Submission to
Emergency Department Taskforce
Attendances at out-of-hours facilities - whether in emergency departments or in general practice have steadily increased over the last 10 years, which is a feature of many health systems in the
Western world. Internationally the growth in ED attendances has been the subject of considerable
speculation and research. The increase in ED attendance has resulted in increased waiting times and
indeed patients now expect to wait to be seen in our ED facilities.
While patient satisfaction surveys have consistently rated the standard of care from ED staff highly,
their overall ED experience has been unsatisfactory, with many reporting resulting anxiety and
discomfort.1 In previous studies, more than a third of patients said that the prospect of an extended
stay had affected their willingness to attend the ED and even more said their experience would affect
their willingness to attend again in the future. Moreover, it has been clearly established that ED
overcrowding has a significant effect on mortality.2, 3
The current situation is damaging for patients and ED staff alike. The NAGP commends our
secondary care colleagues for their efforts to deal with perennial ED overcrowding, but studies have
reported considerable negative impacts on ED staff. A recent survey of staff in Irish emergency
departments found that 29% were experiencing severe stress and a further 8% reported unbearable
stress. The primary causes of stress were understaffing and bed shortages.4
ED overcrowding has been a constant difficulty in the operation of the health services. The initiatives
introduced in January have had little impact on trolley numbers and are further evidence that focusing
efforts on secondary care and discharge measures have not and will not resolve the problem.
There is an ongoing campaign for increased ED resources in personnel and facilities which seems to
be ‘more of the same’ and which is self-evidently failing. This is happening internationally with
similar service results. A pattern has emerged of improved facilities in emergency departments
drawing even more patients into the system which struggles to keep up with demand. It is a case of
‘build it and they will come’. Thought needs to be given to using ED departments for accidents and
emergencies and to using other parts of our health services to prevent people needing to use the
service in such numbers.
Out-of-hours
The general practice response to increased demand for out-of-hours care has been via the co-operative
movement. Nearly all GPs in Ireland now work in an out-of-hours co-operative, seeing over a million
patients per year. One longstanding established co-operative in Kildare sees twice as many patients as
its local ED department and another newly established co-op in Tallaght sees nearly 30% of the
numbers seen at its local ED after 3 years of operation.
The question that is always asked of GP co-ops is if they impact on numbers attending emergency
departments. It is difficult to accurately calculate the impact because we do not operate in a data
driven system and the variables of unmet need and societal expectations are important variables in
such calculations.
The National Association of General Practitioners, 17 Kildare Street, Dublin 2, Tel: 353 1 6622755, Website: www.nagp.ie
However, 2010 figures from the Dubdoc co-operative reported substantial reductions in local ED
attendances during Dubdoc operational hours, particularly in category 4 and 5 acuity attendees.5
Staffing in emergency departments has increased considerably over recent years. However, those
departments that have been extended and better resourced become too small and too busy within 18
months. Emergency departments in Ireland tend to see themselves as part of the hospital system. In
reality they are a revolving gateway between a local community and its hospital. Despite this, it is
unusual to see a local ED working with local general practitioners or engaging GPs in the utilisation
of their own local ED department. ED departments resist the involvement of GPs in their service
despite local and international evidence of the benefits of such involvement.
There is international evidence to demonstrate that integrating GP co-operatives with emergency
departments substantially improves ED utilisation, reduces self-referral and supports the ED in
providing more efficient care to higher risk patients.6
Advanced primary care model
The out-of-hours co-ops provide a model that is capable of playing an extended role in emergency and
out-of-hours care. General practice has a well-trained workforce which is in a position to take on
roles in triaging and managing acute clinical care. The co-ops have responded well in conjunction
with local HSE management and clinicians. An extended role for co-ops can include daytime services
and facilities for ED staff to work in the community, if only to change the current culture of such
departments.
The advanced primary care or patient centred medical home model has been implemented and
expanded in many countries and has shown considerable success in reducing overall healthcare
spending, improving overall population health, and decreasing unnecessary emergency department
visits and inpatient admissions in 61% of peer-reviewed cases.7
The model has been shown to reduce ED use by 29% and reduces hospital admission by 16%. Overall
medical expenses were 21.1% lower in advanced primary care patients.8
The success of the advanced primary care model is proof that a care team based around a primary care
provider and combined with pay-for-performance incentives, is effective in improving overall health
care quality, raising patient satisfaction, reducing demand on secondary care services and cutting
overall health spending.
Diagnostics
However, many GPs rightly complain that our ED departments are unfairly advantaged because of the
access to diagnostic and in-patient facilities that are denied to GPs which puts us at a clinical
disadvantage in terms of providing an appropriate level of care to our patients. Failure to facilitate
direct GP access to diagnostics creates an illogical situation where general practitioners are forced to
refer patients to already overcrowded EDs for simple diagnostic tests. This process places undue
stress on GPs, emergency department staff and patients. International evidence clearly shows that
increased GP access to diagnostics leads to reduced diagnostic delay, reduced referrals to EDs and
out-patient departments, reduced unnecessary referrals and improved quality of referrals.
The National Association of General Practitioners, 17 Kildare Street, Dublin 2, Tel: 353 1 6622755, Website: www.nagp.ie
It is only reasonable that diagnostic facilities, in particular, need to be extended to general
practitioners if we are to play a greater role in emergency and out-of-hours care.
An extended role for primary care in out-of -ours and urgent care introduces design issues for current
co-op premises and primary care centres. Such centres need in-house diagnostic facilities or a service
level agreement with local diagnostic facilities either in the private or public sector.
Chronic care
There has been an increase in the number of people who are more unwell as demography changes and
the population of frail elderly increases. This is set to increase further as Ireland currently has a young
population which will change with time and increasing job opportunities causing people to live out
their lives here rather than in other countries. The elderly spend increasing amounts of time on trollies
waiting for admission and it is rightly a matter of public concern.
Chronic disease management will become even more essential as our population ages. General
practice has proven its critical role in the management of chronic diseases for the betterment of
patients, secondary care utilisation, ED attendances and health care costs. The Heartwatch programme
and the Midlands Diabetes Structured Care Programme have demonstrated the considerable benefits
to be achieved with GP-delivered chronic disease management. While acknowledging the “cycle of
care” program which will be introduced at the end of this month, there continues to be little or no
support for disease-specific, population-wide chronic care programmes in general practice.
The “cycle of care” pogram is certainly a good start but in reality doesn’t reflect any national or
international evidence based protocols.
GPs have the skills and the ICGP has programmes ready to roll out for chronic disease management.
By intensively managing, in a structured way, our patients with diabetes, COPD/asthma and heart
failure, GPs can achieve far better control and stability. This will greatly reduce the acute episodes
that lead to the emergency admissions and the unfortunate patients spending up to 48 hours on
hospital trollies. Funding will be required for extra clinics, extra nurse and doctor time in the
practices, as well as timely access in the community to dieticians, pulmonary rehab and other supports
for our patients.
Conclusion
While there is an element of winter imperative in fixing our ED departments it provides an
opportunity to address problems in the broader system, as merely fixing one area will not solve the
problem.
Genuine and evidence-based investment in general practice, to resource GPs to take on extra work in
a number of significant areas, could have a substantial impact on ED attendances.
This includes primary care focussed management of chronic diseases, dialogue between the ED
departments and primary care, proper 24-hour access to diagnostics and use of analytics to identify
frequent and vulnerable users of both EDs and primary care.
The National Association of General Practitioners, 17 Kildare Street, Dublin 2, Tel: 353 1 6622755, Website: www.nagp.ie
The NAGP recommends the following as an urgent and essential first step in resolving the ED
overcrowding issue:











Expand the co-operative model to all areas
Support the expansion of services provided by co-ops
Establish formal, regular dialogue between EDs and local GPs
Increase integration between EDs and general practice
Support GPs in accessing the training and resources necessary to expand the provision of
relevant services during normal working hours
Introduce in-house diagnostic facilities in out-of-hours co-ops
Provide 24-hour direct GP access to diagnostic facilities
Roll-out the chronic disease management programmes for all patients with asthma, COPD,
diabetes and heart disease
Introduce supports and financial resources to facilitate GPs in delivering chronic disease
management
Increase GP access to dieticians, pulmonary rehabilitation and other chronic disease supports
Inclusion of the NAGP in the Emergency Department Task Force
While some of these recommendations will require initial investment, the evidence clearly proves that
this relatively small cost will deliver significant and continuing results in terms of ED attendances,
secondary care utilisation, population health and health care investment.
The NAGP and its 1,450 members have a valuable contribution to make in improving our ongoing ED
overcrowding issue. We reiterate our call to have NAGP representation on the ED Taskforce.
END
References:
Gilligan P et al. Why are we waiting? A study of patient’s perspectives about their protracted stay in an emergency
department. IMJ 2011; 104(5)
2. Hickey F. Casualty overcrowding and increased mortality; is it time to say no? Ir Med J 2006; 99:248-249.
3. Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: an Emerging threat to patient
safety and public health. Emerg Med. J 2003; 20:402-405.
4. Natin DP, Sheehan J. Stress in an accident and emergency department. IMJ 2015; 108(4)
5. F.D. Kelly et al. Impact of a GP co-operative on lower acuity emergency department attendees. Emer Med J 2010;
27 (10): 770-3
6. Thijssen WAMH et al. The impact on emergency department utilisation and patient flows after integrating a
general practitioners cooperative: An observational study. Emergency Medicine International Aug 2013
7. Patient-Centered Primary Care Collaborative (PCPCC) Annual Report 2012-2013.
8. Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from
Prospective Evaluation Studies in the United States. Patient-Centered Primary Care Collaborative. November
2010.
9. McGrath, E., Glynn,L. Murphy, A., O Conghaile, A., Canavan, M., Reid,C, Moloney,B. and
10. O'Donnell, M. Preventing cardiovascular disease in primary care: Role of a national risk factor management
program Am Heart J 2012; 163:714-9.
11. Marsden, P., Brennan, C., McHugh, S. & Harkins, V. 2010, Audit report of the HSE Midland
12. Diabetes Structured Care Programme. Department of Public Health, Health Service Executive Dublin MidLeinster, Ireland.
1.
The National Association of General Practitioners, 17 Kildare Street, Dublin 2, Tel: 353 1 6622755, Website: www.nagp.ie