary care interventions, and they and their families are fully involved in decisions about their care. And we shouldn't be afraid to say that both families and social care providers have a responsibility to be properly involved in care provision. As with Serious Illness care, there isn't much money to be saved in this area, but not all of the changes we need to make will cost money.

If we are going to solve our emergency care problems, we need to decide quickly how we are going to do business.