DH report shoots down evidence for shift of work from A&E to GPs

Never make assumptions and then go looking for evidence to fit those pre-determined assumptions and disregard evidence that doesn't "fit" but rather look at the evidence without bias. Keep following.........now most surgeons think GPs are lazy, incompetent and cannot triage the most basic medical matters. Now you have the picture? The government wanted to know how to improve general practice and so.......er....asked a surgeon so reaching new levels of idiocy.

so the emperor finally realises he has no clothes?

This confirms my own experience. About 15 years ago in my small semi rural practice in Dorset we looked at the potential for using a nurse to triage and manage minor illness. Each of the three partners noted the number of patients they they judged could have been seen by a nurse instead of themselves. After a month we had collected about 20 between all of us. This was, of course, a very small and uncontrolled study but still illuminating. It challenged the received wisdom of the time and has been borne out by several larger studies by more erudite investigators which have shown that repeat consultations after such consultations are higher and that costs are at least as high if not higher than GP consultations. Similar outcomes have been noted with NHS Direct. Isn't it time we accepted the evidence and stopped trying to train those whose core skills are already underused to do tasks for which they may not be well suited and instead maximise the use we could make of skills and experience they already have. In this I am thinking particularly of pharmacists who should devote more (or even most) of their time to medicine management and none to diagnosis and nurses whose core skills are already in short supply and are needed by patients.

It is important to clarify that the Primary Care Foundation report and Lord Darzi's review Healthcare for London: A Framework For Action in 2008 did not measure like for like activity. The service models for primary care led services in A&E are also different. The Primary Care Foundation concluded that 10-30% of A&E activity was the volume of cases of the same type as would normally be seen by a primary care clinician in traditional general practice. Healthcare for London welcomes the report and acknowledges their findings as a useful measure to enable further understanding of A&E caseloads. The Healthcare for London review of A&E activity concluded that at least 50% of attendances at A&E are within the skill mix of primary care clinicians who have been appropriately trained to handle a greater caseload. This assumes that the system is organised in such a way as to give them the opportunity to see the patients first when they present at A&E. The Healthcare for London service model advocates an urgent care centre (UCC) as the front door for every A&E. This UCC is manned by a multidisciplinary team including primary care clinicians and emergency care practitioners with access to a wider range of diagnostics than is found in traditional general practice. The Primary Care Foundation report recognised that some GPs who develop a special interest could see a larger proportion of cases. The report also agrees that a much larger proportion could be seen if greater changes are made and GPs begin to work in a team with a mix of other skills. An early implementer of the urgent care centre model has demonstrated that more than 60% reduction in A&E activity is achievable. For example, the Charing Cross urgent care centre comprises a hospital based front end polyclinic using a primary care model staffed by GPs and emergency nurse practitioners. This has achieved an average of 65% of all A&E attendances being seen by the hospital based front end polyclinic. Patients are also getting clinical resolution quicker than before, 92% within two hours and no four hour breaches. Healthcare for London analysis of unscheduled care also spanned a much wider review of services outside of hospital that could reduce the number of patients presenting at A&E. For example, more proactive case management for long-term conditions in the community and rapid response teams are just two of the aspects this review considered. When referring to community or primary care settings as an alternative to A&E the polysystem approach looks at a range of alternatives and is not solely dependant on individual GP surgeries. Healthcare for London has concluded from the above that it would be a reasonable starting assumption for clinicians and commissioners to aim to achieve up to a 60% reduction in use of A&E through a combination of the hospital based urgent care centre, better prevention, clearer pathways, improved access to diagnostics in primary care, and better utilisation of the risk management skills of primary care clinicians.

So basically instead of junior doctors seeing A&E patients it would be better to recruit GPs to do it and give them access to better diagnostics?