‘Never been so strained’: Call for change as ED presentations spike

Jolyon Attwooll

9/11/2022 4:39:17 PM

Push for ‘collaborative’ overall healthcare reform, with a record 8.8 million emergency department presentations reported in just one year.

Emergency sign at hospital
More people presented to emergency departments around Australia than ever during 2020⁠–⁠21. (Image: AAP)

There were a record number of ED presentations across Australia in 2020⁠–⁠21, according to a new report from the Australasian College for Emergency Medicine (ACEM).
Its inaugural State of Emergency report details how 8.8 million overall emergency presentations occurred nationwide in those 12 months, the highest number ever recorded.
It also calculates a 14% increase in demand for emergency care compared to five years previously, with the overall population growing by 5% in the same timeframe, and available hospital beds decreasing by 4%.
‘The health system in Australia has never been in a worse state,’ ACEM President Dr Clare Skinner writes in the introduction to the report.
‘There have never been more people requiring acute healthcare, people have never had such complex health needs and the health system has never been so strained.’
Dr Skinner said the Federal Government needs to lead ‘urgent and collaborative reform’.
‘Fixing the healthcare workforce requires a strategic, long-term, whole-of-system, nationwide approach,’ the report reads.
‘Widespread health reform is a massive but necessary undertaking – we need leaders who will stand up for health and can bring all parts of the healthcare system together to reimagine a better, more equitable way of doing things.’
Increasing primary care pressures are also referenced, particularly in regional, rural and remote areas.
‘This can cause people who live outside of city areas to have poorer health outcomes, meaning they will often end up in emergency departments because they couldn’t get the care they needed elsewhere,’ the authors write.
‘Older Australians must have access to high quality primary and acute healthcare that meets their needs, reflects their health priorities, and occurs where they want it, when they need it.’
Dr Michael Bonning, a member of the RACGP Expert Committee – Funding and Health System Reform (REC–FHSR), says ACEM members are well placed to recognise systemic challenges.
‘Emergency physicians are at an interface between undifferentiated health issues in the community and as gatekeepers to the hospital system,’ he told newsGP.
‘They are uniquely positioned to understand the pressures on primary care, the pressures on the hospital system, and the need for whole-of-system reform and for everyone to look outside their own lanes.’
He says a mental health report card published by the AMA this week is further proof of the strain.
It shows the number of patients presenting to hospitals with poor mental health has almost doubled to 121 per 10,000 Australians, up from 69 in 2004.
At the same time, it reports a decrease in mental health beds per capita, citing the number as falling from 45.5 to 27.5 beds per 100,000 population between 1992 and 2020.
‘Both of those are telling documents about the reduction per head of population in the number of accessible beds for patients as inpatients, which is where the load is,’ Dr Bonning said.
He says increasing levels of underlying chronic disease is a significant factor for the increases outlined in the ACEM report, and cites new longevity statistics for Australia – which rank the country third for life expectancy globally – as relevant to the current systemic challenges. 
‘So many of us are living longer with chronic diseases and exacerbations of chronic disease that often require extended management,’ he said.
‘We can’t just make the focus building more hospitals and more beds and having more and more healthcare staff.
‘The idea has to be a transition to precision, preventive healthcare, and the best, most cost-effective and most appropriate place to deliver that is through primary care.’
Dr Skinner has previously made a similar point about the impact of chronic disease, telling Nine Newspapers earlier this year that a reduction in primary care accessibility is causing more pressure on emergency departments.
‘We’re seeing people with chronic and complex illnesses who have deteriorated to the point where they need a hospital admission because they haven’t been able, or can’t afford, to access that care in the community,’ she said.
‘Then there are no hospital beds available for them because there are other people occupying those beds who can’t be discharged for the same reasons.’
Of all the states covered in the report, Queensland had the biggest increase, with a 30% rise in ED presentations up to 1.8 million in 2020⁠–⁠21 compared to 2016⁠–⁠17. The number per 1000 people requiring hospital admission also went up 11% during that time.
ACEM Queensland deputy chair Dr Shantha Raghwan said that immediate action is needed – and dismissed suggestions that the trend is being caused by presentations that should have been at a general practice.
‘There’s been a focus on GP-level patients causing overcrowding in EDs, but our data shows that is not the case,’ she told the Brisbane Times.
‘So while we need investment in primary care … we need to recognise that’s not the solution for hospital access problems – we need to look at the overall picture of the health system, identify the problems and fit the solution to that.’
Dr Bonning agrees that a broad approach is required.

‘Certainly, we need more beds because we’re not keeping pace with the population,’ he said.
‘But if we just say that the hospital system has to manage all of this, then we miss the point.
‘The changing nature of disease and the management of chronic conditions requires long-term incremental inputs into care.’
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Dr Gaston Hubert Marie Boulanger   10/11/2022 7:08:27 AM

The solution is simple. Start by paying General Practice appropriate fees. This is the result of a decade long neglect of the General Practice, The main increase of ED presentation is in the Cat 4-5 GP presentations (it is currently 40% in my town and rising). In order to financially survive GP's abandon bulk billing rapidly. The ED becomes the only option to have free healthcare. Adequate GP funding ( double level B and C rebate and triple level D) will solve this problem immediately. BB level will increase and and this 40% of ED presentations will go to the GP.
ED presentation are very expensive.

Dr Gaston Hubert Marie Boulanger   10/11/2022 7:47:51 AM

Regarding to categorization: In this discussion the Cat 1 2 and 3 presentation in the General Practice are not counted. An increase in GP funding will actually decrease also the Cat 123 presentation for two reasons. 1 GP's treat these presentation 2 Accessible and affordable GP services will decrease the Potentially Preventable Hospitalisations (PPH). There were 120,805 'PPH illness assessments' in Queensland 20/21.
The rhetoric of this article implements the solution is more Hospital Services. A reality check dictates the main problem: a decade of undermining General Practice. GP's used to do 90% of the work for 5 percent of the costs. The 90% is declining... every % work done in Hospital settings will blow out the budget immediately. ACTION TO RESTORE GENERAL PRACTICE IS NEEDED NOW

A.Prof Christopher David Hogan   10/11/2022 8:37:54 AM

So the work of good GPs is invisible & is only noticed when they are gone!
To become medical students we pass the same exams.
We graduate by passing the same exams & have the same potential.
We do the same PGY 1 & 2 work
Then we spend similar time doing Fellowships
So why are our remunerations so vastly different?
History tells us the difference was definitely NOT based on merit but manipulation & manoeuvring.

Dr Suresh Gareth Khirwadkar   10/11/2022 9:18:05 AM

The biggest change we could make isn’t even in the health system. It’s address socioeconomic determinants of health, stopping subsidies to powerful lobby groups that want to sell their junk and don’t care about the toxic effects on the population (like the sugar industry), heavily tax junk and processed foods and sugary drinks, stop toxic work cultures that lead to unnatural amounts of stress and distress and treat the root causes.

Throwing more money at hospitals is a never ending battle that we are losing across the world not just Australia.

We have to treat the root causes.

However this unpalatable and requires governments to stop selling out to powerful rich lobby groups with toxic vested interests.

Will never happen.

Dr James Courts   10/11/2022 9:46:18 AM

Just as well there is a highly respected profession that the government invest in and value, with high levels of morale and energy post pandemic, waiting in the wings available to help.

Dr Ian   10/11/2022 12:47:32 PM

Yet longevity is getting better and unlike the USA there has been no dramatic increase in excess mortality that has been seen .
From General Practice perspective our clinics were not set up for Covid -small spaces , no windows or windows that can be opened ,lack of triage areas leading to respiratory clinics being needed and early as is well known ,low quality PPE as regards N95 masks ,head shields and gowns -.
General Practice in Australia will still flourish but to reduce stress we will need to open the medical school gates .