Should we put more GPs in A&E?
Dr Steven Laitner and Dr Craig Seymour debate
Dr Steven Laitner
Simon Stevens has clearly stated that every hospital needs to have a comprehensive from door streaming service by next Christmas and that this will require a GP in every A&E in the country.
He has acknowledged that this is only part of the solution, but he is correct that it is indeed an important part of the solution.
An A&E consultant I trained with once said to me: ‘There is no such thing as an inappropriate attendance at A&E, just an inappropriate service for that person’. And in relation to A&E we do rather tend to blame the patient, which is terrible. So let’s think about the person who attends A&E. They will be concerned, frightened, anxious and have a sense of urgency to have their concern dealt with as quickly as possible. They may not be registered with a GP, they may not have trust in their GP, they may have tried to get an appointment with their and be told ‘call back tomorrow or go to A&E’ (in my view a breach of our contract with the government and with society). So whilst it may not make sense to us that the person has attended A&E it makes perfect sense to the individual at that time.
So rather than blame them, tell them off, send them away, why don’t we just listen to their concern and manage their need, there and then, with the right professional with the right skills and experience?
And that’s where we, GPs, are fabulous!
That’s our sweet spot, listening to patients and their carers and managing ‘undifferentiated demand’, quickly, holistically and often without the need for expensive tests or specialist opinion. We get somatisation, we get mental health, we get families and communities, we get frailty, long term conditions, social isolation, we get patients' Ideas, Concerns and Expectations.
So let’s celebrate the fact that the chief executive of the NHS gets that too and understands that GP have so much to offer, not only in general practice, commissioning, 111 and urgent care centres but also, yes in A&E!
And it works. For example the Luton & Dunstable (L&D) model is based upon several years of collaboration between providers and commissioners. The end result of which is that now, during the hours of opening, the urgent GP service sees around 40% of patients who walk into the department. Many other A&Es in the country have had similar success with ‘GP front ends’ at A&E.
A GP friend of mine, attending A&E with his child with a head injury, related his frustration at a junior doctor behind the curtain next door taking so long to assess a patient with a simple sore throat, he wanted to go through and assess the patient himself in a few minutes, no hours!
When I was a 'fly on the wall' at a paediatric A&E recently I was amazed at the number of well looking children there who seemed to have fairly minor upper respiratory tract infections that I would routinely manage in my GP surgery. I overheard at least one mum say that she was there because her own GP practice receptionist told her they had no appointments left that day and she either had to call back tomorrow or go to A&E – a real failure of primary care delivery in my opinion. Yes, we must ensure GP practices deliver superb 'same day access' in their own practices, and that needs support too.
But let’s not deny people the benefit of an experienced GP in A&E, often it is all they need and let’s welcome the recognition and the funds that must follow into primary care (in all its wonderful forms).
Dr Steven Laitner is a GP in St Albans, Hertfordshire
Dr Craig Seymour
There are already too many urgent care options for our patients leading to great confusion amongst the public. It is tempting to think GPs working in A&E will simplify and solve this issue; however, what is the problem we are trying to solve? Is it improving care, or improving A&E target performance? GPs working with A&E departments is not a new idea and the different approaches (walk in centres, urgent care centres, triage, streaming, colocation) have not been shown to lead to a meaningful or cost-effective improvement in patient outcomes, according to a Cochrane review. They may contribute to encouraging patients to pitch up at A&E, as attendances in 2016 were at their highest level since records began.
In some areas GPs have been able to reduce ED attendance, but in the context of whole system change and led by primary care. GPs can’t just be parachuted in.
What can reduce A&E attendances and admissions to hospital is longitudinal, integrated, holistic continuity of care that can only be offered by general practice. This is particularly true for those with long term conditions or complex needs. This cannot be offered by a model of GPs offering ad hoc care at the front door of A&E.
How about an innovative solution that offers this care and makes the most of resources? The Islington iHUB, a GP Access Fund Pilot, has developed a model of redirecting patients triaged by A&E with primary care appropriate conditions, and registered with an Islington GP practice, to appointments with GPs working in a local practice. These GPs have access to that patient’s full clinical record and local community services, same as their home practice. For patients this makes these encounters valuable, as their problems can be put into context of their existing care and their comorbidities. Between November 2016 and March 2017, 50% of those eligible for the service with were seen in the hub, resulting in reduction of A&E traffic. With more fine tuning, it could be 100%. Patients were satisfied. It was a limited pilot, but it worked.
This kind of scheme keeps GPs working in general practice where they belong, rather than diluting an increasingly rare resource. The reality is GP numbers have, in real terms, gone down.
There is an opportunity for patient behaviour change, encouraging accessing extended hours and in-hours primary care, and breaking the cycle of attending A&E by default. The act of creating a hub close to, but crucially not actually in, A&E would seem important in turning the tide on an unsustainable situation in A&E. It falls to commissioners and the government to recognise the value of such schemes, rather than investing scarce resource where the evidence doesn’t support it.
I would argue that limited governmental resource needs to be directed at boosting a struggling general practice, the foundations of our health service. Now is not the time to gamble taxpayers cash on evidence-light policy.
Dr Craig Seymour is a GP in Islington, North London and director of Islington GP Federation. With input from Dr John McGrath, a GP in Islington.