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29 May 2013
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The Tragedy of the Commons in Urgent Care: Time to lead out the cattle

"This place is like a cattle market!" exclaimed one visitor recently, upon seeing our A&E waiting room on an evening walk-around. Sure, it was extremely busy - we had been feeling the full force of the A&E "crisis" and the seething crowd of expectant patients bore testimony to that. But on reflection, the reference to cattle markets was profoundly unjust. The last cattle market I happened to be at was an ordered and fairly swift affair. The bovines were fed and watered regularly, without any bidding, and they certainly did not wait around for anything approaching four hours without being either bought, sold or allowed home again.

That said, there is something altogether more sociologically profound about our current urgent care system which does indeed stand up to the cattle analogy, and it is this: we are witnessing the enactment, across the UK and indeed beyond, of the Tragedy of the Commons of Urgent Care. Let me explain, in case you haven't heard of the notion.

In the late 1960's, American ecologist Garrett Hardin published his seminal paper The Tragedy of the Commons which encapsulated the effects of using up, quite literally, a shared resource through a combination of self-interest and lack of foresight. Put simply, imagine a meadow. Lush, green and untouched. A farmer spots the meadow and especially notices it is free to use. He pops his cattle onto the field to graze. Other farmers notice the happily-munching cows and decide to pop their animals onto the meadow, too. And so there are now more cows, and slightly less grass for each. But they all rub along. 

Time goes by. More farmers shoe-horn their cattle onto the now-not-so-lush meadow: it is, after all, still free to use. And, although each farmer realises that the situation isn't half as rosy as it used to be when there were fewer cows around, well, it is still theirs to share, so why should they not have a corner of it? Sure, not all the cattle are as fat and sleek as they once were, and the grass is looking pretty scrubby now, but it is at least still there as a resource, so it may as well be used.

You can inamgine Hardin's forecasted inevitability. The grass eventually gives out; the cows have simply exhausted the shared and increasingly scant resource. Now everyone complains. The community meadow - its Commons - has failed. What is to be done?

I hope you can see the parallels to our urgent care dilemma. The A&E "crisis" represents but one exemplification of the Tragedy of the Commons in Urgent Care. You will be able to think of other examples of your own. We must act now, right now, in the form of assertive, quality-driven and data-rich medical leadership, to prevent our very own Tragedy turning into a catastrophe.


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About the author

Darren Kilroy's picture

Darren Kilroy

Darren Kilroy FCEM M.Ed. Ph.D. is a Consultant in Emergency Medicine in Cheshire, and Director for Network Leadership and Development in Unscheduled Care. He is also Hon. Senior Lecturer in Emergency Care at Manchester Metropolitan University, and Clinical Lead for Unscheduled Care at NHS Stockport. His main areas of interest are the challenges of clinical and managerial engagement around emergent clinical commissioning models, and the role of clinical leadership within transformational change.


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