QJM Advance Access originally published online on May 9, 2007
QJM 2007 100(7):463-464; doi:10.1093/qjmed/hcm037
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Acute medicine: do we need ‘medical traffic wardens’ to make us interested in general medical patients?
Sir,The much discussed ‘4 hour target’—all patients must be admitted into a bed or discharged from the Accident and Emergency (A&E) department (or equivalent) within 4 h of admission—was developed partly in response to clear public concern that patients waited too long in A&E to be seen and sorted. It was first set as a target in early 2004.
So are things improving? In the quarter July–Sept 2006, 737 543 patients were admitted from A&E in England.1 This amounts to about 53 patients per hospital per day (in most UK hospitals, about two-thirds of these admissions are medical). Of these, only 10 411 (1.4%, <1 patient per hospital per day) missed the 4 h target (not in a bed within 4 h of the decision to admit). This is a staggering achievement, especially when compared to the data from the quarter July–Sept 2001, 539 136 were admitted, and 13.0% missed the target. These data are backed up by the Results of the Annual Health Check (2005/6) report, published by the Healthcare Commission, in which 93% of Trusts achieved the 4 h target.2 Clearly, something has happened, with both quantity and speed increasing rapidly. Perhaps related to the 4 h target, UK hospitals have become more efficient at the admission and discharge process.
If this target is part of the reason why the new ‘specialty’ of Acute Medicine has ‘suddenly’ sprung into life, then such targets (and the new specialty) might benefit general medical patients. As part of the response of the medical community to the new target, the Royal College of Physicians has rapidly recognized Acute Medicine as a new specialty,3 and has set up dedicated 4-year Specialist Registrar training schemes. Some consider such schemes as a quick back-route into consultant grade. Certainly, there is concern that the new generation of Acute Physician may burn out after a few years at the consultant grade, worn down by the ‘white noise’ of emergency general medicine admissions, without ‘down times’ in a more specialist form of general medicine.
Other countries (perhaps those still strong in general medicine) have developed specialized admission units, and feel there is no need to develop the ‘hospitalist’ or Acute Physician concept. For example, in Auckland City Hospital (New Zealand), acute medical care is delivered by traditional general physicians. All patients are seen by consultants within 12–24 h, and sooner if necessary. Some 65% of all acutely admitted patients from GPs bypass the Emergency Department, and go directly to the Admission and Planning Unit, to be looked after by in-patient teams.
Is Acute Medicine truly a new speciality? Or is it acute General Medicine in disguise, i.e. consultant-led and efficient, which is perhaps how it should have been practised from the start. Or, as our subtitle suggests, are Acute Physicians just medical traffic wardens with attitude? In New Zealand, Acute Medicine is not considered a specialty, but a response to systems that have failed. Would it be necessary at all, if their model was still practised in this country?
Medical history is littered with ‘breakaway’ specialties: Clinical Pharmacology, Hypertension, Clinical Genetics. None has really taken off in the UK. Acute Medicine may develop and change, or disappear. New specialties are borne out of need and persist due to the success of their treatment: the hip replacement needs to be done and the operation works. Acute Medicine is currently part of the Brave New NHS; and, in a way, is a product of it. It is sexy, once more, to be a general physician. So will Acute Medicine be here in the UK in 20 years time? Only time will tell.
Renal Unit
University Hospitals Coventry and Warwickshire
Coventry
UK
Admission & Planning Unit
Auckland City Hospital
Auckland
New Zealand
email: andrewstein{at}btinternet.com
References
1. Department of Health. Hospital Activity Statistics. [http://www.performance.doh.gov.uk/hospitalactivity] (latest data 17.11.06).
2. Healthcare Commission. Results of the Annual Healthcare Check in 2005/6. [http://www.healthcarecommission.org.uk].
3. Acute medicine: making it work for patients. A blueprint for organisation and training. In: Report of a Working Party of the Royal College of Physicians. (2004) London: RCP.
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