Emergency departments: better safe than sorry?

Emergency departments (EDs) in the UK are under increasing pressure, partly because people use them inappropriately for non-urgent conditions. As part of NHS Wales Choose Well campaign, Betsi Cadwaladr University Health Board, based in Bangor, Gwynedd, commissioned research into public perceptions of EDs and alternative urgent care services. This article reports on the findings, one of which is that parents tend to choose EDs as the default option when their children are unwell. The article also asks how public trust in other NHS services can be built so that demand on EDs can be reduced.

Why do patients with nonurgent conditions present to the Emergency Department despite the availability of alternative services?

The aim of this study was to investigate why nonurgent patients present to the Emergency Department (ED) despite availability of alternative services; also to assess impact of the UK Choose Well Campaign. A convenience sample of nonurgent ED attenders was surveyed in North Wales, UK. More than half of patients sought advice from friends, family, carer or GP before attending ED. Of the one-third of patients who had not tried an alternative service before presenting to ED, reasons given included patients thinking that they might need a radiograph (46%), believing that GP would be unable to help (29%) or stating that GP was not available (19%). Twenty per cent of patients reported they would have changed their decision about attending ED if they had known more about alternatives. Only 12% were aware of Choose Well. Analysis suggests that though Choose Well effectively provides information on alternatives, it does not translate into more appropriate attendance.

Reconciling competing priorities in commissioning: the future of bone densitometry service for North Wales.

BACKGROUND: Osteoporosis creates brittle bones susceptible to fracture, with resulting high levels of morbidity and mortality. Poor access to bone densitometry services for the residents of North Wales led to the Welsh Assembly Government offering capital to purchase a dual-energy X-ray absorptiometry (DXA) scanner, used to diagnose osteoporosis, for the region. The commissioning question for the six Local Health Boards across North Wales was where to site the new scanner. This decision needed to reflect current inequalities in access to services and concerns over inappropriate prescribing relative to Welsh norms. METHODS: Epidemiological, corporate and comparative healthcare needs assessments were performed. In addition, two cross-sectional surveys were conducted to determine the views of general practices and users of bone densitometry services resident in North Wales. An option appraisal and sensitivity analysis of 13 costed options for DXA scanning was conducted. RESULTS: We estimated that only 31% of the people in North Wales who met national guidelines were receiving DXA scans. There was definite inequity of access to the current service provided by area of residence. There was also evidence of inequity of access by age and sex. The most suitable option identified in the option appraisal was a bone densitometry service based in the central location of Llandudno. CONCLUSION: The assessment identified significant unmet need for DXA scanning. A recommendation was made to improve access through the introduction of a new bone densitometry service based at Llandudno. This would double scanning provision provided and reduce travel costs and time for many North Wales residents. This recommendation was adopted by a joint commissioning group established by the six Local Health Boards in North Wales at the end of 2004 - evidence based commissioning in practice.

Trench foot: the medical response in the first World War 1914-18.

The approaching 90-year anniversary of United States entry into the Great War is an apt time to examine the response to trench foot (now called nonfreezing cold injury [NFCI]) in this conflict. Trench foot appeared in the winter of 1914, characterized by pedal swelling, numbness, and pain. It was quickly recognized by military-medical authorities. There was little debate over whether it was frostbite or new condition, and it was quickly accepted as a specific disease. The major etiologies proposed were exposure, diet, and infection. The opinion emerged that it was caused by circulatory changes in the foot caused by cold, wet, and pressure. Predisposing factors included dietary inadequacy and fatigue. A number of labels were first given to the disease. However, the name "trench foot" was eventually officially sanctioned. Trench foot became a serious problem for the Allies, leading to 75 000 casualties in the British and 2000 in the American forces. Therapy for trench foot involved a number of conventional, tried-and-tested, and conservative methods. Some more innovative techniques were used. Amputation was only used as a last resort. Prevention involved general measures to improve the trench environment; modification of the footwear worn by the men; and the provision of greases to protect them from moisture. The medical reaction to this condition seems to have been relatively effective. The causation was identified, and prophylactic measures were introduced to fit this model; these seem to have been successful in reducing the prevalence of the condition by 1917-18.