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A&E should 'repatriate' non-emergency patients back to GPs

A&E departments should not be paid for treating non-emergency patients and be told instead to ‘repatriate’ them back to GP practices, says a leading GP.

Dr James Kingsland, president of the National Association of Primary Care and and a GP in Merseyside, said that the only way to reduce the pressure on urgent care was to have a more ‘accessible primary care system’.

He added that he had implemented the idea of a ‘never full’ practice that provides same-day access to all patients, but that this had been undermined by the lack of change in the rest of the system.

Dr Kingsland also argued GPs could save money if they were given the funding currently provided to walk in centres, saying that as ‘50% of all activity in walk in centres are seen with the same condition by their general practice within the same week’.

Speaking at the the Nuffield Health Summit 2014, Dr Kingsland said: ‘We created the “never full” practice. So we are confident for our registered population, same day care, urgent care, immediate care, pre-booked care, is all available.

‘But having got that, the patient flows haven’t changed, even though patients can access our service any time of the day. They don’t have to ring at eight in the morning, they don’t have to wait on the phone.

‘So to change the patient flows, we’ve got to change where they go to. We’ve got to have the appetite to change the duty of care in A&E. So a patient who goes to A&E, who is not an accident or an emergency, could be repatriated immediately to their “never full” practice’, via an IT system. But then tariffs [have to be] changed, I’d be delighted if A&E see a baby with a temperature for three days, but they don’t get paid for it.

‘Unless we’ve got these mechanisms, the patient flows won’t change, even if we’ve got a good accessible primary care system.’

NHS England’s director for urgent and emergency care Professor Keith Willett agreed: ‘That’s just about the offer, isn’t it? At the moment patients don’t see that as the standard offer. They don’t recognise that, and they don’t work, they don’t respond to that. That’s something we have to get right. 

‘The Healthwatch report, despite four out of five people know 111 exists. Only one out of five choose to use it. Fifty percent choose, to go to straight to hospital. We have to build that they can see that they can get something different. You’re right it can all be done [in primary care].’

Readers' comments (29)

  • Like I use to do 30 years ago, but then it wasnt a money making event for the hospital. The current system is corrupted by a hospital biased tarrif system which doesnt in anyway reflect the cost of treatment which is always 'cheaper' in primary care.

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  • ‘The Healthwatch report, despite four out of five people know 111 exists. Only one out of five choose to use it. Fifty percent choose, to go to straight to hospital.'

    I think the 111 service makes it more likely that patients will go to A+E on the premise that they want to talk to a person not a ' robot who asks them 100 inane questions' .

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  • I think the idea of a never full practice is reasonable however it assumes the aim of walk in clinics was about improving care. It never was, it was an ill thought out way of diverting funds to vested interests who needed sweeteners to enter the health care market.

    Logic would suggest funding capacity in primary care so there is enough access would be the simplest and cheapest method of dealing with this. However considering the degree of cutbacks primary care is undergoing I suspect access will fall as even the least business minded practice realizes they may not survive. And when these practices start providing appointments which correlate with funding we will see serious decline in access.
    What is truly surprising is how many practices are taking a financial hit in the hope and expectation of the cavalry coming over the hill and saving them and acting rationally. Its not going to happen.

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  • How many iterations does it take you for to cotton on to the fact that a&e attendances are not cash cows for hospitals, they are overwhelming them? Financially and clinically. Most Trusts are in the red and losing the four hour battle.

    But turning patients away is hard. Our CCG chair spent a whole day with us and referred a grand total of ONE patient back to general practice. It might be better to relocate urgent care and put GPs to work in A&E and work together.

    And suggesting we turn away pyrexic babies or face not being paid is a pretty inhumane suggestion, and will never be practical. I fear for the future if that is how your leaders think.

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  • Yes this is a good idea only if backed by more resources in general practice . Else it will just fail.

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  • I think JK's suggestion has merit. But I also think the idea of A&E and GP on same site is also a good idea - rapid access to tests for GPs when required. A big part of the reason the patients go to hospitla is they know they'll get same day bloods, ecg and possibly X-Ray. They will go where the facility to investigate is - we need to either be able to offer that when it is required, or change their behaviour with education. Ideally both!

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  • Sorry, I disagree with almost all of the above.

    Think of your work today. Now think what proportion of the consultation were self limiting conditions or administrative problems which didn't really need clinical input? And how much unnecessary tests and treatments did you provide in the name of defensive medicine?

    Problem we have is not that of lack of access. It is uncontrolled demand coupled with bureaucracy of the health, social and benefit system that's the root cause of the problems here.

    Turning away pyrexic baby is inhumane? How do you think our patents managed just 40 years ago when we had temperature? They certainly didn't goto AED or their GP unless we were seriously ill. If the nation expect the health system to compensate for lack of their ability to manage minor illness, then they will have to pay for it by more money or diverting resources from managing serious illnesses.

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  • @ 11:41pm, you make a good case and I do not disagree. Things are out of hand. My feeling is that if patients at least think the GP can offer the same access to tests as a&e (same day blood, ECG or xr) they will be more likely to attend as they will not perceive a difference in what they may be offered. That doesn't mean we actually HAVE to investigate them though - we are of course highly trained clinicians and should be allowed to use our clinical judgment. A&e and GP need to present a united front and tell people when they have attended inappropriately and also only investigate where te result night genuinely change management. The present system = pt not satisfied by GP or thinks won't be, so goes to a&e coz "they'll check me bloods, heart tracing and xray" - the hospital will do this almost as a knee jerk response for fear of missing a (rare) weird and wonderful illness. The situation is akin to a child who turns to the "soft touch" parent to get what they want. Both parents need to have the same resources and agree to a united front an that is how they stop being manipulated. Being undermined by the grand parents (NHSE, DOH, Hunt) has *never* empowered a parent! Hope this makes some knid of sense!

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  • I worked with a locum GP who was also a local A&E consultant. Referred a number of patients unnecessarily to A&E.
    Definite conflict of interest!

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  • Points well made. Too many patients pitch up and waste appts in GP-land or A&E because they have a temperature, and there is no disincentive to waste appts.
    Start charging for appts, so people think twice.

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  • Also GP`s can repatriate unnecessary appointments to local MP clinic.

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  • We had a patient attend our A+E with a 'sore knee'. This patient had injured the knee skiing, had already seen the GP 3 days earlier and had been prescribed pain-killers and been referred to an orthopedic consultant.

    All hope is lost unless we re-educate the public AND turn away non-emergency patients AND have more primary care capacity outside 9-5.

    But who wants to be the one responsible for turning away drunks and violent patients at 3am on a Sunday?

    We tried having GPs working next to A&E but it was staffed by OOH service and they sent most of them back to A&E.

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  • Re Anonymous | 07 March 2014 9:10am

    Start charging for appointments and poor people might well die. Still, at least they'd stop bothering you.

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  • Ronald Graves - They dont seem to die in in Australia New Zealand, Canada, France, Germany......................

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  • The BMA want to keep the NHS free. This is far from what i feel the majority of grassroots GPs think. The BMA are so out of touch. There has to be some control the huge demand from the public on the basis of need not want. In an ideal world a free NHS is what we all want but not when it is being totally abused and not when there are financial constraints.

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  • here here 6:06

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  • Just Your Average Joe

    The NHS should be free for medical problems.

    Start charging all Alcohol related attendances £100 and then responsible drinking will be become the norm again within a very short period of time.

    A&E is the place where education needs to be placed to remind ALL attendances - was this an accident - with risk of fracture/burns etc or an Emergency - ie life threatening MI/Stroke.

    No one with a temperature should go to A&E unless sent there by a GP who has seen them first.

    Patients go to A&E when they don't receive the treatment they wanted - though they were given the treatment needed by their GP.

    A&E often are defensive in their practice (Not meant as a criticism) as have worked the sharp end, so many parents do end up with the antibiotic their GP said no to 4 hours earlier.

    Turn all attendances triaged as non urgent back to primary care, and educate parents, temperatures and viral illnesses don't need to be seen in A&E.

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  • The behaviour of A+E and the tarriff need reform.
    We tried re-direct locally but not really successful as very few sent back - except when A+E overloaded.

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  • Hooray at last common sense ! Putting your hand in your pocket for a nominal sum makes you stop and think. When will any party in government be brave enough to do this though ? They care about votes and image far more than joined up thinking.

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  • Works both ways! I wanted my GP to check out my daughters arm, damaged during a gymnastics session. Didn't think it was brokrn but a lot of pain and she couldn't use it without pain. It was an 'accident' so they refused to see us. We waited 2 hours at A&E to be told it was a severe sprain go home and rest it. No x-ray!

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  • Ms Webb,

    Sorry, your point is? If it had been broken or suspected to be broken and needed an Xray, you would have had to wait for a few days under primary care. And whilst we can all apply simple bandages, we don't have the time nor the facilities to do more complex bandaaging or plaster od paris. You would have been then told to goto AED. Would you have been happy with that?

    As A&E stands for Accidents and Emergencies, surely it is reasonable to advice one to attend for an accident that cannot be self managed. If not, it should be called Emergency Only Department.

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  • Our practice has always seen all emergencies the same day, regardless of how busy we are,

    We also have a system where patients can be redirected from A+E to the surgery with an appointment the same or next day. However we have only had 2 patients redirected in 4 months.

    Like another posted suggested above, the decision to send a patient back to A+E only seems to come up when the a+e is very busy.... If we want people to learn, they should be redirected whenever possible. I agree that it is a difficult decision to make and the A+E will only get blamed when someone is really ill.

    On a side, my best friend works in A+E - he called me on my mobile because the patient was complaining that she could not get to see a GP today. I had seen the same patient a whole 2 hours earlier and declined antibiotics for her cold. He called me in front of the patient which I thought was quite amusing.

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  • I read somewhere that James Kingsland got extra funding of £30 per patient to create his "never full" practice. I am sure he will respond if this is not the case. If it is, then the cost of upscaling his venture to the rest of us is going to be impossible for the public purse to meet...

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  • I would never use the 111 service, the time it takes to answer so many stupid questions I could have an ambulance on my doorstep and be on my way to hospital.

    Of course I wouldn't use 999 for non emergency situations but when a pleb is told you have a heartbeat of 212 and going in and out of consciousness surely the ambulance should be summoned, rather than wait until they complete their list of questions!

    People will always do what makes them feel safe and cared fro, and that does not include being examained in closed rooms by pharmacists or doing multiple choice quiz tests with 111

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  • nhs 111 is a disaster
    the lunatic internal market is a disaster
    the administrators continue to worsen the flaws of the previous flawed system they created
    suggest we sack them all and put money onto patient care

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  • Does that work in reverse too?
    So all the patients that book appointments to see if we've got the letter from secondary care can now be cancelled. We will no longer have to see patients to to inform them of what the hospital tests are, or tell them what actually went on during their consultation because the doctor didnt explain anything.
    I could probably save 20-25% of my appointments that would more than compensate for the few that roll up at a+e unannounced.

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  • If you feel very unwell and can't get an appointment with a GP, of course you go to A&E.

    It is time GP's took action against the 300+ patients at my practice that do not attend for the appointments that they booked!

    It is time wasting and deprives other patients of the care they need.

    111 is not a service I will every use, once was enough, it was an ordeal I will never forget!

    A pharmacists, do you want to risk being alone, being examined by male staff ... I don't think so!

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  • if you want better access to gp's..just like the only other open access system in the nhs..aed..then like the lattter we need more doctors..better patient education..fines for abuse....the answer is not trendy idiocy like telehealth emails telephone...these are admittedly of minor value but are a way of imposing inevitably inferior consultation modes on general practice as a way of obfuscating yet again the real problem...lack of staff..also a less safe and more risky mode for practitioners.
    ask yourself..why does every other part of the nhs seem happy to limit access by waiting list?pray tell the answer
    colleagues i urge us all to totally reject the tsunami of disgusting criticism of primary care.
    truth is we save the nhs from total collapse.
    be proud of ourselves.
    forgive them..ie the tidal wave of people criticising us from their armchairs of absolute ignorance..they know not what they do!...there does seem to be an epidemic of ignorant arrogance in england..no wonder our scottish colleagues rightly want to completely separate from nhs england.
    please tell me where the capacity in primary care is to absorb patients back from aed?...i would love to know..arrant feeble minded pathetic nonsense.

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  • My 76 yr old disabled sister in law had a surgical procedure on her foot yesterday and was told to have it re-dressed by the nurse at her GP's practice on Monday. Nurse only there for 2 hours one day a week and booked-up for weeks. Drop-in centre 4 miles away open 4 hours - and take your chance! Obvious answer A&E (half mile away) but this is now discouraged. Suggestions (polite) please.? NHS or DIY?

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