Together at Last

A follow-on story from the one yesterday on staff shortages, suggests that ED overcrowding might be allieviated by having GP clinics on-site. Dr. David Mountain, an emergency medicine specialist from Western Australia, is unenthusiastic about the idea:

““There are certain areas out of the metropolitan areas, with a high paediatric workload, where after-hours clinics may take the edge off the very crowded ED waiting rooms. But again, that’s not going to sort out the underlying problem of access block and overcrowding that kills patients and causes very bad outcomes.””

David is, of course, correct with respect to overcrowding in the ED. Patients lying in corridors are a function of bed block in the inpatient wards. That sort of access block can only be solved by additional inpatient beds or more efficient discharge processes. Note that I am not talking about kicking out unwell or half-healed patients, I am talking about improving funding approval processes and home preparation prior to discharge, both of which keep elderly and disabled patients in hospital far beyond the length of stay they need.

This does not mean that GP clinics are entirely useless. In the US, ED fast track services (essentially a GP clinic run by the emergency department staff) have been used successfully for a number of years. They offer a cheaper and faster service than the ED. Of course, in New Zealand, the problem is that ED services are “free” (paid by tax) and GP services are not. GP clinics in the hospital therefore represent a form of cost-shifting. 

I predict, therefore, that GP clinics in hospitals will run into trouble very quickly. They will almost certainly have high bad-debt rates. Referrals to them – from the ED waiting room – will guarantee a good flow of complaints and all the concomitant flurry of paper-work. There is nothing like paying money out unexpectedly to generate resentment and complaints. 

Rural hospitals may benefit from GP clinics purely on the basis that rural GPs are a dying breed. Hospital based clinics may be the only option for maintaining any sort of GP service in rural areas.

Most larger EDs have a private A&M clinic nearby that will tend to absorb all of the people that a GP clinic at the hospital would take. Such a clinic would be in direct competition with the A&M, probably forcing it’s closure. DHBs should think long and hard before going down this route. A&M clinics are not the same thing as a GP clinic. They generally deal with more complex cases than most GPs are comfortable with. It is entirely possible that a hospital GP clinic may result in an increase in minor presentations to the emergency department. 

All of this may appeal to the policy wonks as fulfilling the Holy Health Grail of “integrated care”. It is far more likely to add to the staffing headaches of hospital HR department and provide no real benefits.

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