PPL blog: Time to recognise the real impact GP-led urgent care has on A&Es

PPL blog: Time to recognise the real impact GP-led urgent care has on A&Es
posted 22 July 2014 in category PPL Blog A&E

A recent survey by the College of Emergency Medicine significantly underestimates the impact of urgent care centres on A&E attendance, argues our Sam Benghiat, a manager at PPL.

This article first appeared on the Health Service Journal’s website on 17th July. Thanks go to the comments editor, Andy Cowper, for his kind permission to reproduce the article here.

A link to the original piece in HSJ can be found here: http://www.hsj.co.uk/comment/time-to-recognise-the-real-impact-gp-led-urgent-care-has-on-aes/5072740.article#.U852kGeYbIU

Time to recognise the real impact GP-led urgent care has on A&Es

The College of Emergency Medicine's recent article in HSJ endorses the use of primary care centres - also known as urgent care centres or UCCs - as a means of reducing pressure on overstretched accident and emergency.

We agree fully with this position and believe that GP-led UCCs are an effective tool for reducing A&E attendance, improving the quality of care for patients and delivering savings for the tax payer. However, having made the case for UCCs, the CEM goes on to significantly underestimate their potential impact.

A CEM survey of A&E clinicians from 12 hospitals suggests that 85 percent of current A&E attendances are clinically appropriate. According to the CEM, just 15 percent of current A&E attendances could be treated more appropriately by a GP.

A further 22 percent of A&E attendances “could be appropriately managed by a GP working in the emergency department with access to A&E resources”. The implicit argument here is that 37 percent of A&E attendances could be cared for safely in a UCC. This figure is too low.

Practical Pointers

We know this not because of any detailed survey work, data analysis or clinical audit, but through practical experience of real urgent care services operating across London today.

In recent years, we have worked with nine GP-led UCCs in the London area. Of these, six consistently handle in excess of 60 percent of total A&E activity. A further two fall short of this threshold because they are not open 24 hours a day and operate according to a narrow specification that excludes treatment of minor injuries.

According to the CEM’s figures, UCCs managing 60 percent of A&E activity are clinically unsafe, because more than 20 percent of UCC patients are being treated in a primary care-led setting inappropriately. In our six London UCCs alone, this equates to over 70,000 patients a year.

If the CEM’s findings are accurate, the sheer scale of the problem would show up in the data in some form. For example, we would expect to see evidence such as abnormally high UCC to A&E transfer rates and unacceptable numbers of serious untoward incidents (SUI).

In reality, we observe neither of these things. Based on data from the UCCs we have worked with, transfer rates and SUI frequency are no higher at UCCs managing 60 percent of A&E activity than at any other UCC.

Differing perspectives

How should we interpret the discrepancy between the CEM’s survey findings and the results UCCs have been able to achieve? One possible explanation could be the difference in ethos between primary and secondary care.

Most UCCs are GP-led for a reason. GPs perform a well-established role as “gatekeepers” for the health system, ensuring patients receive care that is proportionate to their need, and that unnecessary investigations and referrals are minimised.

The role of the A&E clinician is fundamentally different. A&E clinicians are highly skilled specialists trained to deal with situations where a patient’s life is in immediate danger. It is therefore entirely understandable that precautionary tests are requested and precautionary admissions are made that a clinician from a primary care background may not always deem to be clinically necessary.

Perhaps the CEM’s survey of A&E clinicians was consequently always likely to result in a conservative estimate of the proportion of A&E patients that could be treated by a GP.

As the son of a consultant oncologist and a GP, I can attest anecdotally to the truth of this. To my father, every freckle was a potentially fatal melanoma requiring further investigation – a diagnosis almost always dismissed out of hand by my GP mother.

Practical motivations

On the wider question of the proportion of UCC and A&E activity that could safely be treated outside hospital, the evidence is less clear cut. We have conducted extensive patient engagement to try to understand why some people prefer to attend UCCs rather than their own GP.

Respondents rarely mention access to hospital resources, and instead return consistently to the theme of primary care access. Patient preoccupation with GP opening hours, waiting times and ease of booking an appointment suggests that, for many people, UCC attendance is driven by practical rather than clinical considerations.

There is a debate to be had about whether UCCs are a sticking plaster for the more intractable issue of access to general practice.

We agree with the CEM that UCCs are a pragmatic, partial solution to the problem of over-burdened A&Es, at least in the short term. However, we believe that the college significantly underestimates the potential impact of UCCs on A&E attendances. In practice, UCCs are demonstrating this every day.