Overview: A&E Acute Admissions
The Primary Care Foundation was commissioned by the Department of Health in May 2009 to carry out a study across England of the different models of primary care operating within or alongside emergency departments. We were asked to provide a viable estimate of the number of patients who attend emergency department with conditions that could be dealt with elsewhere in primary care. The work was carried out by drawing on expertise from a reference group, a literature review, undertaking visits to departments and also carrying out a web based survey with completion by emergency departments, primary care Providers working in or alongside emergency departments and the commissioners of these services. The report was released in March 2010 (click HERE)
The number of primary care clinicians based within or alongside emergency departments has expanded rapidly in recent years, promising better care for patients who do not need emergency department services and a reduction in admissions.
Primary care practitioners can enhance emergency departments by bringing vital skills and expertise to a multi-disciplinary team. To achieve this, managers and clinicians need to develop strong working relationships. Building mutual respect takes time, but it is vital if initiatives of this kind are to lead to a more integrated service. As one GP put it “if everyone is involved it becomes seen as a joint baby, not a primary care service in their midst”.
Successful schemes are the product of sustained attempts to test out new ideas, learn from each other and improve patient care, based on clear recognition of the skills of each group of clinicians and mutual respect. However, in practice there can be a clash of cultures, with staff divided by different training, approaches to managing risk, governance systems, language and their experience of different case mixes.
The stated reason for introducing primary care services is often to improve patient care. Yet we found in many cases the main drivers are, in fact, reducing costs and helping to meet the four-hour waiting time target. The argument is that the payment by results tariff is more costly than a consultation with a primary care clinician and that the higher tariff for a patient who is admitted can act as an incentive to admit, an effect magnified by pressure to meet the waiting time target.
In this context, primary care clinicians may appear to represent a challenge to the financial viability of a hospital trust. Simply adding primary care practitioners may create short-term savings for commissioners but, without commensurate savings being made or other benefits being realised, there is no saving to the NHS or tax-payer. In contrast, services that are integrating urgent care and developing local tariffs, that incentivise all partners to work in the patients’ best interests, appear to be heading in a more promising direction. In time, an overall cost reduction may be achieved from this approach.