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Independents' Day

Should we put more GPs in A&E?

Dr Steven Laitner and Dr Craig Seymour debate

Dr Steven Laitner

Dr Steven Laitner

YES

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

Dr Craig Seymour

NO

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.

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Readers' comments (23)

  • "a real failure of primary care delivery in my opinion"
    Our counsellor has a contractual requirement to see a maximum of five patients in a day,as advised by her professional body
    One of my eminent consultant colleagues sees 8 follow up and 4 new per clinic,all have problems he is fully trained and accredited to deal with,and just to help the new ones have a referral letter telling him the diagnosis.
    So Steve as someone redesigning clinical services what is the safe number of patients a gp should see each day,and how many do our overworked casualty doctors see.

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  • There is certainly an imbalance of funding and "time per patient" between primary and specialist care and between primary care in A&E and primary care in practices. One of the huge benefits of GPs is that we can assess people v quickly and without needing investigations and often without examination. We do a lot of telephone consulting and when we need to see people often have 20 min appts

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  • The question therefore is whether anyone other than Steve regards seeing huge numbers of patients quicly with out examination or investigation as a benefit?
    With regard to the original question,no GP professional body actually addresses this.
    Think about it,NICE deliberate on whether a patient should have an asprin tablet,but not the safe workload of the front end clinical doctors

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  • Should we put more GPs in GP?
    The above argument about GPs in A/E is (in my opinion) a staggeringly stupid one in the current context.
    Any more stretching and primary care is simply going to disappear.

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  • Angus is right. We are already seeing competition on recruiting GPs. Local practices are complaining they cannot match salaried GP position being offered by bigger organizations. We have even less chance of recruiting partners as our income is no better then salaried position in those organization with all the risk and none of the benefits.

    Thus we are accelerating the demise of general practice. May be we should get our house in order first? (yes, I realize it may not be that simple as work load in secondary care has impact on general practce.)

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  • Thanks for getting involved in the debate everyone and thanks Steven for being the counter argument - am happy to discuss further. Am on twitter @DrCraigSeymour

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  • I used to work 2 sessions a week in ED at St Georges in London. I covered SHO and middle grade teaching so saw everything from minors to ressuss.

    Yes- patients inappropriately attend but we should not be reinforcing that by seeing them within 4 hrs. We should be educating them and diverting them to a more appropriate place.

    Ive always thought a very senior person, dual trained in ED and GP should be the 2nd line of triage after the nurse. They could either send away, divert to treat or start appropriate investigations.

    But I think the comments about being in breach of contract for turning patients away in GP are hugely divisive when we have a block contract and endless demand. It shows a significant lack of understanding of the realities of general practice.

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  • Thanks Shaba. I very much agree with your comments about senior clinical triage early in the pathway.

    Having been working in general practices for 20 years, I I think I do understand much of its realities, I think I just have a different view on the v large but finite acute demand and the degree to which we can manage it.

    Best Wishes

    Steve

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  • Interesting comments and article. The reason pts are turning upto A&Es and WICs is due to service provision and funding outstripping pt demand especially in Primary Care and General Practice. If this can be addressed then there would be no need to have a GP in A&E.

    Treat the disease of underfunded General Practice not the symptoms if you want lasting solutions.

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  • Vinci Ho

    Respect those who would want to defend things they believe. I bet this marks the difference between us and those succumbing to politicians with their hidden agenda(s).
    There is no such thing as inappropriate service , only an inappropriate provider , especially in a system like NHS funded by this current settings.
    The responsibility of providing and how to provide the resources is still down to an elected government. Resources are money , manpower, expertise and time , one for all ; all for one. I still agree with Julian Tudor Hart when he wrote last year ,'......that in the eyes of majority public opinion, responsibility for collapse of the NHS as we have known it might seem transferable from government to healthcare professionals?' .
    One has the choice to believe or not when Simon said he was the most pro-GP NHS leader as well as Sarah said she would watch closely the impact of Brexit on our health services. Credibility can only be earned bit by bit , day by day with time. For those of us long enough in our profession would certainly understand that very well.
    I am neutral to a yes or no to this debate but I stick to the saying: even though you are not interested in politics, politics are extremely interested in you every bloody day....

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