Report calls for co-location of primary care with A&E
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h3011 (Published 04 June 2015) Cite this as: BMJ 2015;350:h3011
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We were delighted to see that the recent RCEM report recommends GP services to be co-located with A&E departments, however we believe that the RCEM's view that 22% of patients can be managed by a primary care team is a significant underestimate . As a provider of 4 primary care led Urgent Care Centres (UCC) co-located at large A&Es in London we have found that between 50-60% of patients presenting at the front door of A&E can be safely managed by GPs and Nurse Practitioners in our UCC.
Our evidence suggests that using primary care trained clinicians to manage the high number of primary care related problems that now present in A&E allows our Emergency Medicine colleagues to focus on the more seriously ill and injured patients.
The RCEM report states that many patients chose to present at A&E even though they have been offered a same day appointment at their GP practice, this reflects our experience and we believe that managing that 24/ 7 demand at the point of presentation (i.e the UCC) using primary care clinicians is the safest and most efficient option.
As urgent care models evolve we urge commissioners to take the next step and explore combining GP out of hours base services with primary care led UCCs . This will reduce multiple access points to out of hours care which are confusing to patients and are an inefficient use of the workforce.
We look forward to working with the RCEM , commissioners and the patients association to develop models of urgent care that meet the patients needs, support the training requirements of staff and ensure ongoing patient education on appropriate use of services all within the limited financial resource available.
Competing interests: Provider of UCCs
Why are patients in London coming to A&E even when offered same day appointments in general practice?
Editor
I know that mostly people (including me) respond on these pages to express opinions or critiques. Unusually for this forum, Sally Johnson's reply has led me to raise a few questions on which i am genuinely agnostic.
I am also mindful of a recent study in South Yorks reported in the Health Service Journal, surveying a large numer of ED attenders about why they were there and as i recall, about 1 in 3 were simply looking for reassurance (a different way to spin the oft cited " 1 in 3 leave with no medical treatment". Also in Yorkshire, a recent pilot reported in Pulse Magazine of GP Surgery opening through the weekend and very few patients taking up the possibility of appointments.
I am interested in views or intelligence on
1. Is the phenomenom described more common in London and other urban areas with younger, more diverse populations and a large number of acute units in close geographical proximity to patients than it is in rural areas with older and less diverse populations and a long distance to the acute provider?
2. What is behind a member of the public's decision-making/help-seeking behaviour in choosing to attend ED even when they have been offered a same day appointment?
3. If in many cases people do simply want reassurance or indeed rapid access to a clinical opinion at a time of their choosing, should we be castigating them for inconsiderate/irresponsible use of scarce resource and undertaking mass re-education that they should "self manage" or wait or should we accept that acute hospitals provides the one part of our health and care system where the lights are on 24/7 and people know they will be seen that day despite possible noise/inconvenience an a wait of up to 4 hours. At the moment of course we not only blame the patients but want to blame acute hospitals for their very existence and punish them financially for providing a service that people value and use? Perhaps better by far to put primary care trained staff at the hospital front door and accept that people will come to ED rather than wishing them away? Better also to allow acute hospitals to gain income from providing a service people value and use?
4. To what extent has the 4 hour target created some of this problem? Whilst most clinicians including the CEM would agree that in general terms it has been a force for good and clinicians i speak to from other countries are amazed that we are able to offer this for 90% plus of patients, 4 hours applies whether you have severe acute illness or injury or whether you have minor injury or a longstanding primary care sensitive condition - so the message is out for consumption that even if it is something that could wait, you just take yourself off to ED and it will be sorted. Better to apply 4 hours only to higher triage categories and use waiting as a rationing instrument or deterrent?
5. Givem the serious recruitment and retention problem in primary care and community nursing isnt there some virtue in consolidating same day urgent/subacute primary care in one or two sites such as ED or community hospitals with some access to diagnostics and speciality opinion rather than having "1000 flowers blooming"?
Just asking but not presupposing any answers
David Oliver
Competing interests: No competing interests