GPs in EDs reduce wait times, costs: study

New research out of the UK that integrated general practice services into children’s emergency departments (EDs) to treat non-urgent cases, has found it can reduce waiting times, inpatient admissions and healthcare costs.
 
The large, retrospective observational study tracked 13,000 non-urgent presentations over a two-year period and found that patients managed by GPs instead of ED staff experienced on average 18.4% lower treatment costs, fewer hospital admissions, and were less likely to experience a waiting time of more than four hours.
 
According to the researchers, the study shows there is ‘real potential’ for alternative models of providing care in emergency departments that result in ‘significant’ benefits to patients, parents and the health service.
 
But would it work in Australia? Professor Mark Morgan, Chair of the RACGP Expert Committee – Quality Care (REC–QC), told newsGP similar set ups have been tried here previously with good results, but there are a number of factors that can influence how successful these trials are.
 
‘It’s been tried and tested in a number of different ways because for a long time it’s been clear that some of the people in emergency departments have conditions that could be safely managed just as well – if not better – in the community,’ he said.
 
‘But, the different models are very much dependent on what the context is, including regulatory and financial incentives, as well as societal expectations and understanding of the system.
 
‘So what’s worked in England won’t necessarily work in Australia in the same way.’
 
Professor Morgan pointed to GPs working in rural community hospitals as an example of the Australian experience of embedding general practice into hospital EDs.
 
‘There are also variations of having adjacent clinics, or directly employing GPs, or referring people from emergency departments to GP clinics that have agreed to hold appointments vacant for that purpose,’ he said.
 
‘There have been a number of models that have been tried, and most of them achieve what you’d expect them to achieve, which is a proportion of patients who are effectively managed in the community.’
 
However, while he said embedding more general practice services in hospital EDs could help improve outcomes in some instances, it should only form part of the mix of attempts aimed at managing more patients in the community overall.
 
‘Australia’s got a long way to go before they make it an optimum system and it requires people to be able to understand where the most appropriate place to seek help is,’ Professor Morgan said.
 
‘Innovations like telehealth and telephone support services like healthdirect, are all part of the mixture for trying to get the right people to be seen in the right place at the right time.
 
‘There’ll always be a trickle of people that come to the hospital for conditions that could otherwise have been managed in the community and hospitals need a system for dealing with those. If that involves referring back out to general practice, all well and good.’
 
Aside from potentially reducing costs and wait times, Professor Morgan said employing GPs in hospital EDs could also help manage patients with multi-morbidities.
 
‘There are opportunities to work better across the boundaries of our health system. But I think the real benefits would show in complex chronic disease and multi-morbidity, where the GP’s knowledge of community medicine and the history of individual patients would assist hospital colleagues enormously,’ he said.
 
‘It is a bit of a shame that people’s GPs are not engaged … until there’s a clinical handover at the end of the admission. So looking for funding mechanisms, and convenient mechanisms for GPs to be involved in hospital care, I think would be ideal.
 
‘Achieving this has been challenging because of the state/federal divide in funding. Small steps could be achieved by funding asynchronous contribution by GPs in discharge planning case conferences for public hospital patients.’
 
According to the study, one drawback of co-locating general practice services in an ED is that patients seen by GPs were subject to higher rates of antimicrobial prescribing.
 
But, Professor Morgan is sceptical as to whether the same trend would be seen in Australia.

‘To not prescribe, you have to have a plan B, which is the opportunity for the person to re-present easily and effectively if the clinical situation changes,’ he said.
 
‘What we don’t know is whether that was a reason for the finding they found in the UK, nor do we quite know what it would be like in Australia.
 
‘But the general thing is antibiotics are used more often than they should, right across the healthcare spectrum, both by specialist providers, by emergency departments, and by GPs.
 
‘There’s lots of work [being done] … on multiple different strategies for reducing potentially inappropriate antibiotic prescribing.’
 
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emergency departments general practice healthcare reform