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A faulty production line

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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