GPs could save the health budget $1.5 billion by stopping lower urgency cases flooding emergency

Doug Hendrie

11/07/2019 3:30:35 PM

Lower urgency cases are filling up hospital emergency departments around the nation. Could GPs solve the problem?

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Is there a better way to go for lower urgency cases?

New Australian Institute of Health and Welfare (AIHW) data shows 37% – almost three million – of the nation’s eight million emergency department (ED) presentations are considered ‘lower urgency.’
That means they could most likely be treated by a GP at a fraction of the cost of hospital treatment, making major inroads into the $4.9 billion annual cost of ED presentations. 
The data follows a recent study estimating between 20% and 40% of ED presentations in Western Australia could be treated by GPs. 
The AIHW data shows an increase in patients attending EDs for lower urgency issues during daytime hours when general practices are open, boosting the RACGP’s stance that GPs are ideally placed to tackle lower-urgency cases, which can often overwhelm EDs. 
Lower urgency is defined as when a patient does not arrive by ambulance, is assessed as needing semi-urgent or non-urgent care and is discharged without referral to another hospital.
The RACGP has long stated that better support for and use of general practice would help to reduce avoidable emergency department presentations.
Over the last three years, in-hours lower urgency ED presentations rose from 60.5 to 61.1 per 1000 people, while after-hours cases fell from 58 to 56 cases per 1000.
Rates of lower urgency ED presentations are markedly higher in regional areas, at 159 cases per 1000 people, compared to 92 in the cities.
Children aged under 15 were 1.6 times more likely to come to emergency for issues considered lower urgency than the wider population, with 181 cases per 1000 people compared to 117 nationally, while older people were less likely to present with lower urgency issues.
GPs are skilled at managing issues such as injuries, wound care and acute infections that could otherwise lead to patients attending an ED.
Each non-admitted ED presentation costs the taxpayer around $533.
State governments in South Australia and Western Australia have made recent moves to slash the number of lower urgency cases by making better use of GP skillsets and availability in a bid to tackle chronic overcrowding and strain on EDs.
Other states are also grappling with overcrowded EDs, with New South Wales overcrowding forcing more than a third of patients with imminently life-threatening conditions to wait longer than recommended for treatment, while two Tasmanian hospitals were recently ranked the worst in the nation for overcrowding and ambulance ramping by the Australasian College for Emergency Medicine.
A body of Australian and international evidence shows better support for and use of GPs is associated with lower emergency visits and hospital use, decreased re-admissions, health benefits for Aboriginal and Torres Strait Islander peoples and reduced costs to the healthcare system.
Studies have also shown that patients who have continuity of care with a regular GP have lower rates of hospital and ED attendances, and lower risk of mortality.
In 2016–17, all Australian health spending by governments totalled $124.1 billion, of which only $9.1 billion went to general practice. That represents 7.4% of total health expenditure.
The RACGP’s Vision for general practice and a sustainable healthcare system, which is currently under review, documents the substantial savings across the healthcare system that could be achieved through better use of general practices.

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Emil Guirguis   12/07/2019 7:10:34 AM

That can be achieved by showing GPs that they are appreciated, not by freezing their medicare rebates while the costs of running a private general practice are sky rocketing, and the added burden of red tape is getting heavier. GPs need the time wasted on red tape to be redirected towards direct face to face patients care.

Dr Cho Oo Maung   12/07/2019 7:57:16 AM

Each MPS and Hospital should have a Clinic room for GP. The whole Business of GP should be owned by the Department of Health. Providing free accommodation for GP and the deal to make with GP is round about 60-75% of income per patient. That will solve many doctor shortage in country towns too.

John Lamb   12/07/2019 8:21:13 AM

1.5 billion is small change compared to the multi-billions that general practice can save the system by chronic disease management and preventive activities. The major cause of overcrowding in ED's is bed block, not inappropriate presentations. Those ramped ambulances are carrying urgent ED type patients. In fact, a significant problem in general practice is patients with serious emergency conditions such as acute chest pain presenting to their GP rather than to ED.

Joseph Grace   12/07/2019 8:57:41 AM

Appropriate management of lower urgency cases would also significantly reduce patient pain and suffering.

So, what's the plan from here?

Robert Worswick   12/07/2019 10:28:49 AM

I’m a GP registrar working in a very busy tertiary ED. Based on my current experience, I think the rates of lower urgency presentations cited in this article are considerably lower than reality. Reasons for presentation to the ED are:
1. Couldn’t get a same day GP appointment (but actually don’t need to be seen that day).
2. Don’t want to pay for healthcare.
3. Not getting better after seeing GP (my GP gave me antibiotics for my viral URTI and it’s been two days and I’m still sick).
4. Want a second opinion.
5. Inappropriate referral from GP (unfortunately, and disappointingly, this occurs regularly).

The two key perpetuating factors are:
1. Low urgency patients get a better standard of care in the ED than they do at a bulk-billing ‘6-minute medicine’ super clinic.
2. Hospitals won’t turn these patients away (and feel compelled to treat them within four hours).

Graeme Banks   12/07/2019 10:43:36 AM

Try getting a gp appointment in under 3 days. Be prepared for hefty fee.
How many gp’s have “closed their books”?
Bulk billing money factories don’t do fancy time consuming stuff like this ED business, time is money. Whoever wrote this should get out more. Perhaps explain why 80% of the health dollar is consumed by bureaucracy. I despair at the chasm between the RACGP and real life.
Are they really representative or just going through the motions to earn an easy dollar. Start fighting for GP and the way it is bullied by government. If not, general practice will disappear in fifty years time and those at HQ will be out of a job.

Jenny Bloggs   12/07/2019 11:22:37 AM

Go to the hospital at no cost. Go to a non-bulk billing GP (there are no bulk billers in my area) and be out-of-pocket $53 each and every time. It adds up quickly, especially for families with children and self-funded retirees.

Dr Geoff Broomhall   12/07/2019 11:27:57 AM

Eastern Melbourne PHN has been funding an orthopaedic fracture diversion project of which I am the clinical lead
We have successfully diverted about 3,500 Un displaced fractures from ED in Northern, Eastern and Austin Health in 12 months
98% patient satisfaction rate from care from a cohort of specially trained GP’s
The GP community needs adequate funding to support this program as do Healthcare Networks to fund support staff
The project continues for 12 more months and we look forward to publishing the outcomes
Early analysis suggests major benefits for ED , fracture clinics and patients but attention to undergraduate training in the area is urgently needed
Geoff Broomhall
LILYDALE Médical Centre
Clinical Editor HealthPathways EMPHN

Dr. Lou   12/07/2019 11:47:15 AM

What is the cost to see a doctor in ED compared to seeing a GP. I’m am sure that it’s not $37. The government gets its pound of flesh, and no body has questioned this

Doc_who   12/07/2019 11:58:07 AM

The problem is not for people attending ED , the problem is with General Practitioners flicking everything on ED !!! I have seen it all .... I have seen General Practitioners sending people to ED because of haemorrhoids!!, I have seen GPs sending people to ED for FB eyes, ears , nose , ... if you are a qualified medical practitioner and cant remove FB from cornea , eye, whatever ... you shouldnt be allowed to work... where is a college from this mess ? what kind of training the college providing? how the college allow to give fellowship to General Practitioners who cant do basic medicine ?!! if you cant handle the pressure and function as a respected doctor , find another work to do, GP is not the dumping ground for failed people , wake up college and do the right training and provide the fellowship to the qualified people , respect the profession and integrity of medicine ... by the way, send all of these patients to me , I can make good money

Karen   12/07/2019 10:20:46 PM

I’m a bulk billing GP in a ‘no appointment’ clinic run by a corporate. I’m shocked at the lack of respect I get from colleagues and their ill placed assumptions. Shame on you. I don’t practice 6 min medicine. I’m grossly underpaid and disrespected. Perhaps I should start sending more complex patients to ED? No? Show some respect. And increase the Medicare rebate to reflect the real value GPs represent.

Rabid Dog   13/07/2019 8:03:30 AM

Lower urgency DOES NOT equate to admission numbers, or time taken to sort the problem out. I admit LOTS of triage 4 and 5; this article demonstrates an ignorance of triage and all it represents, and could be mistaken for more Polly waffle - lay the blame where it REALLY lies.

david mountain   13/07/2019 6:26:30 PM

As ED dr's We have looked extensively at GP type presentations to ED- because every bureaucrat and many GPs suggest that is why EDs are crowded. GP type patients may be a signficant part of ED waiting rooms BUT almost never come by ambulance and rarely spend any time in main ED. They are not the cause of ramping/access block or delayed care in EDs but some would definitely be better of seeing a good GP for continuity/ long term care. Many (20-30%) of GP type patients are actually sent in by GPs! The cost differentials in terms of real additional costs are not the 550 vs 35 talked about. The additional cost (e.g. extra resources above already being open 24/7, and staffed, requiring Xray/path etc etc. is more like $55-150, for GP type patients, which is not much more than a non-bulk billing consult or after hrs rates. We won't mend the health budget or ED overcrowding by diverting GP pts BUT good access to good GP practices in timely fashion will improve long term pt outcomes

Dr Craig Andrew Morris   14/07/2019 8:48:37 AM

Filling the "after hours" space remains a big challenge. Public hospital emergency departments are expensive. Metro Gps don't wish to be "oncall" and lose sleep, but if operating in the space want a big call out fee as recompense.

When emergency call outs after hours were funded with higher rebates, the deputising services happily filled the space, but regular GP clinics complained about the fragmentation of care and the disparity and the rebates and after hours visits dropped.

As is pointed out in the comments so far , there is no particular desire to fill this space beyond the current model and the current general practices continue to defend their turf ie Any other funded service becomes competition and is criticised.

Dr Hein Strydom   14/07/2019 5:27:38 PM

Multifactorial issues , but the fact that a town's GP practices are closed on week-ends and public holidays as well as after-hours, is significant.

Dr Tim Begbie   14/07/2019 6:57:56 PM

Dr Robert Worswick made very good points. Sequence of events:
Bill Hayden (Labor) introduced MEDICARE with the promise of "Free Health Care for ALL Australians" in a multi-million dollar campaign (based on lies and paid by taxpayers) to try and put a wedge between private practitioners and patients. "age of Entitlement began" All downhill from there! CPI went up, effectively Rebates went other way. Large scale GP bulk billing finished us off. QED.