24 June 2022

The cure for the ED crisis lies in general practice

Comment Hospitals TheHill

Urgent care clinics are based on a fallacy. Invest in ongoing care if you want to relieve hospital blockages.


Seven hours. Sixteen hours. Nineteen hours. Thirty-six hours. Days on end.

This is how long patients are waiting for an inpatient bed after completing their initial care in an emergency department.

I had stern words with a psychiatrist recently when I felt they were not contributing in an efficient and positive way to make space for my long-waiting patient who was in a manic phase of her bipolar disorder. The patient’s condition was complicated by the fact that she had just tested positive to covid.

My male colleague sitting adjacent as I made the call commented to me: “That was a bit aggressive”.

As I stalked off to review my patient I replied archly “I prefer assertive”, but that’s a discussion for another day.

The inability to transfer patients to a ward bed after they complete their emergency treatment is known as access block. It is the absolute bane of an emergency physician’s professional life. The Australasian College for Emergency Medicine sums it up nicely:

“Access block is a whole-of-health-system issue that essentially acts as a negative feedback loop.

“Significant delays in emergency department patient flow (due to lack of available hospital beds) leads to delays in the treatment of new patients (as emergency department staff are managing access-blocked patients). This leads to ambulance ramping and longer wait times for newly arrived patients. More patients are therefore likely to leave the ED before receiving the essential treatment they need.”

ACEM

It’s important because access block increases the likelihood of death for those affected. Mental health patients are disproportionately affected by access block.

Not being one to pay much attention to politics, I hadn’t heard until recently of the Labor Party’s election promise to spend $135 million over four years on the creation of 50 urgent care clinics. While clinicians welcome any investment in health care for Australians, the rationale that the clinics would reduce the burden on the already stretched emergency departments is a fallacy.

The number and complexity of patients coming in the front door of the emergency department is increasing exponentially, out of proportion to the population growth.

Emergency clinicians want it to be known that it’s not “GP-type patients” who create overcrowding and access block. While primary care in the community is desirable where possible, non-urgent presentations to the ED are usually managed quickly and discharged back to the community. These patients do not occupy acute care bed space.

A 2018 review showed that the increasing number of presentations by the elderly with complex and chronic conditions is an active driver of ED overcrowding.

The government is constantly urging clinicians to choose wisely, but if those in power invested their resources more wisely they would achieve better health outcomes.

One way to do this is by bolstering the existing staff and infrastructure that manages chronic disease – namely, general practice.

I cannot emphasise enough that establishing a regular, ongoing relationship with a GP is paramount to maintaining a physically and mentally healthy lifestyle. These community specialists are ideally placed to notice the subtle and cumulative signs of deterioration which if managed promptly would reduce the likelihood of deterioration requiring a presentation to ED and admission to hospital.

Medicare rebates for GP consultations have not grown adequately with inflation and the salary gap between general practice and hospital specialties continues to widen. This leads to higher-out of-pocket costs for patients. In a recent TMR piece, Dr Louise Stone outlined how “lady doctors” carry the burden of caring for patients with complex health care needs and as a result are experiencing a gender pay gap of at least 30%.

Medicare rewards quick medicine: those who churn simple cases are compensated. Those who spend more time with patients with chronic conditions including mental health issues are not remunerated adequately. These empathetic, compassionate doctors are part of the answer to improving health and reducing hospital admissions and the system needs to compensate them appropriately. Perhaps a salary, comparable to their hospital specialty colleagues?

Fewer graduating doctors are choosing general practice as a vocation, resulting in the GP-to-patient ratio spiralling in the wrong direction towards a collapse of community healthcare. You know where the patients will go instead, don’t you?

Chronic conditions such as heart failure, emphysema and mental health problems have been flagged as most likely to re-present to ED after a hospitalisation. Strategies aimed to reduce admission and readmission are also worthy of consideration. Investing in initiatives to strengthen mental health care in the community will reduce presentations to the ED. Rapid access physician clinics, such as this respiratory clinic in Northern Ireland, was shown to both avoid hospital admissions and improve patient experience. Multifaceted transitional care interventions, shown to reduce readmission rates, might also be worthy of government interest.

Any mental health patient remaining in the emergency department at 24 hours automatically generates a report to the health minister. To the surprise of no one, my patient found a bed at 23½  hours. A success on one hand but an utter failure on the other. We need to do better. If only the government would listen.

Dr Bethany Boulton is an emergency physician working on the Sunshine Coast and a founding member of WRaPEM (Wellness Resilience and Performance in Emergency Medicine), dedicated to bringing the non-technical skills of medicine to the fore.

Something to say?

Leave a Reply

15 Comments on "The cure for the ED crisis lies in general practice"

Please log in in to leave a comment


Sort by:   newest | oldest | most voted
Donald Rose
Guest
Donald Rose
1 month 15 days ago
No-one, I think, quite grasps what is actually happening in general practice. Our new breed of medical graduates do not want to develop relationships with complex patients. Quite the opposite. They want flexibility, mobility, not too many hours and don’t want to be tied down. They would prefer torture than to give out their mobile number. They get upset and angry if their down time is disturbed. They steer away from Practices that have extended hours, weekend surgeries or provide services to RACFs. Many are drifting to single service Practices such as skin clinics, womens clinics, sexual health clinics and… Read more »
Max Kamien
Guest
Max Kamien
1 month 14 days ago

The corollary to your accurate formulation is that GPA, GAMSAT and interviews are reasonably accurate predictors of success in completing a medical degree but are close to useless in predicting the type of doctors needed by the Australian population.

Peter Bradley
Member
Peter Bradley
1 month 14 days ago

A sobering, but probably fairly and scarily accurate statement..?

Margie Gottlieb
Guest
Margie Gottlieb
1 month 16 days ago

Dr Aides et al discuss 15 new entry points into the medical system to reduce ED presentations. We could chose US, UK or NZ models. Ask the people in those countries how well the health care system works for them. JUST FUND GENERAL PRACTICE PROPERLYy. Urgent Care Clinics would still need primary care doctors ie GPs. They would fragment care and still be costly (read the Aides article)

Margaret Faux
Guest
1 month 16 days ago

Dr John Aide is Australia’s leading expert on UCCs, having just completed his PhD on the topic. His doctoral research included synthesizing the international experiences of UCCs, including Australia. I have read many of his published academic articles, and have learnt a great deal about UCCs in the process. It would be great to get his comments here. Here’s some links: https://pubmed.ncbi.nlm.nih.gov/34013684/, https://www.publish.csiro.au/PY/PY21078, https://www.researchgate.net/publication/319416089_Entry_Points_to_the_Health_System_a_review_of_the_emerging_community_models_for_management_of_non-life_threatening_urgent_conditions_relevant_to_Australia, https://pubmed.ncbi.nlm.nih.gov/30503764/

Margie Gottlieb
Guest
Margie Gottlieb
1 month 16 days ago
Bethany, you have written a coherent, accurate and succinct explanation of what has been brewing for the last decade. Covid has simply accelerated the issues. As a GP who often deals with people’s psychological health, though not exclusively, I agree with all the problems you’ve identified. My medical students are not choosing GP practice as a career option. As an oldie I have the luxury of doing my work for love, not money. The government’s practice of underfunding longer GP consultation times simply builds churning, failure to identify crises and expedient care into general practice. This desperately needs to be… Read more »
Anthony Tsamoglou
Guest
Anthony Tsamoglou
1 month 16 days ago

I am one of those who spends the time and apart from lower remuneration I have always mindful of a tap on my shoulder by the boogy man to please explain as I failed to write an essay long notes to sutisfy my “colleague” intriguing me!!!!????….

wpDiscuz