UCCs cannot fill the general practice-shaped hole

As ED presentations continue to rise, we need a shakeup, not non-evidence-based stand ins, to staunch the bleed.

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Both high and low acuity emergency department presentation have risen over the past 20 years, demonstrating a weakness in general practice that is not being solved by non-evidence-based initiatives, suggests analysis of Australian Institute of Health and Welfare ED data.

“In Australia and around the Organisation for Economic Cooperation and Development it is commonly presumed that rising low acuity presentations, especially of non-urgent cases, are blocking emergency departments,” said the paper.

“There are multiple initiatives aimed at this contingency.

“In the absence of data, these initiatives cannot be said to be evidence based.

“Research has questioned their usefulness.”

This month, the Australian Population Research Institute published a research report outlining changes in ED attendance from 2003, when AIHW first publishing ED data, to 2023.

The researchers found that non-urgent and semi-urgent attendance per 1000 population increased by 5% from 2003 to 2023.

Resuscitations, emergency and urgent (high acuity) presentations per 1000 population increased by 125% over the 20-year period, with the most significant increase in women of working age.

According to the paper, the supply, availability and effectiveness of general practitioners largely determines the volume of ED attendance.

Low acuity ED presentation plateaued around 2011 when the FSE GP supply reached 0.87 per 1000 population in most jurisdictions, having risen by 23% since 2003, said the authors.

“Between 2017 and 2022 financial years, vocationally registered GPs (with specialist or specialist status equivalence) headcount rose from 74% to 80% of the total [working doctors] and their proportion of services from 81% to 86% [of total services].”

But general practice care has remained limited, with many proposed solutions not sufficiently addressing the problem or lacking evidence, noted the paper.

This included the lack of after-hours access to GPs.

“Only 51% of Australians have a regular GP and only 43 % of Australian GPs were found to conduct after-hours care,” said the researchers.

“The elderly can be accommodated more easily in daytime hours but often the working population and their families can’t be.

“The provision of a few urgent care clinics in a number of states (since 2022) does not address this aspect systemically and is not on a scale sufficient to significantly benefit population health.”

According to the paper, most of the high acuity ED presentations were working-age and young people.

The paper surmised that, to be effective, after-hours care needed to be provided on a walk-in basis, with access to an up-to-date health summary for the patient and “in a stand- alone setting with RACGP defined acute care facilities”.

“The provider needs to be trained as a GP or supervised by one with such training, but not necessarily be the patient’s usual GP,” the report read.

“These conditions cannot be met in present day Australia and would probably not be met by use of the New Zealand Urgent Care Clinic model.”

According to the authors, specialisation is also highly incentivised, with higher pay and larger cohorts.

“A focus on acute hospital care has diverted attention from the need for more effective general practice,” read the paper.

“Redressing the balance would mean placing limits on specialist training in hospitals and equilibrating the benefits of GP and non-GP specialisation.

“To reduce its pull on domestic graduates, the private medical sector needs to be returned to the market by ending the private health insurance tax rebate.”

According to the paper, it is not necessarily a mass increase in the number of GPs that we need, but “properly organised general practice”, similar to that of The Netherlands.

“Reorganisation of the structural operation of general practice needs serious consideration,” it said.

“A long-term, nationwide structural approach is required.

“The problem of rural medical workforce supply simultaneously needs attention to further reduce the need for overseas recruitment.

“These changes are needed to maintain high levels of healthcare access and quality in the long run.”