Comparing evolving Australian urgent care clinic models to other established Western models

Since 2019, Australia has seen a significant investment in general practitioner (GP)-led urgent care clinic (UCC) models for the management of non-life-threatening urgent conditions (NLTUCs).¹ UCCs manage predominantly minor illnesses and injuries.^2–4 Infections are defined as patient presentations with International Statistical Classification of Diseases (ICD)-10 A00–B99 categories and infections from other ICD-10 groups, while injuries correspond to patient presentations with ICD-10 S00–T88 categories.⁵ In Australia, the largest model is the federally funded Medicare UCC model, with 137 UCCs in total planned to be open across all states and territories by the end of the 2025–26 financial year.⁶ In addition, there are state funded Priority Primary Care Centres (Victoria) (n = 11), Urgent Care Services (New South Wales) (n = 10), Priority Care Centres (South Australia) (n = 5) and St John Urgent Care (Western Australia) (n = 6), alongside a number of privately operated services.^1,7,8

Ensuring quality, safety and operational excellence is essential to the success of UCCs. This study represents the second part of a national survey study of doctors working in Australian UCCs. The first paper⁷ focused on concerns raised by doctors related to capacity, accreditation standard, qualifications and experience of doctors and nurse practitioners (NPs), training, funding and public education. This paper focuses on operational issues and compares practice in Australia with other Western UCC models.

Many Western countries have well established UCC models from which Australia can draw insight. These include the US,³ New Zealand (NZ), and the UK.⁹ Common features of these international models include extended opening hours, walk-in availability, onsite radiology services, as well as standards for accreditation, and, certification, often overseen by independent regulatory bodies.⁹ Each of these international models reflect differing priorities and approaches for delivering urgent care, providing a basis for comparative analysis and policy development in the Australian context.

UCC models provide patients presenting with NLTUCs an alternative option to presenting to an emergency department (ED) when presentation to a GP is not available. However, there are differences as to how this is achieved. In the US, most UCCs are hospital owned or in joint ventures with hospitals (52%), and most are community based, either in a shopping centre, a retail strip mall (46%) or freestanding (29%).¹⁰ England’s model of UCCs are increasingly expected to be co-located with EDs.⁴ In Australia, many UCCs are co-located with integrated primary care centres (IPCCs).¹

International models have an UCC standard,^11–13 vocational training and vocational registration,^11,14,15 whereas Australian models do not. UCC standards guide UCC practice for operational issues such as opening hours, requirements for imaging, referral pathways and staffing, including the role of NPs and paramedics, as part of an appropriate multidisciplinary workforce supporting a senior clinical leader.^11,12,14 Comparison of evolving Australian UCC models with established Western UCC networks could help inform the development of specific UCC standards and vocational training in Australia.

Objective

This survey explores a range of operational practices of UCCs in Australia to demonstrate inconsistencies of practice and encourage the formation of a UCC standard in Australia.

Methods

This project was explored using survey methods chosen to gain lived experience insights from doctors working in UCCs, particularly as no aggregated databases of services currently exist. The methods have been described previously.⁷ Doctors were chosen for two reasons; first, the authors could leverage existing special interest groups to promote participant numbers, and second, the research was exploratory to determine breadth of models and not to quantify the proportion of each.

Questionnaire design

The survey instrument was custom designed because no validated questionnaires were identified that were able to be used in this study. The basis for this questionnaire included literature reviews in a PhD thesis,¹⁶ known UCC models from Western countries,¹⁷ and issues identified in UCCs by the authors. The 22 items in the survey included categorical and open-ended questions that identified emergent or a priori items (Table 1). From the 22 items, 18 themes were identified. The initial 12 items and corresponding eight themes related more to performance of medical doctors who work in UCCs and have been discussed in a previous article.⁷ In addition to the item and theme of location, repeated from the previous article, 10 further items and themes will be discussed. Participants were recruited using convenience sampling through a professional body membership database, and the survey was administered through Qualtrics.^7,18 The first paper explored eight themes. These related to ‘perceptions of medical doctors working in Australian UCCs with the goal of formulating solutions to concerns raised by participants’.⁷

 

Questionnaire review

The survey was piloted by three GPs with experience. One was also a public health physician and senior federal government health sector bureaucrat. Changes to the survey were based on their feedback, which included suggestions on content, face validity and functionality. The survey was presented and disseminated to members of The Royal Australian College of General Practitioners (RACGP) ‘Urgent and emergency presentations to primary care’ (UEPPC) Specific Interest Group (SIG) on 17 October 2023.

Sampling

The method used to sample medical doctors with expertise in UCC models was anonymous convenience sampling of doctors who had worked in UCC models in Australia since 1 July 2023, when the first Medicare UCCs opened. This online survey was administered through Qualtrics¹⁸ and the invitation to doctors to participate was done in six ways: (a) RACGP UEPPC SIG newsletters (emailed every 4 months); (b) Royal New Zealand College of Urgent Care (RNZCUC) ‘Australian Faculty’ newsletters (emailed every 4 months); (c) emails sent to medical doctors working in two corporate general practices with UCCs; (d) emails sent to two UCC peer review groups; (e) emails sent to Primary Health Networks (PHNs) related to the overseeing of UCCs; and (f) a LinkedIn invitation sent on 26 April 2024. Doctors could participate in the study between 2 September 2023 and 5 June 2024, after which the study was closed because no further results had been received for 30 days and successive attempts at advertising the study were resulting in few extra survey completions. At the time of the study there were 50 federal UCCs opened or opening, with a further 27 promised. In 2025, a further 50 UCCs were committed to bringing the total number to 137 UCCs.⁶ There were also state funded and private UCCs operational where doctors working in these settings could participate in the study.

Data analysis

Descriptive analysis was performed on the numerical data. For textual data, thematic analysis was used to discover themes within the data.¹⁸

Ethics

Ethics approval was provided by The University of the Sunshine Coast Human Research Ethics Committee (A232000).

Results

The online survey had a total of 52 doctors who completed it. In this second paper, 11 new themes arose from three open-ended and eight closed questions (Table 1). The themes deemed to be operational issues are the basis of this study. Response rates to each question varied, with lower response rates for the categorical questions than the questions that were open-ended (Table 2). The numerical data was summarised and displayed as descriptive statistics (Tables 1–5). The items listed are the survey questions. Themes were then developed from the textual responses to the items using thematic analysis¹⁹ to explore the perceptions of the participants. Each of the 11 themes are presented below.

 

 

 

Location

The six states worked in by respondents were Queensland (n = 14, 29%), Tasmania (n = 9, 18%), New South Wales (n = 8, 16%), Victoria or South Australia (both n = 7, 14%), and Western Australia (n = 3, 6%). Most participants worked in state (47%) and federal government funded (41%) UCCs. Some (9%) worked in private UCCs. One UCC was both federally and state funded (1%), others did not know.

Opening hours

There were 20 different opening hours of UCCs on weekdays, weekends and public holidays (Table 3). The most common opening hours were 8 am to 8 pm (40% on weekdays, 40.8% on weekends and 32.7% on public holidays). The next most common was 8 am to 10 pm (14% on weekdays, 12.2% on weekends and 12.2% on public holidays). Two UCCs were open 24 hours per day, one was closed weekends, and four were closed on public holidays.

Availability of radiology

Data were obtained for the modalities of X-ray, ultrasound scan (USS) and computed tomography (CT) scan on weekdays, weekends and public holidays. This garnered 36 patterns of availability (Table 4). Some radiology was provided off-site by private providers and the local public hospital. Some UCCs had doctors who were proficient in point-of-care USS (n = 20, 18%) which was a required skillset of doctors working in 3% of responses (n = 3, 2.6%). The most common weekday opening times for X-ray were: 8 am to 5 pm (n = 4, 13.3%), for USS 9 am to 5 pm (n = 2, 12.5%), and CT scan either 8 am to 5 pm (n = 3, 15%) or 8 am to 6 pm (n = 3, 15%). All clinics had some availability for X-ray on weekdays, whereas some clinics did not have USS or CT scan modalities available on weekends and public holidays.

Referral sources to the UCC

There were fifteen referral sources (Table 5). The most common referral source was self-referral by patients walking into the UCC. The following six next most common referral sources (with 15 or more responses) in descending order were: other GPs; Ambulance Service; EDs; healthdirect;²⁰ public health unit; and Workcover from local businesses.

Doctors and nurse practitioners working

While 100% of respondents (n = 49) had doctors working in the UCCs during the week and weekends and 98% (n = 47) on public holidays, fewer UCCs had NPs working during the same times (n = 30, 61%, n = 30, 61% and n = 28, 58% respectively).

Practitioner-to-nurse ratio

Most UCCs (n = 35, 71%) had a ratio of one practitioner (doctor or NP) to one nurse, some (n = 10, 20%) had a ratio of two to one over the 7-day week.

Schedule 8 medication storage

While most UCCs (n = 38, 73%) stored Schedule 8 (S8) medications onsite, others had storage in an on-site pharmacy (n = 7, 13%), and some did not store S8 medications onsite (n = 6, 12%).

Onsite services and equipment

Some (n = 32, 44%) respondents reported having a slit lamp at their clinic, some (n = 18, 25%) had a portable blood analysis system (eg an I-stat machine), few (n = 8, 11%) had a GP-led fracture clinic and few (n = 3, 4%) had a specialist led fracture clinic.

Triage process

In the UCCs most respondents worked at, some (n = 39, 72%) had all patients triaged by a nurse. Some (n = 10, 19%) had reception identify patients who required triage assessment by asking patients to read a poster and depending on outcome of certain identifiers, referred to the nurse for triage. Few respondents (n = 2, 4%) had an online check-in that identified patients who require triage assessment and referred the patients to the nurse for triage, and few had no formal triage (n = 2, 4%).

Surge plan

Surge planning occurred where the number and complexity of patients presenting to the UCC were more than what the GP working in the UCC considered safe to manage. The most common surge plan involved the triage nurse attending to patients who cannot be seen by the UCC doctor and advising next steps. These steps could include refer to local ED, refer to local GP, or referral to ‘healthdirect’ (n = 27, 44%). Patients presenting with life-threatening conditions would still be managed even though the UCC was at capacity. This was followed by UCC staff either calling a doctor who was not on call to see if they could work at the UCC (cold calling any doctor) and closing the door of the clinic (n = 10, 16% each), or calling in an on-call doctor (n = 5, 8%). Three (5%) respondents had no surge plan at their clinics and one each (2%) responded that there was no surge issue or that they would see all who wait.

Discussion

This analysis found 11 important themes: clinic location, opening hours, imaging options, availability of radiology services, referral sources, staffing models (including doctors and nurse practitioners), practitioner- to-nurse ratio, Schedule 8 medication storage, onsite services and equipment, triage process and a surge management plan. These themes will be discussed under four headings: (1) Provision of UCC services; (2) Referral sources; (3) Triage; and (4) Surge demand.

Provision of UCC services, radiology, slit lamp, I-stat machine and onsite fracture clinic

There were 20 differing UCC opening hours identified from weekdays, weekends and public holidays (Table 3). This was comparable to the US, where 70% of UCCs open 8 am or earlier and 95% closed after 7 pm.²¹ A report of UCCs in the US found 67% open every day, 18% are closed on weekends, and 11% are open Monday to Saturday.³ UCCs in England and NZ are required to open from at least 8 am to 8 pm, 7 days per week.^11,12 Access to radiology was usually less than the opening hours of the UCCs.

The wide range of 36 different opening hours for radiology modalities was inconsistent with UCC models in some Western countries. Opening hours for radiology services depended on the day of the week and type of imaging (Table 4), which was predominantly X-ray, but also included USS and CT scan. UCCs in England and NZ are only required to have X-ray onsite.^8,9 In England, the requirement for access to X-ray facilities and clinicians able to analyse and interpret results is throughout opening hours.¹² In NZ, the requirement for access to X-ray facilities on site is for a minimum of 6 hours per day weekdays, 3 hours per weekend or to operate an on-call service for at least 6 hours per weekend.²² UCCs in the US provide X-ray in some form in at least 85% of clinics, but only 5% provide advanced radiology services.¹⁰ Our survey also found greater access to radiology modalities such as USS and CT scan compared to the US, England and NZ. In addition to radiology services, some clinics had access to other equipment and clinics.

Access to medical assessment devices like slit lamps, I-stat portable blood analysis systems, and fracture clinics varied between respondents. In comparison to international literature, the availability of slit lamps, portable blood analysis systems and access to fracture clinics in this study was more than described for UCCs in the US.¹⁰ A US report found few UCCs had access to a slit lamp (1%, compared with 44% in our convenience sample), few provided onsite blood analysis systems (2%, compared with 25% in our convenience sample), and few provided fracture care (2%, compared with 15% in our convenience sample).¹⁰ All UCCs in NZ have fracture clinics and slit lamps.²³

Referral sources

Unlike other Western countries, federal and state government funded UCCs in Australia have a wide range of referral sources to the UCC, but a limited scope of occupational health or telehealth services. The Medicare UCC design principles include that Medicare UCCs will:

 … Support people to connect to pathways of care through integration with the broader health system: ensuring connectivity to hospital and ambulatory services and other supports and services, streamlining access to urgent care.²⁴

Although this study identified fifteen referral sources, compared to the US and NZ, there is less emphasis on occupational health and telehealth services.

In the US, UCCs offer occupational health services such as ‘pre-placement physicals, drug screening, post-injury testing, annual employment physicals, flu immunisations, and workforce health education’ and telehealth.³ The top reason US UCC providers gave for continuing telehealth post COVID was not because of profitability, but that patients expected it, and to keep the UCC competitive.¹⁰ In NZ, 31% of patient presentations are for accidents (including those that occur in work and for which the UCC can claim for under the national insurance scheme)²³ compared to a study from Southeast Queensland that found 20% of patient presentations were for accidents.⁹ The difference could be that the NZ government have a national insurance scheme for accidents called the Accident Compensation Corporation (ACC),²⁵ which includes initial and ongoing management of occupational injuries, which are able to be managed at UCCs.²⁵ Expanding the offering of services provided by Australian UCCs to include occupational health and telehealth services could allow Australian UCCs to better serve patients. The next relevant finding from this survey study was how patients are initially dealt with when they arrive.

Triage

Self-referred or walk-in patients are the most common source of presentations to UCCs in this study. This is consistent with the federal and state community awareness campaigns that promote UCCs as available for walk-ins, bulk-billed, and with extended hours, simultaneously re-directing patients with NLTUC away from EDs experiencing unprecedented growth.²⁶ Walk-in patients are clinically undifferentiated when they arrive at the UCC and studies from Australia, the US and NZ find some patients presenting to UCCs will be high acuity.²⁷ Timely recognition of patient acuity by a trained professional is required to maintain quality of care and improve health outcomes.²⁸

Most UCCs in our study had a nurse to triage all patients. However, some hybrid models had reception staff or the patient using images or words to self-identify the need for referral to the nurse for triage. Others had no formal triage. This is inconsistent with international UCC standards and the Australian Federal Medicare and State Funded UCC guidance.^29,30 There is unequivocal evidence that sorting undifferentiated patients to identify life-threatening conditions such as stroke and acute coronary syndrome will allow for prioritisation of care and contribute to health outcomes.³¹ This theme highlights the importance of the adoption of evidence-based tools, education, implementation, and evaluation of clinicians performing triage in Australian UCCs, which may also contribute to patient outcomes.²⁸ This survey did not delve into specific triage tools utilised in Australian UCCs.

The use of the Australasian Triage Scale (ATS), endorsed by the Australasian College of Emergency Medicine^32,33 aligns the patient triage category with those across Australian EDs. The Urgent Care Association (UCA) requires triage to be performed by a nurse and emphasises that triage is not within the scope of a medical assistant.¹⁰ RNZCUC requires UCCs to internally audit 50 triage entries every 6 months to verify triage has occurred.¹¹ The last point of discussion relates to triage and occurs when the UCC is at capacity.

Surge demand

Responses to surges in demand varied across the sites where the surveyed doctors work from. These included every patient being triaged by a nurse, closing the door, and having the ability to call a doctor in.

The UCC walk-in model, like EDs, is designed to manage unscheduled and unplanned NLTUCs. This will inevitably lead to unpredictable presentation volumes during opening hours and the probability for surge in demand. The current fixed staffing ratio over operating hours (one doctor and one nurse) in 71% of UCCs where doctors were surveyed, will lead to patients waiting much longer for care during a surge in demand. In undifferentiated patients this wait time may be detrimental to their health outcomes.^31,34 Health services need to have a framework to safely and consistently provide a rapid response to surges.³⁴ This includes a clarity on metrics to recognise a surge, clear actions to expand capacity on-site (ie increase staffing), and setting clinical goals (ie standard of care remains, but level of service for the individual may change).³⁴ Coordinating responses to surges in demand, like in other countries, could improve wait times for patients.

In England, the National Health Service plans to expand and improve links in healthcare outside hospitals to better support patients with services at home (this includes virtual wards).³⁵ Australian providers have developed and piloted unpublished tools that have been shared with Primary Health Networks and government in relation to the safe clinical treatment times recommended in the ATS.³⁶ The tools take into consideration the number of new patients arriving, the number of doctors on-site and the estimated clinical treatment time. The treatment time is estimated in a graded escalation matrix that activates workflow changes, provides scripts for staff to manage patient expectations and undertake activities to increase capacity in the clinic during times of surge.

Having UCC standards like the US, England and NZ^4,11,37 could ensure standardisation of services like access to radiology, equipment like slit lamps and I-stat on-site portable blood analysis systems and onsite fracture clinics. The standards could also give further guidance for triage and management of UCCs when in surge demand, and protocols for surge demand. This could occur under the National Safety and Quality Primary and Community Healthcare Standards.³⁸

Limitations

There were several limitations in this study. First, that this study utilised convenience sampling. While this limits the generalisability of the data, the purpose of the study was to explore the range of models rather than quantify them, and the outcomes demonstrate a need for a central repository for industry data. Second, only 52 responses were received, which also limits the generalisability of the results. While this is a limitation, the purpose of the study was to explore the diversity of service models. Finally, the study was biased towards state (47% of participants) and federal government (41% of participants) funded UCCs.

Conclusion

This paper is part two of a survey study of 52 doctors working in UCCs in six Australian states since 1 July 2023. Part one focused on the themes of capacity, accreditation standard, qualification and experience of doctors and NPs, training, funding and public education. This paper focused on themes related to operational issues. These include clinic location, opening hours, imaging options, availability of radiology services, referral sources, staffing models (including doctors and nurse practitioners), practitioner- to-nurse ratio, Schedule 8 medication storage, onsite services and equipment, triage process and a surge management plan. This paper also compares the evolving models in Australia with other Western UCC models to inform development of a UCC model that can better serve Australian patients, providers and our healthcare system. The introduction of UCC standards will address unwarranted variation in the provision of health care in Australian UCCs.