Diminished trust with GPs has emerged as a factor in patients presenting at hospital EDs
Diminished trust and connection with GPs has emerged as a factor in patients presenting at hospitals with non-urgent conditions.
Melbourne’s Royal Children’s Hospital recently put out a call on social media saying its emergency department was overwhelmed and asking parents to avoid bringing in children who could be treated in general practice.
ED presentations at the hospital jumped to 7000 in May, compared with 5000 in January, prompting the hospital to warn parents that children with less urgent ailments were waiting up to eight hours to see a doctor. A few weeks later, in June, it renewed the call.
“Two weeks ago we came to you for help when the number of children in our Emergency Department reached very high levels. We’re extremely busy again today. At 1pm there were 83 children waiting to be seen, a large number with cough and cold symptoms,” the hospital said in a Facebook post.
While many parents responded by heaping praise on RCH for its excellent care and criticised those who crowded the waiting room with non-urgent cases, some took the opportunity, via the hospital’s Facebook page, to vent frustration about bad experiences with GPs.
“I understand your inundated with children in the ED but if the smaller hospitals/GPs treated children with the same respect and love that the doctors/nurses RCH did it would be less likely that parents would rush to the RCH. There is a lack of trust from past experiences unfortunately from many parents,” one mother wrote.
Another parent posted: “I went to the GP who said there was nothing wrong with my child. Bullsh*t. Ended up in RCH with breathing issues.”
The significance of parents side-stepping GP care for ED visits has received scant attention until recently, according to Professor Gary Freed, former director of the Health Systems and Workforce Unit at the University of Melbourne’s Centre for Health Policy.
One consequence of a continued decline in GPs’ involvement in managing children’s health was that it could affect their comfort levels and competency to address acute and chronic illness in children, as well as the recognition of normal and abnormal development, the US paediatrician warned.
Despite growing concern about the cost burden of unnecessary ED visits, Professor Freed said the magnitude of the very young patient group went under the radar because policymakers were preoccupied by the demographics of older patients.
“No one had ever bothered to look at the children,” Professor Freed told The Medical Republic. “They had the blinders on, only thinking about the problem of the elderly.”
Research led by Professor Freed found that 90% of very young patients (aged 0-4) who presented at EDs across Victoria met the criteria for a “primary care-type visit”, compared with 70% of all patients, during the 2002-13 review period.
Even as their proportion of the population declined, the very young accounted for a higher proportion of ED visits than any other age group (followed by 20-24-year-olds). They also made up the greatest absolute number of ED presentations across the state, increasing their visits by 29%.
Further research, conducted in August-September 2014, challenged assumptions that parents took young children with minor ailments to hospitals because they could not get a GP appointment or could not afford the cost.
Using “secret shopper” methodology across 225 general practices in metropolitan Melbourne, outer suburban and regional areas, they sought treatment for a three-year-old with an earache and mild fever and an eight-month-old with a slight cough, runny nose and fever.
The research team found same-day appointments were available at 78% of practices – half within four hours – although not necessarily with the GP requested. Significantly, 75% of the clinics offered bulk-billing for children.
Among findings published in the MJA in August 2015, they said parents and guardians might simply assume a lack of availability of GP appointments and believe they were more likely to be provided with timely care in an ED.
“Publicising the availability and accessibility of same-day appointments for children in bulk-billing may allay concerns over the cost of appointments,” the report said. But parents’ goal of always having ready access to one particular GP might increasingly be unrealistic as more doctors worked in larger practices.
A recent study in Brisbane identified similar trends in after-hours ED visits from surveys of 300 patients and analysis of two years of hospital data.
The study, commissioned by Brisbane North PHN, found one in three patients had a condition that could be treated by a GP and more than half of were aged under 30, including babies and young children.
Focus group discussions revealed that parents of a pre-vocal child were most inclined to head straight to an ED in the event of illness, but they would relax and consider other options after the child was of speaking age.
But the main finding was the strikingly low awareness among parents and young adults that after-hours GP services even existed.
“Our survey revealed that three-quarters of patients had never accessed an after-hours GP service,” GP Dr Anita Green, who is also deputy chair of the PHN, said. “Data also showed almost no one had used the Health Direct symptom-checker which provides free medical information online.”
The PHN has launched a campaign to inform the public of the range of options, with a colour-coded guide to advise appropriate action to take, at www.emergencyalternatives.org.au.
“The message we need to get out to young adults is that that they should have a practice to attend when they need it. Many don’t, because they usually are well,” Dr Green said.
“The other important group is patients who are chronically unwell,” she said, adding: “Younger staff at EDs also need to be educated to contact a patient’s GP in cases of complex and chronic conditions, so they do not get over-investigated or overtreated. ED doctors can spend an entire weekend and 10 grand trying to sort someone out who would have been better off seeing a GP who knows them.”
GPs could contribute by making sure patients knew about information sources that might ease their anxieties to get them through the night, and ensuring they had a plan of action to cope with an emergency, she said.
