"Admit medical".

Editorial "Admit medical" As the fog of uncertainty surrounding the purchaser/provider relationship in the restructured health service begins to clear, many doctors responsible for providing acute services find that darkness has already fallen. For those who are charged with managing acute medical admissions to hospital, difficult nights finding beds lie ahead. Hospital physicians and referring general practitioners will be forced to ration health care in a way for which they are unprepared and untrained. A service that has been taken for granted by many and whose worth has been assumed to be self-evident by most, is under strain. What is going wrong and what can be done? Much of the difficulty that lies just around the financial corner relates to the fact that most emergency admissions, of which those to acute medical wards form a very large proportion, are paid for as part of relatively non-specific block contracts. Unlike much procedure-based medicine which is relatively easy to quantify and cost, the service of acute emergency admission is being purchased rather than a precisely defined number of medical interventions. Managers start from the assumption that acute medicine in Northern Ireland is characterised by over-referral, over-admission, over-staying and over-bedding, and so it is easy to see that steady downward pressure on the resources for provision of acute services is inevitable. These assumptions cannot in any absolute sense be proven to be true. Their only validity stems from comparisons, using simple measures of medical activity, with other areas of the country, whose level of need is probably different. Be that as it may, rationing of emergency health care has arrived. Even before the financial pressures became acute, Internal Medicine faced several difficulties. Much of the acute service is provided by broadly trained and practising generalists, who combine to a greater or lesser extent a specific subspecialist interest based more in an outpatient or investigational setting. The image of the general component of the physicians' work has declined. The layman does not readily understand what general medicine is. Not every physician has cherished their general role as much as their subspecialist role, and some have been happy to allow accident and emergency departments to encroach upon their work. Amongst many patients and a few doctors a subspecialist ascendancy cult exists. Those in primary care, without much knowledge of the relative cost of services, see less need for referral to a general physician. In short, …