Dr. David Hanlon:

It is a very good question. By focusing on trolleys, we have tended to focus on people who were admitted, but it is also useful to look at those who were not. As was said, anyone attending an emergency department is there for some perceived reason on their part. Again, our data are very good at collecting information around discharges and diagnostic groups, whereas much of the technology in terms of tracking the reason for people attending and what the actual diagnoses were has not been very well collated and analysed. We have looked at specific data for one hospital and it is interesting to see the patterns emerging from those. We hope to collect more information to see if that is replicated nationwide and what we can learn from it.

The large number of discharges points to a number of different things happening. For example, whereas sick elderly people are likely to be admitted, sick children are very unlikely to be admitted. However, they may need a period of observation or investigation and may need fluids for a number of hours to get them drinking again to resuscitate them and get them home. In some ways, that high level of discharge is in part a success in terms of senior decision-makers seeing them, deciding they do not need to be admitted and making an acute intervention in order that they are turned around and fit to be discharged.

However, as has been said, it also hides some dysfunctionality. Within this are almost certainly elements such as problems with accessing diagnostics, and we are working on trying to improve access for GPs to services such as ultrasounds and other such elements. Some people need assessment in a timely fashion which cannot practically be done. A person may have a clot in his or her leg. I could do a blood test and look for a scan, but with the best will in the world, turning it around getting all the ducks in a row and making a decision might take one, two or three days, whereas I would really need answer within a couple of hours. Some people are being seen, assessed, having a decision made and being discharged entirely appropriately, and it is a good outcome when these decisions are made.

It is an easy decision to make in an emergency department to admit someone. Discharging someone is always more risky as we need to be more certain. We take more responsibility when we send people home than when we put them in a bed. In some ways we should look at it as a success that we manage to discharge as many people as we do. As Mr. Woods stated, we look at the propensity to admit. We get caught both ways, depending on how one looks at the figures.

People attend because of problems accessing outpatient services or with difficulties getting services such as an endoscopy. People often feel something must be done, and a GP will wonder about the alternatives available. Mental health is another example. Acute assessment of someone with a mental health problem has been established in most of the emergency departments. Many of the people attending will be seen, assessed and supports put in place. For better or worse, it has become the access point for these acute services. There is a mix of the good and the bad. We do not have an analysis, but it is something about which we are very much aware and we hope to be able to make a bit more sense of it in the near future. We will try to inform decisions with information and intelligence and try to avoid anecdotally-driven decisions.