Urgent services have co-opted our tactic of sending patients away with simple advice – but this is both frustrating and dangerous, argues Dr David Turner
A few years ago, I was talking to a friend who was moaning about their GP. Their complaint went along the lines of the following:
‘You always have to go to the GP twice with a problem. The first time, they just fob you off with advice to rest and take painkillers or whatever. But you go along with it, knowing full well it won’t work and you’ll have to go back again in a couple of weeks with the same problem to get blood tests, X-rays and whatever else to get it sorted out. Why can’t they just do all that when you first go?’
As GPs, we all know this is true, and we all know it is true for a very good reason: most things are mild and self-limiting and will likely get better on their own within a couple of weeks, so they won’t necessitate the return visit. And of course, for those who do come back, we will take things further.
There is a purpose to this process. It rations demand for further tests and investigations to those who really need them. It is by no means a perfect system, and we occasionally get it wrong. But for most of our patients, it usually works.
More recently, I have noticed that our local A&E department has started to use similar tactics. A patient with a swollen arm, who we suspected had a blood clot (the diagnosis later confirmed this), was bounced back to us twice from A&E with suggestions that the GP tries antibiotics and analgesia.
Several patients with a range of infections obviously needing admission, who we have sent up to hospital, have been discharged back to us with helpful advice, such as ‘GP please prescribe antibiotics’ – in what world would we not have already done that?
Why is this a problem? Well, first and foremost, despite some of the bad mouthing we get in the media, it is not such a common practice to send patients to hospital. Set against a background of dealing with 40 to 50 patients a day as a full time GP, I would probably send one or two a week to A&E at most. And if I do, it is for good reason: because I cannot provide the further investigations and care they need in the community. It needs to be provided in hospital.
You’d think that this would be reasonably evident to the doctor (who is usually junior) assessing the patient in casualty. It is incredibly frustrating and potentially dangerous for patients to be bounced back from A&E to us. Only for us to reassess them and ping them straight back to hospital where second time round they usually do get dealt with properly. It makes us all seem unprofessional, quite apart from wasting all our valuable time.
I know some of the reasons why this practice has developed, and I won’t waste words describing in detail an emergency care system stretched to breaking point. However, using the primary care tactic of sending the patient away with simple advice when they have been sent up by their GP is not going to make the workload lighter in hospitals. In fact, it will do the reverse.
Dr Turner is a GP in Hertfordshire. Read more of his blogs here
So investigate properly first time round in GP and stop dumping on one’s colleagues in the ED.
I’m MRCEM, MRCGP BTW.
“Set against a background of dealing with 40 to 50 patients a day as a full time GP, I would probably send one or two a week to A&E at most. And if I do, it is for good reason: because I cannot provide the further investigations and care they need in the community. “
I would be interested to know if the patients are sent to A&E with a letter containing relevant information or just told to go to A&E ? Do you not refer direct to specialty rather than A&E so helping the patient to avoid long waits for a further A&E assesmrnt before specialist referral or discharge .
Surely a ? subclavian vein thrombosis goes direct to ambulatory medicine for investigation and further management ?
Well, then GPs would be the AE and we can shut down the other AE.
UK A+E systems are dumb. In better run countries, all key on-call teams are homed in A+E. Not running a clinic or half ward round, fighting the referral. There’s no fighting and there’s a common goal, get the work done, and shut down. But that needs political will and a brain, not begging for medics to accept and a cardiologist and geriatrician to see. Completely inefficient, and running on F2 will power. An F2 discharges to a senior GP with no outpatient ultrasound booked. How efficient of the managers. Where are the geriatricians btw? Oh, it’s you.
I’m saddened by the content of the blog and some of the subsequent comments. This demonstrates a lack of understanding of how most modern day EDs function & a lack of professional courtesy & effective communication to ensure we are all doing the right thing for our patients. Most EDs operate a senior controller model 24/7 which means that the majority of patients have senior input prior to discharge and ensure patients are on the most appropriate clinical pathway.
Sadly overwhelmed primary care is rapidly becoming a triage unit. Les and less actual clinical care is – can be undertaken. Those with a few minutes read up about what the latest management system (was CCG now ICB) has done to Ambleside HC. Barrow and Lancaster A and E in for a shock.
“As GPs, we all know this is true”. It’s not and I do not recognise this as a valid approach. I do not know of any GP who would turn every patient away because it is their first visit. It may be Dr Turner’s approach, but not that of every other GP. Patients who end up having to come back are usually those who unnecessarily rush to the GP 2 days into an illness that is usually self-limiting but on average takes 7-10 days to resolve. Unfortunately, this group of patients is rather large. It’s these patients, where parents and/or society have failed to teach selfcare, that end up feeling “fobbed off”. When some of them return after 2-3 weeks, then by definition they no longer present with a self-limiting illness and now warrant further investigations.
These are not “tactics” as Dr Turner calls it. It’s simply a reflection of the GP having to take on the role that in the old days parents or grandparents would have played: giving the reassurance that common things are common and the body is surprisingly good at fixing quite a lot on its own.
The patient who appropriately present after 2-3 weeks for the first time does not get turned away by default but ends up being investigated. Immediately, without “being fobbed off”.
This article is embarrassing – a GP badmouthing not only his own branch of practice, but that of our colleagues in ED as well.
Eek – I found many of the opinions above were not expressed in a manner I was comfortable with… I understood it that Dr Turner was explaining that in GP it is often appropriate to use ‘watchful waiting’ with self limiting illness/ patients presenting very early and no signs of serious illness (not a ‘tactic’ of sending home but it may appear like this to patients). But if 1-2 times a week in a small minority of patients serious pathology is suspected and urgent bloods/ radiology needed then they are sent to A+E (or a same day unit). I do not think A+E are using a tactic here – but perhaps this under recognition of significant Illness is a result of over stressed, high demand workload without them having any knowledge of the GP who has recognised potential problems. All putting patients at risk as healthcare services are failing and becoming more chaotic and inefficient as a result.