THERE has been much written in The Herald about the difficulties faced by emergency departments, or EDs, in Scotland ("NHS holiday plan rejected by unions", The Herald, February 7).

I write in the hope of expelling one or two myths about the causes of the problems we face and to suggest that the solutions require an all-systems, inclusive approach. The views expressed are my own, based on working as a consultant in emergency medicine in Tayside for almost 20 years.

EDs do not sit in isolation between the community and the in-patient wards of hospitals. Simply throwing extra resources in their direction will not solve the problems of long waiting times and delays to admission to an in-patient bed. We need to tackle the problem on a number of fronts.

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First, there is a need for better communication to inform the public of how to access medical care, particularly in the out-of-hours period. We must shed ourselves of the notion that A&E means Anything and Everything. Public health has a role to play here, but so do primary care practitioners and emergency departments themselves. From our experience in Tayside it is feasible to institute a screening process at the triage desk whereby patients who self-refer with a primary care problem can be re-directed as appropriate.

Secondly, we must look again at the out-of-hours period (6pm – 8am weekdays, all day Saturday and Sunday and public holidays). ED attendances peak at these times. In day-to-day clinical practice I am increasingly struck by the numbers of frail elderly people who end up being shunted in an ambulance, sometimes over considerable distances, to their nearest ED during the out-of-hours period. The most significant change in the past eight years concerns the re-organisation of primary care in the out-of-hours period. After the changes to the General Medical Services (GMS) contract GPs have become less involved in providing the "gate-keeper" role. This, together with the inception of NHS 24, has led to an increase in ED attendances.

I understand that the staff at NHS 24 have an extremely difficult job and I understand why they are often risk-averse, which results in patients being directed to their local ED. This situation is exacerbated by there often being insufficient numbers of GPs employed in the out-of-hours period. Many decisions to transfer patients to hospital are made by phone because of the lack of an available GP to perform a home visit. We need to regionalise NHS 24 and link it more closely with the local out-of-hours GP service. This view is shared by many GPs.

I would urge Finance Secretary John Swinney to examine the budgeting around this as there are many who believe that such a re-organisation of NHS 24/out-of-hours GP arrangements would provide a better service for less money.

Lastly, our hospitals need to work differently. Whole hospital systems need to be developed to ensure that patient flow happens. We need better, timeous access to reliable transport home from our EDs, particularly for elderly patients. Senior decision-makers need to be available daily to make decisions about in-patients and facilitate discharge planning, thereby freeing up beds. Why do so many hospitals still insist that patients who have been referred for admission by their GP are sent to languish in the ED?

Acute hospital managers must lead the changes. I have seen such changes in Ninewells Hospital, Dundee, where our overall performance in terms of the Government's four-hour target has been consistently among the best in the country.

Such changes cannot be made overnight but I believe they are achievable.

Dr Michael Johnston,

Consultant in emergency medicine,

Ninewells Hospital and Medical School,


IT seems inconceivable that front-line staff at Staffordshire Hospital were unaware of the appalling standard of care they lived with daily ("NHS boss refuses to quit over hospital scandal", The Herald, February 7).

The personal cost to a whistleblower is enormous both financially and emotionally and few dare to have the moral courage to attempt to fight the overwhelming bureaucracy which controls its employees by a pervasive culture of bullying, fear and secrecy and uses public money to suppress information of great interest and importance to the public.

We in Scotland cannot afford to be complacent. If NHS boards ignore and restrain the whistle-blower the NHS will be undermined.

Throughout the last 30 years I have had extensive help and care in the Western Infirmary and Gartnavel General Hospital undergoing various procedures and operations. The treatment I have received has been professional, vigilant and informative at all times and frontline staff have demonstrated a positive and caring attitude.

This is not the case everywhere and it is vital that we have a culture of openness and transparency whereby staff can speak out when there is wrongdoing.

J B Gardiner,

Thorn Drive.