Feature
Why do patients go to emergency rather than to their GP?
Experts say the reasons for the phenomenon are complex – but underfunding of general practice is a key issue.
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
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