In my experience, drunken patients in A&E generally fall into one of two categories. The comatose types, usually brought in following a 999 call by a concerned friend or passer-by in the street. Or, the alert and chatty types, with some other problem like a head injury or broken ankle to contend with.
It is these patients that Edwin Poots, Northern Ireland’s health minister is considering charging for A&E attendances. This is not a new idea, and on the face of it appears to have merit. We constantly hear about the financial pressures that the NHS is facing and of the increasing number of attendances to A&E departments. A study has estimated that potentially two million A&E attendances in England and Wales are related to alcohol. Certainly in the hospital that I work in, doing a weekend night shift without encountering such admissions is more myth than legend.
Would I prefer not to have to deal with such patients? I’d be lying if I said no, but not because I don’t think they are “deserving”. These patients are notoriously difficult to manage safely. Is the alcohol masking pain somewhere? It is not uncommon to find an injury that the patient wasn’t even aware of. Is the reason they are drowsy due to just alcohol or is there something else going on? Maybe they’ve hit their head and have a bleed in the brain – there’s a labyrinth of possibilities to contend with. Most drunk patents I have encountered are very apologetic – when sober enough to express this. Some can be challenging but verbal abuse is rare and physical abuse is so infrequent that I didn’t witness any during my six months in A&E.
The notion that drunken patients get seen at the expense of more unwell patients is nonsense. Every A&E department has a system of determining the priority of patients – triage. The sister in charge, more akin to a commander-in-chief, has an innate skill in knowing and letting staff know which patients need seeing to first. This system is the reason why I have been in the awkward position of explaining to a frustrated patient or family member why others, arriving later, have been seen to first.
Besides if patients start getting charged for “self-inflicted” A&E attendances, where do we draw the line? I’d argue that many medical conditions and injuries are a result of personal choices. What about the lifelong smoker with acute breathlessness due to chronic pulmonary obstructive disease? Or a patient with an injured hand from DIY? Perhaps a patient that has attempted suicide? Conversely many drunks attend through no fault of their own, as victims of assault for example. Charging patients in each of these scenarios wouldn’t sit right with my conscience.
If finance is truly the driver for Poots’s suggestion, then such suggestions must be evidence-based. Beneath the surface, there is a bigger alcohol problem for the NHS. In my first medical job in gastroenterology, I was witness to long hospital stays and repeat attendees due to chronic alcohol abuse. Spending a few hours in A&E sobering someone up, whom I am likely never to see again, is cheap. Compare that to managing a jaundiced patient with decompensated liver failure on a ward for the second time in three months. Data from the charity Alcohol Concern supports this, with alcohol related inpatient admissions costing three times as much as alcohol-related A&E attendances (£1,993.57m vs £636.3m vs in 2010-11). Alcohol-related inpatient admissions, largely due to chronic conditions, have doubled and are continuing to rise.
Focusing on the cheap part of the problem is understandably a potential vote winner. It might make A&E night shifts better for doctors like me, and improve the experience for sober patients unfortunate enough to need medical attention in the early hours – but it is discriminatory. The focus of health policy, and what is far better value for the taxpayer, is a blueprint aimed at preventing dependency and providing effective rehabilitation.
Alcohol Concern suggests that £5 is saved on health, welfare and crime costs for every £1 invested in specialist alcohol treatment. Perhaps this would be a good place to start.
Jason Sarfo-Annin is a junior doctor working in south-west England.
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