A&E is very busy. Compared with 2010 there is the equivalent of 8 full jumbo jets a day more people, landing in A&E. But, if I were writing this back in 2004 it would have been 'busy' within target. At that time Tony Blair had set the four hour target at 90%. Later the target was hiked-up to 98% and later lowered in 2010 to 95%.

Do we measure what matters? No. The four hour 'thing' is a political target. It's true, hanging around in A&E is no good for anyone but there is scant clinical evidence that 4hrs, 3hrs 45mins, 4hrs 10mins, 90%, 98%, 95%, 94%, 92.5% makes a difference. Heart attacks need treatment now and verrucae can wait a bit longer.  It's a clinical issue.

We measure the wrong stuff. Only outcomes matter; internationally comparable, clinically validated measures; the rest (like this latest row at the CQC) is fairyland.

Is the surge in attendances unique? No. It started in 2003 when the public started going to the smaller A&E units and minor injury centres (Type 2 and 3 units). I seems patients with less severe injuries and ailments are most responsible for the rise in A&E arrivals... maybe because they can't get to see their GP?

The major rise has been in the 18-35 year olds which might suggest they are working and GP opening hours don't sync. The 65-85's account for a larger proportion than five years ago. That must say something about social services and primary care.

What else? Well, there is a shortage of A&E doctors; consultants, middle-grade and trainees. A&E is pressured, not popular as a career choice and leads to no private practice later in life. Beds? Yup, not enough and you can't put two patients in the same bed.

Did we see this coming? Yes, back in May 2013 the A&E community were sending up warning flares. It was described as an urgent priority.

What have we learned? Not a lot.

Social services, part of local government, has had its budget emasculated and the Billion4BettercareFund is yet to have an impact.

What to do?

I told you the story of my local Morrison's supermarket. They landscaped the car-park and included an ellipse of grass and flowers at the front door. Instead of admiring the horticulture and taking the long way round the punters made a bee-line across the grass and gardens, treading a muddy path. If the supermarket had been run by the NHS they would have built a fence and accused the customers of shopping 'inappropriately'. Morrison's put down 20 paving slabs and created a convenient pathway.

The NHS doesn't 'get' customer focus. Look at the graph. Since 2003 the public have been by-passing primary care.

Primary care, as much as we all love it, is probably finished as a workable model. Despite bribes (scroll down for comments), closed for the best part of a week over Xmas and the New Year, staffed by a dwindling breed of knackered professionals that younger doctors don't want to join, in premises that mostly cannot be expanded to accommodate new services or growth. The leadership is still huffing about, wanting more money and behaving like the 5YFV was never published. There are 7,962 practices, one in 20 gone since 2010.  More here. 

What would Morrison's do? They'd circle-the-waggons and move GPs into A&E. So would I. Along with the rest of the confusion of OOH, walk-in, minor injuries and palaver. Scoop the money together and let the Trusts sort it all out. NHS111; I'm out. Spend the money on paramedics and let the ambulance service sort out what's what.

Wards choc-a-bloc with ready to discharge patients; what would Morrison's do? I know what I'd do; a deal with Premier Inn or Travel Lodge for £30 a night!

Social Services. What would Morrison's do? They sell bread and don't send you to Sainsbury's for the jam. They'd merge health and social care. So would I.

We have this model of care because it was the way it was in 1948 and the best deal Bevan could get from an obdurate medical leadership. Would we design it this way today?

Ask Morrison's.  

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What's the future for primary care?

If you want to know, too, join me, the NHSE Primary care Tsar and Deputy Medical Director Mike Bewick, leading GP Dr Clare Gerada and the president of the NAPC and former policy advisor Dr James Kingsland, at the Kings Fund for a night of

 The Big Conversation about Primary Care. 

  Details here. 

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roy.lilley@nhsmanagers.net 

Know something I don't - email me in confidence.

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