A and E admissions

absent Do people generally have some sort of insurance scheme? Is it compulsory to have health insurance? What happens when people are unemployed or retired?

"Crun, you are basing what you say on a theory stated in 1954 and repeated by the same man in 1984. Slightly out of date, I would have thought. In 1984 I do not think any sort of triage existed."

Out of date? Myers was published in 2004, with more references than just Meehl. What are you suggesting has happened in the last 60 (30) years? The human brain hasn't suddenly developed the ability to memorise and retrieve the whole of medical science on demand, complete with associated probabilities. As far as I can see, the obvious development is that computers will now process in a fraction of a second statistics that would have then taken an age to compute manually, and do it without bias. The point at issue is not whether triage existed in 1984, but that statistical prediction has been shown to outperform expert opinion about 95% of the time.

I am now living with a completely different sort of health service from the NHS. We pay for GP appointments and I think, although I am not sure, for elective surgery. We do not pay for emergency treatment, whether it's a visit to A & E or in-hosital care. (No charge for maternity care either.) It's not necessarily great that way – but it's certainly fast.

We have a small cottage hospital/health centre which has a maternity unit, another ward and a very small A & E-no specialists (one doctor), no out of hours xray, plaster technicians etc. The ward takes patients (mainly elderly) on release from main hospital 35 miles away so that they can be nearer home, it does serve the function of a convalescent unit. We also have another larger unit which specialises in psychogeriatric patients and stroke rehab. Like Ariadne we can have consultant appointments there and currently the breast screening unit is there. I think we still retain these facilities because of the rural location and distance to main hospital although there are often mutterings about the rural maternity units closing.

I have to say that when my husband had his 2nd heart attack at home the ambulance was there in under five minutes ( fortunately they were virtually passing the village at the time) and he was in hospital within the hour. I cannot fault the care given, it was superb.

That's what I thought would happen here, Ariadne, especially as Simon Stevens was filmed walking through the hospital after he took the job as head of NHS England. So why have they downgraded the minor injuries unit?
They say that 40% of the people who went there could have seen their GP, but that meant that 60% went to the right place.
My next door neighbour's wife was sent to the cottage hospital. They could not cope with her and sent her to Durham hospital. Unfortunately she died in the ambulance before she got to the hospital. That wasn't a problem of the cottage hospital. It was a problem of 111 making the wrong call.

Patients are sometimes sent to our cottage hospital here, when they leave the big district hospital. Perfect!

This small one is next to a big medical centre, and we can have routine X-rays and preliminary meetings with a consultant at the cottage hospital; there are Physio, opthamology, chiropody and minor injuries departments too. It is a godsend. And guess what? Cottage hospitals in the area are slowly being closed...

katek and rose in my experience people are encouraged to go into nursing homes for a short while. I know of two in the immediate area that are designed for rehabilitation just to get elderly folk back on their feet they seem to be quite successful. Convalescent homes do seem to be a thing of the past though. My dad went to one in Llanffarfechan (sp?) back in the fifties.I seem to remember it was run by the co-op which is where he worked. I think many of them were owned by large employers. Always by the sea-side too.

Crun, you are basing what you say on a theory stated in 1954 and repeated by the same man in 1984. Slightly out of date, I would have thought. In 1984 I do not think any sort of triage existed.

Katek I think I asked that on another thread; they were such a good 'halfway house' for people who didn't need to be in hospital but needed some building up before they went home.
MIL spent a month in one in the late 1990s and it was excellent.

One question.....where have all the old convalescent homes gone? So many people are too well to stay in hospital but not well enough to go home without a comprehensive care package which takes far too long to set up and is often inadequate for their needs. A simple transfer to a convalescent facility would lessen bed blocking. Would it cost so much to reinstate thee facilities?

I'm not entirely sure I follow what you're getting at Soutra, you seem to be criticising 111 the way it is, which I wouldn't dispute, but my post related to the way it could be or should be. You say that a nurse will ask supplementary questions, but that's precisely what I suggested the statistical system could/would/should be doing. You seem to be criticising 111 as an alternative to GPs, but my argument related to making it the point of access to a GP: instead of ringing the surgery for an appointment you ring 111. By the time you walk into the surgery, all the primary questions have already been asked, and a list of all the candidate conditions produced, along with probabilities, and also recommended tests. That's got to be good for the patient and good for the NHS. If half a century of research has shown that it's more accurate, it's a scandal that we're not already doing it.

My last experience of NHS Direct was very poor.

Here in Stockport we have an excellent "out of hours service" well it was excellent the last time I had need to use it. You ring and relay your symptoms and in a relatively short time you are rung back to give more details. At it's inception a Dr rang back but the service has grown so rapidly that it is usually a nurse now. We have had a Dr come out quite quickly to DH and I have been asked to go down by appointment twice, once on Good Friday evening and once on Saturday afternoon when it was suspected I had a DVT. I then spent several hours in the short stay ward of the local hospital until it was sorted. We think it is a great service and gives us peace of mind at all times.

"Souls" was meant to be should bl***y spellchecker!!!

Well I don't agree. Crun despite all the learned links you may wish to produce. There are I believe certain " trigger" questions which will cause the 111 operative to tell you to go straight to A&E including "Do you have chest pain?" Chest pain may be heartburn, gallstones, the aftermath of a cough, muscular or a heart problem. I believe a doctor or nurse souls be able to ask supplementary questions to triage more accurately. Walk in centres where available are an excellent alternative to A&E depending on the symptoms, but to be told to " consult a doctor" is not very helpful when the reason you have called 111 is precisely because a doctor cannot be reached!
NHS direct may have had its faults but you stood a better chance of informed advice.
If you can't even ring your GP on a Saturday any more the obvious place for the worried is A&E and the 3 hours before you are told that you didn't need to be there are part of what is causing the system to implode.

"it would help if 111operatives were at least trained nurses"

All the evidence says otherwise. It has been known for some 60 years that statistical, actuarial, prediction performs as well or better than expert opinion in every field it has ever been tried, including medicine. Paul E Meehl, a clinical researcher at the University of Minnesota, published a book in 1954 drawing this conclusion, and when he reviewed the subject 30 years later he said this:

"There is no controversy in social science which shows [so many] studies coming out so uniformly in the same direction as this one.

......When you are pushing 90 investigations, predicting everything from the outcome of football games to the diagnosis of liver disease and when you can hardly come up with half a dozen studies showing even a weak tendency in favour of the clinician, it is time to draw a practical conclusion."

It's not surprising, no human can hold a database of all the potential diagnoses, symptoms and their relative probabilities in their head like a computer can. Computers don't suffer from bias either, clinicians have been shown to see what they expect to see. A recent review of 134 studies found that clinicians outperformed statistical methods 8 times, and on 63 occasions statistical prediction fared better, the remainder were a draw. It has also been shown that clinicians fare even worse if they interview the subject rather than diagnose from a file of records. A few studies have tried combining statistics and expert opinion, they fared less well than statistics alone.

It will only work if the system is adequate, however, a few tick boxes won't do. The minimum you need is an interactive system that will choose the next question on based on the answer to the last as a clinician would. It's a win-win situation, the patient gets a better diagnosis, and the NHS frees up a huge amount of manpower.

Meehl: Clinical Versus Statistical Prediction
Myers: Intuition: Its Powers and Perils

I wondered why no one mentioned NHS 24. We still have it here.

"David Cameron has insisted the health service is “safe in my hands”, as the company behind the only privately-run NHS ended its contract blaming the soaring number of A&E patients.

The Prime Minister invoked the memory of his late son, Ivan, as he insisted he could be trusted to defend the British people’s “birth right” of public healthcare."

From the Telegraph today.
Do we believe him?

That's what NHS Direct was, using nurses in the callcentre. However, the government decided they wanted to do 111 on the cheap, asking for bids from private companies.
NHS Direct took over many of them, then when the price was cut, they backed out. Circle took over 111 in the West country and handed that back as well.

This is what happens when emergency services are privatised.
Does anyone know who runs 111 now in their area?

Soutra Definately. If only they used experienced people on these phones.

This happened with my job not long before I retired.

Our previous team of qualified and experienced SWs on the duty line were much more able to ask the right questions and dig beneath the context of the initial call and you needed to do that to make a proper decision. A lot of our callers did not/could not always make a clear account of their concerns.

I am sure the same thing must happen in the 111 system.

You cannot do such stuff properly if you are limited to a set range of tick box questions and tick box answers.
I cannot see that improving in the current climate.

I agree Soutra. Luckily I have never had a need to ring the number but I would feel very frustrated knowing a lot more than the call centre staff.

And it would help if 111operatives were at least trained nurses and not call centre staff with a list of questions and tick boxes.

If we phone our GP out of hours number it is directed to the GP surgery attached to our local A&E which allows the GP to either treat someone or if necessary, refer them to A&E.

Sadly the local hospital is on the cards for developers to transform the building into flats and our nearest A&E will be miles across the city.

It's just been reported that there are eight GP surgeries opening this weekend to relieve some of the pressure on their local A&E. However the access to the GPs will only be via the 111 system.

If the 111 system is made to operate correctly, it seems to me that there's some scope for introducing this more generally so that you always access the GP via a triage at 111.

Soutra Hope you and DH managed to get some sleep and all goes well

Soutra