When government-run health care systems encounter difficult problems, the bureaucrats ”solve” them by imposing new regulations and guidelines. Thus, when wait times in British emergency rooms (or A&Es, as they refer to them across the pond) became a national scandal, the government decreed that no one would wait for more than four hours.

Unfortunately for the patients, this command from on high had no effect on the underlying causes of the ever-lengthening wait times. So, the only effect of the four-hour target was the creation of perverse incentives. The NHS trusts knew they couldn’t meet the targets, but they didn’t want to incur the wrath of the Government. The Daily Mail reports the result:

Thousands of people a year are having to wait outside accident and emergency departments because trusts will not let them in until they can treat them within four hours, in line with a Labour pledge.

How many?!?!

Figures obtained by the Liberal Democrats show that last year 43,576 patients waited longer than one hour before being let into emergency units.

Why are wait times so egregious? Because, in order to keep physicians from jumping ship over low pay and long hours, the Government gave GPs a little more control over the latter. This created a shortage of after-hours GP care, so patients end up heading to the A&E.

And what do the health care bureaucrats say about all of this? Why, they deny it, of course. They claim that the figures actually mean something else than what they appear to mean. In the end, however, there will probably be a special inquiry and a blue ribbon study.

At least that will give those folks languishing in the ambulances something to read as the hours tick slowly by.

Comments 26

  1. drmatt wrote:

    There is no doubt that govt mandates, in response to public opinion, without planning, foresight or funding, create perverse “side effects”. It is interesting however how similar we are, even though GPs have recieved no such gift here, in order to stay in business they have to “stack” thier schedules so when people get sick they have to plan to be sick three weeks in advance or go to the ER (which they do in droves). Also, notably similar, I have worked in 10 hospitals in the US and have seen people stay in the ER for days, no beds or not sick enough to take up a precious bed, so we get all the same stuff for $3k more per person per year!!!! that sucks, we are getting ripped off.

    Posted 22 Feb 2008 at 8:20 am
  2. Rich wrote:

    Sorry, waiting outside in an ambulance is NOT the same as waiting, in the ER, for a non-ER bed.

    I also differ that physicians “have to ‘stack’ their schedules.” They do not. I do not, and I provide primary care to a predominantly blue-collar demographic, and I am doing just fine. I also use some flexible scheduling so that I can attend to sick patients same day, and still, I am doing just fine.

    Yes, there are often not enough hospital beds (Wonder why?) But I have successfully provided complete care for patients while they waited for a bed in the ER, ultimately discharging them directly from the ER. I don’t think the same could be done in an ambulance.

    Is getting into the ER an hour or 2 sooner (especially when being delivered by an ambulance, we are not talking about those who arrived on their own power) worth 3K/yr? Knowing you were going to have an MI five years from now, would you opt for 15K in your pocket today, or quick entree into the ER, however crowded? Ripped off, indeed.

    Posted 22 Feb 2008 at 9:59 am
  3. Nurse K wrote:

    Sounds like a good idea to me as long as I get to pick who stands outside. Stuffy nose, cough for a month, “fever” of 99.1 (“it’s high for me!), and 10th visit this year for low abdomen pain can all wait outside.

    Posted 22 Feb 2008 at 10:05 am
  4. Rich wrote:

    Problem is, Nurse K, that those cases generally don’t arrive in ambulances.

    (Don’t worry, the sarcasm is not lost on me.)

    Posted 22 Feb 2008 at 10:52 am
  5. Nurse K wrote:

    Uh, have you been to any ER in America ever? The word “cabulance” wasn’t invented for nothing.

    My last shift, an obese lady called 9-11 because she exercised and “her muscles hurt really bad” afterwards. DUH.

    Posted 22 Feb 2008 at 11:40 am
  6. drmatt wrote:

    Your right rich, I much rather defecate in the middle of a room full of sick people for two days than sit in an ambulance for four hours!

    I am really impressed, blue collar also means insured right? your story is anecdotal not representative (hope you dont practice medicine that way), i did the research for a book, call around and see what the average wait time for an appt is, infact pretend your someonelse and call your office and see what they actually say to people.

    as far as your 15K anecdote, it doesnt apply, do your research, people are being triaged and emergent cases get the same care they always have.

    forget all of what I said, just put your blinders back on an keep telling yourself everything is ok

    Posted 22 Feb 2008 at 11:52 am
  7. Rich wrote:

    So, of the last 10 ambulances that arrived, how many were “cabulances?” Of the last 10 patients with minimal, non-emergent comlaints, how many arrived by ambulance.

    Is it not true that the majority of patients that arrive by ambulance are not “cabulance” passengers, and that most non-emergent complaints in the ER arrive by some other method?

    I’ll add emphasis:
    …those cases GENERALLY don’t arrive in ambulances…


    Posted 22 Feb 2008 at 12:30 pm
  8. Ian Furst wrote:

    The Canadian persepective is not much different. We have the same issue with patients left in ambulance due to patient safety concerns (e.g. the ER is so overloaded there is no more room or staff to monitor). The main issue is apparently bed shortages but limited staff in the ER and people that would normally see a GP being unable to find one are also major factors. There is no easy answer (although the 4 hour rule seems to have had an unrealized effect and should probably be reversed) but it has to start with increase capacity and/or efficiency at the GP level. Normally increased capacity should mean less waits, but the opposite is true in Canada — the smaller the hospital the less the wait and even in larger centre’s sicker patients are still assessed quickly. The ironic thing in Canada is that some ER physicians are pushing for time standards for high triage score patients. If the UK is an example, those standards may actually limit access for patients because they’ll be left in the ambulance. My personnal opinion is that increasing physicians and efficiency at the primary care level is the solution for the next 5 years. http://www.waittimes.blogspot.com

    Posted 22 Feb 2008 at 1:16 pm
  9. Nurse K wrote:

    Well, it depends on what you mean, Rich. Are suicidal psych patients who walk in with the medics “urgent”? Is mild muscle strain in a healthy person after a low-speed car crash “urgent”? How about a car crash resulting in a bruised knee? How about a young person with vomiting x a few hours or a middle-aged person with chronic back pain that happens to be worse that day? How about a relatively healthy elderly person with a cough and normal vitals? These are all common ambulance calls.

    Posted 22 Feb 2008 at 1:42 pm
  10. Rich wrote:

    drmatt –
    I didn’t say my practice was typical, I was demonstrating that your statement that doctor’s had to stack patients to stay in business was false.

    And yes, many, but not all of my patients are insured. The uninsured patients get good care from me too, and they are scheduled irrespective of their insurance status.

    I know what people hear when they call my office, I have done what you suggested. But it is a bit hypocritical for you, I think, to deride my observations as a misapplication of anecdote when you so often cite your own difficulties in practice as evidence of a broken system.

    And if emergent cases are getting the care they always have, they must then be getting it in the ER, where they are waiting for days for a precious bed.

    I suppose that they are checking your troponin in the hypothetical ambulance while you wait, your dignity intact, and your wallet 15K heavier.

    Posted 22 Feb 2008 at 9:51 pm
  11. DrShroom wrote:

    Certainly in Britain there is an (un)healthy number of patients arriving by ambulance who would fit Nurse K’s description. Ambulances cannot refuse to take anyone. So, if I get drunk in town, need a ride, and live near the hospital, I can dial 999 and demand to go to the hospital. For whatever reason. Rather than ‘cabulance’ we had the ‘London Big White Taxi Service’. Sore throats are a particular fave of mine, and they all want an ambulance to take them home…

    Posted 24 Feb 2008 at 11:19 pm
  12. drmatt wrote:

    No offense Rich, but I must say, I cite my practice difficulties because they also led to a year of research on the topic, use of resources and cost of running a practice (couldn’t believe it was just me) so my citations “are” representative. In regards to insured patient, I am not implying that you treat your uninsured any differently, what I am getting at is how the current business model works, the greater number of insured patients a practice has (good insurance that is) the more flexible scheduling becomes (to a point of course) There are only two ways to stay in business in primary care #1 limit the number of uninsured/underinsured patients you have #2 make up the difference with volume. With a sense of responsibility to the community it is difficult to “limit” your proportion of uninsured or underinsured should be a percentage representative of the community you serve, unless of cours you take #1 which really is just skimming the cream, nice for self, bad for community.

    Posted 25 Feb 2008 at 6:42 am
  13. Rich wrote:

    “…because they also led to a year of research on the topic…”

    Well, then, it must be so.

    Posted 25 Feb 2008 at 7:21 am
  14. drmatt wrote:

    maybe, maybe not, but is far from anecdotal, which is what I was accusing you of and your argument was that I cite my practice experiences, I am just saying that in respects to proper approach to discussing evidence and facts, my study has way more power.

    Posted 25 Feb 2008 at 8:32 am
  15. Rich wrote:

    “…my study has way more power.”

    I’d love to see it, and decide for myself.

    Of course, you have no idea what I do, or how I do it, other than that I practice medicine, and you have no idea of my consulting experience, etc., which I also do. But you are free to draw your conclusions from a paucity of facts.

    Posted 25 Feb 2008 at 10:26 am
  16. Matt Horn wrote:

    Drmatt, now you are being silly. I can show you many business where a number of people have failed and others succeeded. Private practice is no different. Your experiences are not unique and they have to do with your own choices. Every private practice physician in you area faced the same hurdles you did. If the circumstances were widespread and were out of your control, then there would be no doctors in private practice.

    Posted 25 Feb 2008 at 12:21 pm
  17. drmatt wrote:

    Call around and find out how many “private practices” are being bought up by hospitals and large conglomerates, then ask whay, thanks for making the point, this is going on across the country.
    you also have no idea what I do or have done, consulting etc, I was only pointing out that what you offer as an arguement that primary care does not “stack” thier schedule was anecdote while I offerd more than anecdote. You dont have to see the study results, you know as well as I do that if I contacted only three other practices that would still have more power than your single anecdote.

    Posted 26 Feb 2008 at 7:26 am
  18. Rich wrote:

    You win.

    Posted 26 Feb 2008 at 9:27 am
  19. Matt Horn wrote:

    drmatt, I know all about the market forces in the private practice community. Buyouts happen in every business. There is large scale consolidation of insurance and financial brokers in my area right now. It is primarily done to create economies of scale in order to capitalize on operational efficiencies. As long as there are docs in private practice in you area, you have failed in your assertion.

    Your evidence was anecdotal unless you conducted a scientific sampling of a number of practices. I don’t know if you did or not, but from this conversation it doesn’t seem likely.

    Posted 26 Feb 2008 at 3:50 pm
  20. drmatt wrote:

    Sorry Matt, you are wrong, anecdote by definition means “single story” as soon as you pool more than one it is no longer anecdotal and it is immediately stronger evidence than anecdote, after that strength is improved by “scientific sampling” (which is a very general assertion, there are many ways to sample that are considered “scientific’)
    Sorry again Matt, I did not fail in my assertion, which was in order to stay in business PCPs have to fill thier schedules, do the math, in medicine we have no control over what insurance companies reimburse, but we do have control over the number of patients we see, just as market would predict, the more money we need the more patients we see, in most hospital owned practices thier are “performance” bonuses if you see more and more patients.
    Finally, unless you can describe to me what “Operational efficiencies” are exactly when it comes to the complex care of the unpredictable human patients, I think you should stick to your pie graphs and calculations.

    Posted 26 Feb 2008 at 4:33 pm
  21. drmatt wrote:

    In anycase what people like you seem to forget is we are not really talking about, “market forces and economies of scale” we are talking about people.
    incidentally how is it that you “know all about the market forces in the private practice” I suppose you have owned one, run one? or just more hot air? oh i bet you read about one, ahhhhh i get it. I guess I know all about the amazon because I read about that once.

    Posted 26 Feb 2008 at 4:35 pm
  22. Rich wrote:

    I HAVE owned one (medical practice), and run more than one.

    But still, abundance of anecdote is NOT evidence of anything, other than that you have an abundance of anecdotes.

    Also, while we may not have the ability (not really true, negotiation DOES occur) to control what insurance companies reimburse, we do have control over what we will accept as payment. Given that control we can each decide, individually, how much “pro bono” care we can give. It is NOT anecdotal that declining reimbursements reduce the amount of charity care freely given. Just as it has been documented that lower taxation is correlated to higher charitable contributions to social welfare programs (in excess of the reduction in tax revenue). [ Cite: RALPH BRADLEY, STEVEN HOLDEN, ROBERT MCCLELLAND (2005) A ROBUST ESTIMATION OF THE EFFECTS OF TAXATION ON CHARITABLE CONTRIBUTIONS
    Contemporary Economic Policy 23 (4) , 545–554 doi:10.1093/cep/byi040 ]

    To blindly take whatever you can get, be it less than your costs, or whatever, is irresponsible to yourself, your family, your employees, and your community. Every business owner in a comunity is

    Posted 26 Feb 2008 at 5:41 pm
  23. Matt Horn wrote:

    drmatt, so bitter. Other definition of anecdotal evidence:

    reports or observations of usually unscientific observers – Merriam-Webster

    Notice the plural.

    I would agree that PCPs do have to fill their schedule, just as any other service professional. I was under the impression that your assertion was that in order to succeed and not to be acquired a PCP had to stack their schedule.

    I would be happy to give examples of operational efficiencies in private practice. A doctor may choose to partner up with some other physicians to consolidate administration. I set up up an office that contained an administration base for a number of my physician clients. We consolidated bookkeeping, payroll, HR. I also showed three of my physician clients the benefits of combining their practices. In that case, we saved the practice over $200K per year and it allowed them to grow by bringing on new docs. Last time I talked with them, they had gone from 3 struggling practices to a top-tier practice with 5 partners and 4 physicians practicing under the partners.

    I am not a doctor, I am a businessman with years of experience dealing with insurance, financial advising, consulting, and investment banking. The last three almost exclusively with physicians. While you may be able to cure the various ails of your patient, I cure the ails of business. If you had brought someone like me into your practice before it went under, we might have been able to salvage it.

    We both deal with people, so get off your high horse. I make sure people can make a living and provide for their employees. If you are not looking at the bottom line of your business, you have no place running a business, and have no call for sour grapes. If you do not focus on your bottom line, you fail in your responsibility of stewardship. There are tough decisions to be made in life, but they are decisions which must be made.

    Posted 26 Feb 2008 at 7:44 pm
  24. drmatt wrote:

    Matt, no, no, not bitter, I enjoy lively discourse, a little emotion is what makes it lively. Yup, had business consultants, lawyers, bankers and accountants (truly, a group of people I was unprepared to deal with).
    Anecdotal, right, none the less you know as well as I do when you get a particular number of stories with the same input and output it is now called…………that’s right, a survey, I use the particular anecdotes to examplify what the survey showed. I have no doubt that your expertise may have saved my practice, so no sour grapes here. I do however resent you making comments about whether or not I was responsible in my practice decisions, unless you review the books, the community, the patient and insurance base of my practice and the reimbursement schedule, let’s stick to what we know.
    As far as my point, no, you missed it, infact I gave two examples farther up the string as to how a practice could succeed (simple of course but I dont have the business experience you do, though that does not make me stupid). Why don’t you call the practices that you helped do so well and ask;
    1 how many patients does a doc see a day?
    2 what percentage of uninsured/underinsured do they have in thier patient base, does it match the community percentage?
    As far as my “high horse” if you study human behavior you find that when a person becomes people then becomes numbers they are much more easily discounted, so unless you are going out into the community and suffering with the people who cant access care under your model, you are doing the same thing, I took a vow not to do that and intend to keep it. No moral judgement, that is the way it is.
    Rich, call your third party payers and ask that the increase reimbursement and let me know how you do.

    Posted 27 Feb 2008 at 7:20 am
  25. Rich wrote:

    “Rich, call your third party payers and ask that the increase reimbursement and let me know how you do.”

    We have done this. The success rate is low, and in some instances, we could not tolerate the plan, and so dropped it. (If more docs paid attention, and dropped intolerably low reimbursing plans, they would raise their fees or disappear – THAT is the free market. The same could be said of government programs – until they are compulsory).

    But some did raise their rates to keep us on panel.

    Posted 27 Feb 2008 at 9:51 am
  26. drmatt wrote:

    Fun huh? too bad it is illegal for us to get together and do just what you say (all drop crappy plans). As far as docs paying attention, in my experience most docs dont really know what is going on, the “business manager” is in charge of all that. despite our disagreements you have a much better fund of knowlege regarding the nuts and bolts.

    Posted 27 Feb 2008 at 11:47 am

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