How GPs can play a crucial role in helping to cut emergency admissions
Ps have a pivotal role in emergency care in the future. They have had a pivotal role in the past: the difference is that, from now on, such care must be provided as a co-ordinated component of a whole system of care.
What are the aims of emergency care? They are to provide appropriate, timely, high-quality and convenient care. This can and should apply anywhere, not just in hospitals.
GPs have been seeing patients with urgent needs from time immemorial, and less than 10 per cent of these end up with hospital contacts. As RCGP chair Professor David Haslam pointed out recently, general practice acts as the 'heartsink' of the NHS, absorbing fluctuations in demand and taking pressure off other parts of the system. This was recognised in the document 'Reforming Emergency Care' published in 2001, which emphasised that emergency care starts and ends in the community.
Some patients are referred to hospital emergency departments, but many attend by choice, and a significant proportion of these could and should be treated more conveniently, more quickly, and as effectively in other settings. Traditionally pre-hospital care has been provided by primary care centres, out-of-hours services staffed by GPs, and ambulance services, with the latter geared to taking patients to hospital.
A total rethink is needed, with the emphasis clearly on patients and their needs and on the whole system. Various alternatives have been proposed and are being used, but there is still dislocation. The alternatives include GP co-ops, NHS Direct, ambulance service paramedics, walk-in centres, minor injury units, GP units associated with hospitals, and more specialised home visiting teams.
A fundamental requirement is an empowered network of providers covering a geographical area, based around (but not controlled by) an acute hospital. This should plan emergency care services for that community with the emphasis on convenient, high-quality, rapid services.
The partners in the network should include PCTs, co-ops, the Acute Trust, the Ambulance Trust, social services, the council, the voluntary sector and patient groups at the least. The network could be facilitated by any of these, but the key is equal voices without any group being dominant.
So where do GPs fit in? GP services have changed considerably over the years. During working hours many GPs maintain 'urgent' slots, and practice nurses are also skilled in dealing with acute problems. In one or two places, ambulance paramedics work closely with primary care groups to provide urgent home visiting. Out-of-hours GP co-ops have been a resounding success. In other cases, GP services have been established within or next to hospital emergency departments.
The situation has obviously been changed by the new GP contract, the increasing proportion of part-timers, and the emphasis on chronic disease and many other aspects of care. My hope is that GP co-ops will continue to function, but again a change in emphasis will be needed. I anticipate a major growth in 'minor injury units' (these should be renamed emergency care centres it is demeaning to a patient in severe pain or discomfort to be referred to as a 'minor') with a network of nurse-led units across the patch co-ordinated by the PCT with the Acute Trust.
The development of GPs with a special interest in emergency care will also help with a supervisory/participatory role in emergency care centres.
Co-ordination and integration of services will be vital to prevent waste of time and resources. Co-location of the co-op, NHS Direct and an emergency care centre with a team of ambulance paramedics should allow best use of valuable GP time. They could play a largely consultative supervisory role for the other health professionals, with much of the home visiting being done by paramedics or community care practitioners.
Finally, GPs have a major role in prevention. Many urgent cases could have been prevented. Regular visiting and assessment of the frail elderly, working in concert with social services and care of the elderly physicians and community chronic disease teams, again run together with secondary specialists, could
pre-empt many emergency referrals.
of GPs with a special interest in emergency care will help~
A total rethink of the GP's pivotal role in emergency
care is needed, according to
Sir George Alberti