Accident and emergency departments — Why people attend with minor injuries and ailments

Pubfic Health (1986), 100, 15-20

Accident and Emergency DepartmentsWhy People Attend with Minor Injuries and Ailments T. C. A. W o o d Fifth Year Medical Student K. S. Cliff MB:BS, DM, PhD, FFCM Senior Lecturer

Community Medicine and Medica/ Statistics, Leve/ B, South Block, Southampton Genera/Hospita/, Southampton, S09 4XY

A survey of 218 patients who walked into and were directed to the cubicle side of Southampton General Hospital's Accident and Emergency Department indicated that 76% presented with minor injuries or ailments. Of the patients, 57% were selfreferred and 21% had been referred by a General Practitioner. A total of 42% of patients indicated that they attended the Accident and Emergency department because they were of the opinion their General Practitioner would not have been able to deal with their problem. Other reasons for attending included: accessibility of the Accident and Emergency department; the patient anticipated he/she would be referred to the Accident department by their General Practitioner; and the provision of a twenty-four hour service at the hospital. Introduction

The tendency for people having minor injuries or ailments to attend the hospital Accident and Emergency department in preference to their own General Practitioner has been a phenomenon noted in studies of attenders at these departments for over 150 years. 1 '2 3' 4 '5 ' The reason for these attendances could be understood in respect of the provision of health care prior to the introduction in 1948 of the National Health Service, when General Practitioners charged on an item for service basis whilst many hospitals provided free or subsidised care. The continuation of this p h e n o m e n o n after the introduction of the National Health Service is not so readily understood, given that access to General Practitioners is no longer impeded by financial barriers. The last 40 years has also seen the growth of group practice premises with treatment facilities, and the employment of Practice Nurses for which the General Practitioner receives some financial reimbursement. In addition, Health Centre development has also increased markedly in the last decade, again providing facilities for carrying out treatments. Both of these factors should, therefore, in theory have improved community based services to provide care for patients registered with their General Practitioner who suffered minor injuries or ailments. Coupled with this there has also been an improvement in the training of General Practitioners through vocational training schemes, many of which provide six months' experience in Accident and Emergency d e p a r t m e n t s . . Various factors have been mentioned that might obviate against the patient being able to receive care from a General Practitioner, and in this respect appointments systems and deputising services have been mentioned. 6 In respect, however, of patients attending the © The Societyof CommunityMedicine, 1986

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Accident and Emergency department, reasons given have included: accessibility of the hospital, knowledge of the twenty-four hour provision of service, and the patient was of the opinion that their condition warranted special care. 7 This study aimed to identify whether any of the factors found over a decade ago, which influenced patient attendances at the hospital Accident and Emergency department, had changed. Method

The major Accident and Emergency department at Southampton General Hospital serves a population of 407,000, including Southampton Borough, which is the main area from which patients come. Within the borough there were at the time of the study three Health Centres within a three-mile radius of the General Hospital. The remaining General Practitioners in the borough provided their own premises. The study period covered the months of January and February 1985, and a sampling frame was devised such that all the days of the week over a twenty-four hour period were included. Only those patients who walked into the hospital and were directed to the cubicle side of the Accident and Emergency departments were included in the study, and a 1 in 4 sample was taken from this group. The cubicle side of the department is used under normal circumstances to examine and treat those patients whose presenting problems are not considered to require immediate life saving attention based on initial assessment by a senior nurse. These patients are normally seen 'in-turn' although discretion is exercised where attention is obviously necessary on an immediate basis for the comfort of the patient. Specifically excluded from the study were patients who were taken to the resuscitation area of the department and ambulance cases. In addition, children under the age of 16 years were excluded unless accompanied by an adult. Before collecting any data the patients' consent was sought; only two refused. Using a pre-tested questionnaire, details were obtained which included age, place of injury, date and time of onset and contact with the General Practitioner. In addition they were asked about their attendance at the hospital rather than seeing a General Practitioner, and whether they thought the problem could have been dealt with by their own practitioner. The use of a questionnaire including some semi-structured questions has been validated by other workers investigating this problem, s Results

In this section we report only those results which have identified factors leading to an understanding of why patients attended the Accident and Emergency department with minor injuries and ailments. A total of 218 patients, 149 male and 69 female, agreed to participate in the study. Of the patients, 65% lived within the Southampton borough, 24% in Hampshire and the remainder outside of Hampshire or of no fixed address. Twenty-eight% were aged 14 years or under, 26% between 15 and 24 years and 6% over 65 years of age. Based on the Nuffield Provincial Hospital Trust classification,4 there were 165 minor cases (76%) and 53 major cases (24%) within the study population of 218. Of the minor injuries, the most common presenting problems were: contusions without skin breakage (23%); small lacerations not involving deep tissues (17%); and ligament.ous injuries (sprains/strains), 12%. The major injuries comprised in the majority factures, mainly to the hand or wrist. These particular injuries had resulted in many cases from

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slips or falls on icy pavements and roads, a heavy snowfall having occurred during part of the study.

Source of Referral Of the patients 57% were self-referred and 22% had had contact with, and subsequently been referred to the hospital by, a General Practitioner. This 22% was divided into 14% having a letter and 8% having no letter. Of the remaining 21%, referral from school and place of work accounted for 9%, the remainder being brought either by a friend or relative who had made the decision to bring the patient to the hospital rather than the patient themselves. In these cases they were not counted as self-referred as the decision had been made by others.

Factors Found to Influence Hospital Attendance Based on the responses to the questionnaires, including the semi-structured part, the following factors were identified as playing a major role in influencing hospital attendance. (1) Availability of own Practitioner. Of those people who attempted to contact their own Practitioner, 11 out of 64 patients indicated that the absence of their own Practitioner was a deciding factor in coming to the hospital. They were not prepared to see another doctor at the practice. (2) Low expectation of care from General Practitioner. Of the total study sample (218) 91 patients (42%) indicated that they were of the opinion that their own doctor would not have been able to deal with their condition. Generally this represented a feeling that their doctor would either not be willing or not have the resources to deal with them, and that therefore they came directly to hospital rather than even try to contact their own practitioner. (3) Direct referral by their employer or advised by someone else. Approximately 21% of patients fell into this category where the decision was made by some other person. (4) Geographical availability of the hospital. This was frequently mentioned as being a reason for attending the Accident and Emergency department. (5) Provision of a twenty-four hour service. Patients mentioned in particular that the hospital provided a twenty-four hour service and therefore they could guarantee receiving attention as opposed to trying to contact their General Practitioner. Some mentioned that they had had difficulty in the evening contacting a practitioner because of the deputising service, though this was a very small number. (6) Anticipating referral. A number of patients mentioned that in their opinion, even if they had contacted their General Practitioner, they would have been referred to the hospital Accident and Emergency department. From the study data of 63 patients contacting their General Practitioner directly or indirectly, 53 were subsequently referred to the Accident and Emergency department, and only one claimed to have received any actual treatment before referral. Of these 63 cases, 11 were major in nature and 52 minor. (7) Appropriateness of condition. A number of.patients considered that their condition was such as to warrant them visiting the Accident and Emergency department as being the most appropriate place, as opposed to the General Practice premises.

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T. C. A. Wood and K. S. Cliff Discussion

The factors influencing the patients' attendance at the Accident and Emergency department appear to fall into seven main categories. Of these, geographic accessibility, provision of a 24 hour service and referral by another agency were possible predictable factors. In respect of the latter, the patient had really no control over where they were treated and, in respect of referrals from school and place of work, those referring quite rightly wished to ensure that the person injured was sent in their opinion to the specialist department. Unexpected, however, was the finding that for a small number of individuals the absence of their own General Practitioner was the deciding factor in attending, indicating a reluctance to see other doctors in the practice. Whilst this was only a small proportion, clearly to some people continuity of medical care by their own doctor remains a very important issue. An important finding, requiring some interpretation, related to the patients' answers to the question: 'Did you expect your GP to have been able to deal with your problem?' Ninety-one patients (42% of the total) indicated that they did not think their General Practitioners could have dealt with their problem. To some extent this may be related to the problem they had and their own perception of the extent or otherwise their General Practitioner could have helped. This would be particularly true in respect of patients who thought they may have suffered a fracture and required an X-ray. This group could consider that coming directly to hospital was the most sensible course of action in the circumstances. Analysis of the data indicated that 35 (66%) of all major cases were fractures. Of this group 19 (54%) came directly to hospital (self-referred) and 8 (23%) were referred by their own doctor having first contacted him. Further analysis indicated that 18 of this group were of the opinion that their General Practitioner would not have been able to deal with this problem. Thus within the 42% of patients indicating they did not think their own doctor could heave dealt with their problem were a specific group of patients (fracture group) who might have replied negatively because they recognised their special requirements. Further analysis of the data showed that of the 53 major cases, 27 (52%) came directly (self-referred) because they did not think their own General Practitioner could have dealt with the problem. Of the 165 patients with minor injuries, 64 (39%) expressed a similar opinion, but 54% were of the opinion their General Practitioner could have dealt with the problem. The overall 42% replying negatively compares closely with the figure of 41% found for an almost similar type of question used in a study in Newcastle in 1975. 7 This attitude might be as a result of previous experience of contacting the General Practitioner services with similar problems. The present study found that of 44 patients with minor injuries who contacted their own General Practitioner only one reported being treated, the majority 97% were referred to the Accident and Emergency department for care. This finding might also account for the finding from the 'free question' which showed that patients anticipated referral. This factor was also found in the Newcastle study, as was geographical location (accessibility) and 24 hour service. The study indicated that in the decade between the study in Newcastle and the present one, despite increasing availability of facilities for treating minor injuries through Group Practice formation and Health Centre provision, the factors influencing patients' attendance at major Accident and Emergency departments with minor injuries have basically not changed. Patients' expectation of their General Practitioners remains low in

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respect of these conditions and, even if the General Practitioners do see the patients, the evidence suggests that referral to the Accident and Emergency department is the usual outcome rather than treatment. This may reflect the fact that Accident and Emergency services are now Consultant based. General Practitioners may consider this to be the correct place to refer all patients with injuries. For those patients who walked into the department with major injuries (53), 11 were referred from a General Practitioner and the remainder were referred by other agencies or were self-referred. The diagnosis as to whether a patient is major or minor is clearly retrospective, but many patients considered that irrespective of the seriousness of their injury, the hospital Accident and Emergency department was the place in which to seek care for a variety of reasons.

Conclusions The workload of the major Accident and Emergency departments still consists of a large proportion of patients with minor injuries or ailments. The main factors influencing their attendance would appear to be principally a combination of low expectation of care for such problems from General Practitioners and anticipation of referral. This study did not look at General Practitioners' attitudes to the provision of services for minor injuries or ailments, but the Newcastle study in 1975 suggested that 63% of General Practitioners questioned were willing to see patients with minor injuries. The present study suggests that, even if a patient does manage to see a General Practitioner, they are very likely even with minor injuries to be referred on to the Accident and Emergency department. This may seem surprising, with the growth of Health Centres and Group Practice premises with treatment facilities and often a Practice Nurse. General Practitioners have a responsibility placed upon them for the care of patients with minor injuries or ailments as indicated by the Department of Health and Social Security. 9 But as we have suggested earlier, the provision of a Consultant based Accident and Emergency service at many hospitals may be seen by General Practitioners as the correct one to which patients, particularly with injuries, should be referred. This course of action being in the best interest of the patient. If the major Accident and Emergency departments are neither to be overwhelmed nor to require increasing funding, an urgent solution needs to be found to the problem of the provision of services for patients with minor injuries and ailments who clearly do not need hospital care. Could this be by training more nursing staff in Accident and Emergency Care through the English National Board courses and designating certain of the larger Health Centres, particularly in conurbations, as Minor Accident Centres? The role that the nurse can play in Health Centres and in alleviating the problems of major hospitals has been well documented. 10 Such solutions, however, are of some urgency if the annual growth rate of 5% per annum in terms of new patients' attendance at major hospital Accident and Emergency departments is to reduce, and hence the ever increasing cost to the Hospital and Health Authority services.

Acknowledgements We wish to acknowledge the kind help and co-operation of the patients and staff at Southampton General Hospital, and in particular Dr Rodger Sleet, Consultant in Accident and Emergency Medicine. We express our thanks to Mr Mark Mullee (Faculty Programmer) for his invaluable help with the data handling and computer analyses and to our Secretary Mrs Christina Perry for her

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patience and skill with the typing. We also wish to acknowledge Dr J.S. Robertson's helpful suggestions and criticisms.

References I. Hodgson, J. (1849). The Genteel Outpatient Abuse at the Public Charities. Lancet, ii, 705. 2. Lancet Committee (1869). Lancet Investigation - Great Ormond Street Hospital. Lancet, ii, 553-4. 3. Out-Patient Departments (1938). British Medical Journal, i, Supplement 1-3. 4. Nuffield Provincial Hospital Trust (1960). Casualty Services and their Setting: A study in Medical Care. Oxford'University Press: Oxford. 5. Brackenbury, P. H. & Jaya-Ratnam, J. S. W. (1985). Accident and Emergency Service - The contribution of the Community Hospital. Health Trends, 17, 31-2. 6. Department of Health and Social Security (1975). Accident and Emergency Services. Government Observations on the fourth report of the sub-committee of the Expenditive Committee. Cmnd. 5886. HMSO: London. 7. Holohan, A.M., Newell, D.J. & Walker, J.H. (1975). Practitioners, Patients and the Accident Department. Hospital and Health Services Review, 71, 80±3J 8. Morgan, W., Walker, J.H., Holohan, A.M. & Russel, I. T. (1974). Casual Attenders. A Socio-Medical Study of patients attending Accident and Emergency departments in the Newcastle upon Tyne area. Hospital and Health Services Review, 70, 189-194. 9. Department of Health and Social Security (1968). Accident and Emergency Services. Circular HM (68) 83. DHSS: London. 10. Dixon, P.N. & Morris, A. F. (1971). Casual Attendance at an Accident Department and Health Centre. British Medical Journal, iv, 214-16.