Should an urgent care standard be established?

A Queensland-based GP and researcher is pushing for an urgent care clinical standard to be introduced in Australia as State and Federal Governments work on expanding options for treating non-life-threatening urgent conditions.
 
Dr John Adie, who is working on a PHD looking into urgent care, believes a universal standard should be applied, as it is in his native New Zealand.
 
The Australian convenor of the Royal New Zealand College of Urgent Care, Dr Adie has contributed to four published studies as part of his research.
 
In the latest, published this month in the Journal of Health Organization and Management, Dr Adie and his co-authors compared presentations to an emergency department, an after-hours GP practice, and an urgent care centre (UCC) in Queensland on Sundays across one year.
 
Taking in 6065 patients, the research found there were ‘statistically significant differences’ in presentations according to different factors such as age, time of day, season and types of injury, among other variables. 
 
It notes that more younger people went to the UCC, and that 97% of those seen in the UCC were not admitted to ED.
 
It also highlights that older adults are more likely to be admitted to hospital compared with other age groups, and that there were more presentations in the morning and in winter compared to other times, a situation ‘which has implications for staffing’, according to the authors.  
 
They make a series of recommendations for UCCs, beyond calling for a clinical care standard. These include a push for UCCs to have extended hours (seven days a week from 8 am – 8 pm), as well as walk-in availability and on-site radiology.
 
The Federal Government is currently seeking to finalise a 2022 election pledge to establish 50 UCCs around the country, while both NSW and Victorian Governments separately committed last year to 50 bulk-billing urgent care clinics in a bid to ease hospital demand.
 
Dr Adie, who has been involved in starting UCCs in Queensland, NSW, South Australia and Victoria, believes they should complement general practice.
 
‘In my opinion, [urgent care] belongs in large general practices that can provide extended hour service, walk in X-ray on site, with doctors that have experience of urgent care,’ he told newsGP. 
 
He also believes there is no reason UCCs are likely to fragment continuity of care – a criticism that has been made by the AMA, among others – and points to directives for the UCCs he has helped to set up, ensuring discharge summaries are always uploaded onto My Health Record.
 
‘Having an urgent care centre in a GP surgery, rather than the English model where it’s more in the hospital, I think is better for continuity of care, cost and patient outcomes,’ he said.
 
However, Queensland practice owner and RACGP Expert Committee – Funding and Health System Reform (REC–FHSR) member Dr Cathryn Hester says she does not see a compelling argument for UCCs. 
 
‘Unfortunately, what we have seen from the disastrous NHS experiment with UCCs is that prioritising access over longitudinal continuity of care with a regular general practitioner is harmful to the functioning of the health system,’ she told newsGP.
 
‘The risk is that UCC diverts funding and political attention from what we already know is the most effective and cost-effective segment of the healthcare system: general practice.
 
‘We already can see from the UK experience where UCCs were used as an expensive band-aid to help the shortfall in general practice capacity – it just doesn’t work in the long run.
 
‘Costs are driven up by nursing and allied health practitioners that have been promoted beyond their scope of practice, care is fragmented and often duplicated, and patient safety is at risk.’
 
Dr Michael Bonning, who also sits on REC–FHSR, expresses concern about the walk-in model.
 
‘The big thing, from my point of view, is that walk-ins are likely to become saturated services because people will use them for non-urgent things that do not require immediate attention and could be seen by following up with their GP in one to two to three days,’ he told newsGP.


Both NSW and Victoria have commmitted to 25 Urgent Care Centres respectively, separately to the Federal Government.

He notes that for the models he has seen in NSW, there is a commitment to a single-entry point which has appropriate triage.
 
‘If you are an urgent care service, seeing 100 patients a day and three are going to emergency, that’s still a reasonable number that you may want to be diverting to emergency earlier,’ Dr Bonning said.
 
While Dr Adie says a model where doctors receive hourly pay equivalent to hospital rates should be considered, Dr Bonning believes the current set-up can work if it is better resourced.
 
‘After-hours and urgent care would be significantly supplemented simply by encouraging and incentivising general practice to open longer and manage patients,’ he said.
 
It is a view Dr Hester shares.
 
‘Despite what politicians would like to believe while they desperately grasp for a solution to our health crisis, UCCs categorically do not reduce hospital admissions, but they do cost the system more overall,’ she said.
 
‘Workforce is diverted away from where it would be most effective – general practice – and costly infrastructure has to be replicated.
 
‘Building urgent care centres near to EDs is one example of this madness.’
 
Dr Hester wants health leaders to analyse proposed models ‘to ensure they are fit for purpose, and not just repeating the mistakes of our colleagues from overseas’.
 
‘We already have a solution that is fit for purpose: general practice,’ she said. ‘It just needs to be funded appropriately.’
 
However, Drs Bonning and Hester differ on whether there is a need for a new urgent care clinical standard, with Dr Bonning suggesting there is a place for them among larger services, while Dr Hester believes the general practice standards suffice.
 
‘If they don’t bring together their thinking and reach agreement on how to deliver goods in Australia, then different models will develop,’ Dr Bonning said.
 
‘If you have a Commonwealth clinic in one suburb and a state clinic in another suburb 20 minutes down the road, and they run differently, that could really undermine the quality and the understanding of access for the public.’
 
Kerron Bromfield, a health operations consultant who has worked closely with Dr Adie in setting up other urgent care centres, also supports accreditation.
 
‘From a recruitment perspective, if you’ve got your GPs, and if we can get accreditation, then you’ve got your GPs actually choosing to work in that area of urgent care,’ Ms Bromfield told newsGP.
 
She also notes that funding and resources have posed challenges for setting up UCCs.
 
‘To attract the doctors, we need the funding,’ she said.
 
‘There’s an amazing array of doctors out there that could be of huge benefit to the practices to provide these services to patients, get them out of the hospital, reduce that burden, the ambulance need, the ramping, all of the issues that Australia is facing.’
 
Along with co-authors of the recent Journal of Health Organization and Management study, Dr Adie highlighted other areas for future research, including involving GPs and other clinicians to pinpoint the type of patients who should be diverted to UCCs more accurately.
 
According to the article, future studies should also consider the right public health messaging to push patients with non-life-threatening urgent conditions, especially infections and injuries, to present to UCCs.
 
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