Why do patients go to emergency rather than to their GP?

Doug Hendrie

12/07/2019 3:48:28 PM

Experts say the reasons for the phenomenon are complex – but underfunding of general practice is a key issue.

busy emergency department
Shifting patients from emergency to GPs is a complex challenge.

Two weeks ago, Adelaide GP Dr Alvin Chua witnessed emergency department (ED) overcrowding firsthand.
Sitting in the Royal Adelaide Hospital with his father, who has renal failure, Dr Chua saw what he describes as an immense backlog of patients.
‘In the waiting room, it was a shambles. Every seat was taken, every floor space was taken. The ambulances were ramped up. My dad was seen at 8.30 pm but didn’t get a bed until 11.30 the next morning,’ he said.
‘The doctors and nursing staff were doing the best they could – but they couldn’t get out of the backlog. There were a lot of non-urgent patients waiting to be seen when I came in, and six hours later they were still sitting there.’
The episode strengthened Dr Chua’s belief that the last six years of the Medicare rebate freeze for GPs is having an effect on the rest of the healthcare system. 
‘At our clinic, we bulk bill kids. But we have some adults who come in with their kids but don’t want to pay the gap fee. They’d rather sit it out in the ED,’ he said.
‘We need to fund general practice properly. If we did that, we could afford to reduce our gap fees. After being frozen since 2012, we got a 1.6% rebate rise on 1 July. That same day, reception and nursing wages went up 3%.
‘So that rebate increase – which was not even in line with CPI [consumer price index] – got chewed up immediately with the cost of running a business.’ 
Dr Chua’s story comes in the wake of new data suggesting more than a third of patients attending an ED are there for lower urgency issues.
The cost of tertiary care is one reason Denmark has cut the numbers of hospitals from 98 to 32 over the past 20 years in a bid to decentralise healthcare and have most care delivered in the community.
A recent Australian study analysed what happened when GPs were put in EDs, and found the GPs could resolve between 20% and 40% of ED presentations.
But experts say the reasons for the phenomenon in Australia are complex, with the cost of care only one among many.
Dr Michael Wright, Chair of the RACGP Expert Committee – Funding and Health System Reform (REC–FHSR), told newsGP the prolonged Medicare freeze has meant some GPs have had to increase their costs to patients.
‘Given that ED care is delivered free, that means the Government is potentially pushing people to go to emergency if GP fees are acting as a deterrent,’ he said.
‘The cost of a Category 5 [non-urgent] attendance at a hospital ED is $533. For that, a GP could do around five 40 minute Level D consultations.
‘It is obvious that big cost savings could be made by providing some of this care through general practices. GP care would still be cheaper even if Medicare rebates were doubled.’  
Dr Wright said reassuring patients that GPs can deal with many less urgent conditions is vital.
‘There are complex reasons why people might choose to go to an ED ahead of a GP, some of which will be improved with better education and better support for GPs,’ he said.
‘But there will always be people who think the ED is the place they should go to. That isn’t a sign GPs aren’t doing their jobs. We live in a system where patients can choose to do that, and once they arrive, most EDs will feel the responsibility to manage them.’
Dr Wright added that the triage method of measuring urgency is a ‘blunt measure.’
‘There will be people who are identified as Category 5 who still need to be admitted to hospital. So it doesn’t mean they don’t have a problem that needs hospital, it just means it wasn’t urgent – and could, potentially, have been managed outside the hospital setting,’ he said.
‘There’s a growing recognition that hospital care should be focusing on people who are very sick and need that care, while a lot can be managed in the community.’
Dr Wright said that while only a small number of patients cite cost as a reason not to see their GP, it is not insignificant. ABS data from 2017–18 shows that one in 11 patients (9%) saw their GP for urgent medical care, while one in 25 (4%) delayed or did not see their GP due to cost concerns.
‘Understanding the reasons why people choose to attend an ED rather than general practice is a vital part of this discussion. Why would a patient choose to attend an ED where the reputation is long waits for low priority conditions?’
That’s Associate Professor Mark Morgan, Chair of the RACGP’s Expert Committee – Quality Care (REC–QC).
He lists the questions that need to be answered in order to directly address the issue:

  • Are patients misjudging the severity of their condition and truly believe that they must attend hospital for their safety?
  • Are the rebates for attending general practice insufficient to pay for the service, leading to out-of-pocket expenses?
  • Are general practice clinics having trouble managing demand so that there are no appointments available?
  • Is the coding of medical condition in the ED sufficiently accurate to determine that one third of visits should have been handled in primary care?
Associate Professor Morgan cited research suggesting that a major reason is self-assessed urgency of a condition, such as a 2006 Australian paper which found the three top reasons for choosing an ED over a GP were self-assessed urgency, being able to see the doctor and get tests done in one location, and self-assessed seriousness of the issue.
Other factors listed in a review covering 38 papers between 1995 and 2016 on why patients choose emergency and urgent-care services include confidence in primary care, access to primary care, perceived urgency, cost and access to investigations such as X-rays.
UK research shows another factor is the difficulty of accessing a GP, particularly for people with English as an additional language.
Influential research from 2003 found that the heaviest repeat users of an inner-city ED in Melbourne were not suitable for GPs, due to the urgency of the issue, the fact that many were in an acute psychiatric episode, or were homeless.
‘For medical conditions that can safely be assessed and managed in general practice, there are numerous benefits [of being seen by a GP],’ Associate Professor Morgan said.
‘GPs will often have background medical information, are set up to be able to provide follow-up visits, and have skills and training covering a much broader range of presenting conditions than in many smaller EDs.
‘GPs will also be much more confident about managing issues like multimorbidity, uncertainty or a co-morbid mental illness.’

care department emergency hospitals overcrowding primary tertiary urgent

newsGP weekly poll Which of the below incentive amounts (paid annually) would be sufficient to encourage you to provide eight consultations and two care plans to a residential aged care patient per year?

newsGP weekly poll Which of the below incentive amounts (paid annually) would be sufficient to encourage you to provide eight consultations and two care plans to a residential aged care patient per year?



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Rabid Dog   13/07/2019 8:00:49 AM

I'm a tertiary ED trained rural/remote ED MO, therefore I think I have a better perspective than most on this topic. I'm actually writing during a break while on nightshift in a remote ED.
There is a continuous claim by our political masters (and suggested here) that EDs are full due to 'GP patients' .
Rubbish, in fact, Alvin's observation that:
"There were a lot of non-urgent patients waiting to be seen when I came in, and six hours later they were still sitting there."
undoubtedly demonstrates that the hold up is the constant influx of patients by ambulance, or walk-ins with chest pain etc (not to mention the high case load of Psych) that is the problem NOT 'GP patients.' Admittedly the severe cold and flu season has resulted in LOTS of children presenting but that may just be a special case.
And yes, I know the RAH intimately.....

Lisa   13/07/2019 8:08:29 AM

In our rural town we BB because if we did not- they would go to the ED which the GPs also staff. It is not sustainable for us. My GP wage is less than I earn as a resident. My hospital wage for covering ED provides the income to support our family. Either charging in ED for non urgent presentations or adopting universal private billings in GP could make more sustainable. I don’t feel our service is valued by the community - rather pay for a plumber - doctors are seen as free.

Michael Fasher   13/07/2019 9:43:36 AM

This is a useful article with valuable links. Thank you.
All the points made and questions asked are important.
Yet, there is at least one other.
The primary health care system and the health system within which primary health care sits are no longer fit for purpose

Hugh Grantham   13/07/2019 10:08:43 AM

A very complex problem, don’t forget the many patients who have been to their GP and are then appropriately referred to ED and get non urgent triage codes. They are in the right place having had the opportunity to be seen by their GP first.

The other point I would make is that the ED option is not always the least traumatic for the patient, this is particularly so for the elderly residents of RCFs and those with mental health problems.

Hugh Grantham

Stephen McCappin   13/07/2019 11:23:59 AM

I am now an old GP :( 30 yrs. This is not a new phenomenon. It is just much worse now. The newer generation of GP's are just no longer willing to work the extraordinarily long hours that older GP's used to work when they were the equivalent age. I believe this is mainly due to their healthier attitude towards work life balance. The waiting lists in general practice are certainly related to this as GP's are increasingly less willing to take up the slack in a system in which economic imperatives are so skewed. The public has been educated to think that tertiary care is where they will receive the best in all things medical rather than education and time in a poorly funded general practice. Anyway, these are only the rantings of an old GP :) - not proof read -

Chris Hazzard   13/07/2019 12:36:03 PM

The Federal Government does not have much incentive to increase GP rebate rates. If they do the cost goes to treasury. As it is, the cost of public hospitals is born by the states.
I work in out of hour deputizing and I would say that in at least 50% of my pediatric cases the only other option for worried parents is the ED. As well as assessing the child I usually give them a handout which lists signs and symptoms that would indicate the need for a review or ED presentation. I will ring the next day to ask how they got on. Very rarely have they needed to go.
I am not paid for the extra effort. In my view, an extra item should be added to the consult in both in and out of hours consultations, and that may result in fewer ED presentations.

Dr Michael Charles Rice   13/07/2019 3:30:12 PM

rather than "The cost of a Category 5 [non-urgent] attendance at a hospital ED is $533. For that, a GP could do around five 40 minute Level D consultations" I'd frame it as "the GP would most likely be happy to see the patient for half that"

After hours is a bit of a trick though: am I going to return and re-open the practice for half that? Maybe not; because patients who require it wouldn't have access to 24-hr fully stocked pharmacy, imaging, rapid pathology, security and assistants.

Certainly IN hours, if EDs handed patients a voucher redeemable for $300 at GP I think a lot of this would change very quickly.

Dr Peter Robert Bradley   13/07/2019 10:32:15 PM

I've worked in ED in a city hospital, and more recently 20 years in GP, now retired.
My view is the issue is caused by two main factors.
1. The very real bed-block in many hospitals because they have just simply failed to create enough beds in time to meet the increasing needs, so patients are not moved out of ED fast enough to clear the decks.
2. The woeful Medicare funding for GP, such that it is no longer economic to keep surgeries open extended hours, let alone 24/7. So yes, many cases that could be dealt with by GPs instead go to ED. Yet when I moved to Brisbane in 1989 there were at least six 24/7 hour medical centres, now there are none.
One quick solution, in my view, is simply for the federal Govt to allow GPs to direct bill rebates and charge enough up front to make extended hours once again financially viable.

Dr Peter J Strickland   14/07/2019 6:17:43 PM

There is no doubt in my mind after being in GP practice for > 40 years that the solution to non-urgent patients going to Emergency is to charge them a fee equivalent to their social position for consultation, x-rays and blood tests. ---- kids and pensioners and healthcare holders at Medicare rebate, and the rest at a gap of about $10 for all major medical items such as consultation, x-ray and blood tests --- charge at the door, and make it debatable via Medicare. That suggestion would be up for grabs and discussion between the States and the Commonwealth. Increasing the out-of-hours, and the rebates for GPs in and out of hours for home visits as well would almost certainly be more productive and time-saving for patients, increase GP practice incentives for better incomes, and in the end save the Australian governments lots of dollars. Lawyers at conferences I have attended laugh at the ridiculously low GP fees for consultations and reports.

Gillian Eastgate   15/07/2019 10:49:38 AM

I am a GP. I go to a very good local GP practice. But the practice is not open after hours. Neither are the local Xray or pathology services. So when a child falls off a scooter, or develops abdo pain in the middle of the night that may or may not be appendicitis, or I fall off my bike, where do we go? The ED of course! Could the GP stitch us up, order some basic blood tests, put on a cast, organise early review? Of course they could. If they were paid $533 a time to do this work, I'm sure at least bigger practices would be organising a weekend roster...

Dr Cho Oo Maung   16/07/2019 8:41:44 AM

ALL hospitals should have a room for GP. GP business of the hospital must own by the hospital or the local community, not business Co. Employ AMC doctors who have already passed AMC exam and Citizen of Australia in these GPs, supervised by RVTS or GP synergy or RACGP / ACRRM and ED specialist of Tertiary hospital directly will solve the GP shortage in country side and reduce ED influx. Can't get appointment in GP on time , has to pay $65 for 15 min./ Amoxycillin script, these all contribute ED influx.

Dr Jitendra Natverlal Parikh   20/07/2019 9:47:01 PM

Very good presenatation of all balanced participants. I wonder what was happenning before the start of medicare inhopsital emergency department. I do remeber in those days apart from teaching hospitals most of these were staffed by local GPs and in those days emergency medicine rheumatology andsports medicins as speciality was not developed.Most in charge collegues have surgical fellowship and few are still around.The crowding of the hospital as it happens now is there 24 hours functioning and ability to do xrays and pathology on the spot which patients love. Now as an added bonus they can say appropriate on call consultants free.I am sure 50 % of them do not see the consultant after words due to cost factor.A flag fall of 50 or 100 dollars on presenatation will get rid of 50 % of patients immediately.Add to this pathology and radiology cost will get rid of another 50 % particularly if the option of bulk billing is available through GPsurgeris as it happens now

Lucy Ng   24/07/2019 2:55:00 PM

These incidents happened years ago,but have stayed in my mind.When I had to visit E.D. with a relo who did need E.D. care,I chatted to others in the waiting room.Some,who appeared to be recent immigrants andwho had "G.P.non-urgent problems" informed me that E.D. Drs. were "superior" in providing care for G.P.problems.I was shocked by their stetements,but did not reveal my G.P.status.I wonder if these attitudes prevailed in the countries they emigrated from.