As a person who has worked in EDs for over 25 years, managed them, reviewed them, studied them and written about them, I think I know ED casemix. Why are EDs overloaded?
No, it isn’t general practice patients.
It’s because of growing community risk-aversion and rising expectations, delayed transfer to inpatient beds and because EDs cost money and don’t generate revenue.
Many of us had hoped that a full federal takeover of hospital funding might end the incentive to cost-shift that fuels mythology about “GP-type patients” in EDs.
This is purely a cost-driven argument.
Of course there are overlaps between general practice and the specialties. However, we don’t talk about “GP-type diabetes” or “GP-type asthma” – these conditions are treated by both GPs and specialists, all through Medicare.
One of the most soul-destroying aspects of managing an ED is being blamed for your own success.
Imagine any private practitioner setting up a practice – their numbers build up, referrals increase, their waiting time grows. In the real world, this is called success.
However, as EDs become busier, the people providing the service are urged to encourage the patients not to come! Imagine an industry where you were punished for success, and urged to send your customers elsewhere, although they chose to come to you.
So, what do EDs really do? The few patients who attend with minor problems are quick and cheap to treat, and don’t occupy beds. In city hospitals they might represent at best 10% of numbers – and perhaps 1% of workload.
At the other end of the triage scale, about 10% of cases need intensive resuscitation. In between are the vast majority of ED cases – the sick and injured, mostly elderly, often complex, commonly referred by GPs.
In a risk-averse society, EDs are the community’s safety net. Both patients and GPs rely on the ED to be always available as a back-up, a second opinion, a risk manager.
I like to think that our community really does value these functions – they keep voting with their feet. Patients are referred in greater-than-ever numbers.
EDs provide the only acute service that can be accessed same day, without appointment, and generally provide a definitive answer.
In my ideal world, the success of EDs would be celebrated and supported. A service would be paid for the “efficient cost of service”, and rewarded for providing what the community wants.
General practice and emergency medicine would be seen as complementary services, and be paid from the same pool. Patients would not be blamed for their choice. And ED clinicians would not be punished for their success.
Dr Sue Ieraci is a specialist Emergency Physician with 25 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. In addition to her emergency department work, Sue runs the health system consultancy SI-napse.