Issue 3 / 19 July 2010

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.

3 thoughts on “Dr Sue Ieraci: Emergency departments are not full of GP patients

  1. Oliver Frank says:

    This is a curious piece. It suggests that we should accept that patients choose to refer themselves to hospital emergency departments for problems for which they know it is unlikely that they will need admission, and that we should therefore stop “punishing” ED physicians for their “success”, by pooling the funding for general practices and EDs and letting the patient decide freely where to seek care.

    Dr. Ieraci implies that it is appropriate for all patients with chronic conditions such as diabetes or asthma to be treated by medical specialists, including ED physicians, instead of by GPs, and that “the few patients who attend (EDs) with minor problems are quick and cheap to treat”. The average cost of an ED attendance in 2007-2008 was $302 [1] (and probably has risen since then), while the current Medicare benefit for a GP consultation is $34.30.

    I suspect that Dr. Ieraci’s views have been shaped by the disproportionate numbers of patients attending EDs who have no usual GP or practice, or whose usual GP or practice is unable or unwilling to provide quality care. One important and necessary element of quality care in genereal practice is the long term personal relationship between the patient and his or her usual GP or practice. This is not available in hospital EDs. While almost any service (and in some cases no service at all) may be better than poor quality general practice, there is evidence that good quality general practice provides the best quality of care most efficiently for most of its patients most of the time.

    1. South Australian Review of Government Service Provisions 2007-2008.

  2. Peter Arnold says:

    Once again, Sue, you’ve hit the nail on the head.
    But don’t expect the bureaucrats or the bean-counters to take any notice.
    You and the likes of you are simply taken for granted.

  3. sue ieraci says:

    In response to Oliver Frank – I think we might be talking at cross-purposes here. EDs provide episodic acute care, some of which is urgent or complex, some of which is non-urgent or non-complex. They also provide risk-management and second opinions for patients who have already seen their GPs. EDs do not provide general practice or family medicine services, they provide unsceduled episodic acute care. Patients do not attend EDs for long-term control of chronic illness, and EDs do not pretend to be able to provide that. Patients who do require that type of care are referred back to their GPs for ongoing care.

    The point about the “average cost” of an ED attendance if also a point for debate. The figure Oliver Frank provides is a statistical calculation – ie it is the total cost of an ED set-up, divided by the number of patients seen. Does that mean that all ED attendances consume hundreds of dollars? Of course not? These costs include the major trauma resuscitation and the complex elderly patient work-up, as well as less complex injury and illness. The fact is, EDs are not episode funded. ED budgets have nothing ot do with attendances – the major cost if staff, and the staff numbers are based on a combination of historical figures and whatever enhancements have been fought for over the years. There is no “fee for service.” Considering that an ED basically consumes set-up costs (staff and equipment, which are constant shift by shift) plus consumables, one could argue that a quick consultation in an ED for a simple acute problem is essentially zero – the staff are there anyway, and no consumables are used.

    It is important in this discussion to avoid ideology and look at real data. ED attendances have been rising by 5 – 8% per annum across the country, despite decades of campaigns to get people with so-called “GP-type” prpblems to go there.The increase has been in the middle-level acuity and high-complexity areas. Admission rates are still 30 – 40% in big city hospitals and 20 – 30% in regional hospitals – this hasn’t changed much over the years. Most patients are assessed and treated, but not admitted. Most patients are seen by ED doctors under the supervision of specialists – not directly by specialists in most cases. Our current model provides an accessible and efficient service for short-term problem-solving – that’s why patients go there, and why GPs and community specialists send patients there. How can that be a bad thing?
    Sue Ieraci

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