Considering the huge cost of the public health system, now running at over NZ10 billion dollars a year, and tipped to rise rapidly, it would be a pity if the article by Richardson, Ardagh, and Hider did not attract comment: New Zealand health professionals do not agree about what defines appropriate attendance at an emergency department; http://www.nzma.org.nz/journal/119-1232/1933. They looked at emergency departments (EDs), and came to the conclusion that health professionals do not agree about what defines appropriate attendance at an emergency department.

I am not surprised. The term "inappropriate" is hopelessly vague, and consequently we cannot allow the answers to influence policy. In a scientific journal, one might expect to see the word "inappropriate" used in connection with a harmful or inefficacious treatment or procedure or line of research, but not about the motives of the patients themselves.

The authors begin their Abstract by noting that EDs worldwide are "facing a crisis from overcrowding", and conclude it by saying that the lack of a clear consensus on what constitutes appropriateness "has implications for any interventions aimed at addressing ED 'overcrowding' that assume the presence of a consensus understanding of this concept." It took them a lot of sifting and asking and analysis, set out in nine densely-written pages, to get to that mysterious point.

In attempting to unravel this woolly verbiage, I have decided that what the authors were trying to say was that EDs need to know which patients shouldn't be there before they grow any bigger. If I have misunderstood what they mean by "implications for interventions," they can let me know.

Why did these authors confine their enquiries to the caregivers? They failed to ask the patients why they went to the ED, and I think we can put this omission down to a curious blend of arrogance and diffidence. If they had put the question "do you think it is appropriate for you to be here?" to 100 consecutive patients, a large number would have informed them that they had paid their taxes, or that they found the question offensive, or that they go, and will continue to go, wherever they choose.

A familiar problem in EDs is the length of the wait, but patients know this and they tough it out. The canny ones will, of course, summon an ambulance, and that will usually place them higher in the queue.

EDs clear the way to a complete range of inpatient and outpatient and specialist services, all offered free of charge. A prolonged wait is a small premium to pay. General practice is in decline, and in spite of huge increases in funding, it cannot compete with a free service for acute illness, which is being continually upgraded.

Roger M Ridley-Smith
Retired GP
Wellington
(r.sdekka@actrix.gen.nz)