more_vert
The difference between working in general practice and working in emergency shows just how difficult it is for clinicians to provide continuity of care in a hospital environment, writes Dr Jillann Farmer.
Those of you who take an interest in the brief biography at the and of my articles will have noticed that I moved from community general practice to emergency medicine a few months ago.
I had previously worked in emergency departments (EDs) when my other commitments prevented me from providing continuity of care to my patients and I had reached that space again.
When knowing that patients are waiting weeks to see you because of low in-practice time and it feels like you are getting in the way of, rather than helping their health care.
I have always felt that continuity of care is the “secret sauce” of general practice, the place where trust is forged, secrets are shared and challenging issues are probed, let rest when necessary, and resurfaced when opportune. When we lose continuity of care, we lose a lot.
Changing from general practice to ED
I am now in the space of looking back into general practice from the perspective of fly in-fly out locum in a small community hospital where general practices have been closing.
Where newcomers to town struggle to get an appointment with a general practitioner (GP), and where patients will end up in ED with things that are within the scope of general practice to treat.
But nobody comes to the ED (at least our ED) with absolutely no reason. Some days, several patients will ask me to open a practice or ask me where they can book in. It’s heartbreaking but also affirming not just of me, but of our specialty.
People recognise the value of having a regular GP
Those who have experienced the “secret sauce” crave it when they are grappling with something difficult. And contrary to what health ministers might like to say, very, very few people who turn up to an ED are there for something trivial.
Every single one of them has reached their breaking point of something – of pain, of fear, of consequences for neglecting their health care, of homelessness, of poverty, of a society that likes to look the other way and pretend that we don’t have poor people in this country.
That was my biggest awakening, moving from mixed billing GP to ED work – the interaction with a whole subset of the population who simply don’t access primary care.
They don’t feel that the system is for them.
No matter how much we might try, they don’t feel that they can walk through the door of a general practice and ask for care without being embarrassed or judged.
They might smell bad or have lice or scabies. They might have no clean clothes or poor dental hygiene. Or they might have a condition they have neglected that is now so bad they can’t bring themselves to discuss it – until they have no choice as crisis looms.
These are people who live in poverty that most of us can’t even begin to contemplate.
Of people who have absolutely nobody else in their life to care for them, to pick them up from the ED, whose lives and circumstances are so chaotic that booking an appointment three days in advance, let alone three weeks, is beyond their capacity.
Not knowing where you are going to sleep or where the next meal is coming from will have that effect on you.
I delight in delivering care that is free at the point of delivery. Our public hospital system is amazing for all the strain it is under (and there is plenty of jaw-dropping strain).
Lack of continuity of care
But an ED doctor or nurse cannot provide continuity of care.
We need to find ways to ensure that every single person can have continuity of care, and a place to receive that care that is accessible, accepting and responsive to their needs.
I know that many of my GP colleagues are in services that strive to do this, but they are working against a system that forces monetisation of every patient interaction and so confronts them every 15–20 minutes with the non-viability of a practice that delivers such care.
I would not presume to have the solution for all of primary care’s woes, but it is becoming increasingly clear to me that there is a gap that is being ignored by both state and federal governments.
It won’t be fixed by Medicare Homes.
It could potentially be fixed by a much closer partnership between Primary Health Networks and EDs to identify patients who are floating without a GP, but who need one.
It’s not enough to just tell these patients to “go and find a GP”.
We need the health care system to reach out to them and help them to navigate its complexity.
We need somehow to have services that care for them, perhaps bridging until they can be matched with a practice for ongoing care, but we cannot keep leaving the most vulnerable without access to GPs.
I have had several patients in the past few weeks who need that advocacy combined with ongoing complex care that in our current models of care only a GP can provide.
Someone to rage against the inertia of the system on their behalf, to support them while they feel ignored by it, and to help them to get the care they need.
Nurse practitioners
Nurse practitioners and nurse navigators will be an important part of the solution, but nursing is not medicine.
The value proposition of medical versus nursing-led care is something that is currently being hammered out, and I work alongside excellent nurse practitioners every day.
They are not, and would never pretend to be, GPs.
Urgent care clinics
Urgent care clinics might provide a pathway that is not ED, but they won’t provide continuity of care. They will undermine continuity.
No matter the solution, state and federal governments must close this gap.
We must have primary care services that are not fee-for-service based, that have a close relationship with the hospital sector and where the marginalised can regain trust in a system that has been not fit for purpose for them for a very long time.
The solutions are likely not complicated, they just aren’t funded, and when things aren’t funded, all players in the health care system look to GPs to do it for free.
It is simply not reasonable to expect private businesses (which is what general practices are) to take this on out of some sense of altruism or community service.
Taking care of the vulnerable
The current general practice environment with increasing gap fees, crowded waiting rooms, long waits for bookings, is not conducive to the most vulnerable finding a pathway to care (here, here and here).
Governments exist for myriad reasons, and one of those is to ensure that the most vulnerable are cared for with dignity and respect.
Ignoring needs and keeping them invisible might be convenient, but it is immoral and an abrogation of responsibility.
When a patient presenting in the middle of the night to the ED has a problem that does not seem like an emergency to me, I have learned to be curious, and ask “so what makes tonight different? I know you don’t want to be here, so what was it that made you come in here at this time of the day? How can I help?”.
That compassionate curiosity uncovers a spectrum of unmet need that I wish our health ministers could hear for themselves.
With acknowledgement to Father Bob.
Dr Jillann Farmer is a Brisbane-based physician, currently working in emergency.
She is also the National Project Manager for the Royal Australasian College of Medical Administrators’ Culture of Medicine Project and worked to support the United Nations Mission for Ebola response from 2014 to 2015.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
Subscribe to the free InSight+ weekly newsletter here. It is available to all readers, not just registered medical practitioners.
If you would like to submit an article for consideration, send a Word version to mjainsight-editor@ampco.com.au.
“We must have primary care services that are not fee-for-service based, that have a close relationship with the hospital sector and where the marginalised can regain trust in a system that has been not fit for purpose for them for a very long time.” – Sounds like Aboriginal Medical Services – they could be a great starting model to work with.
My first hospital was not that far from our nation’s capital, and the 3 institutions in town pretty much meant the disadvantaged, the vulnerable and the less self-actualised made their own healthcare issues the local hospital’s problems. The local GPs do have a high (but not universal) bulk billing rate but they were not simply giving everyone that privilege. Primary care was in short supply, such that some specialists start to provide basic primary care out of altruism, with limited effect on the overall situation. Every day, including Sunday, at least 5 people will turn up at the local ED for basic primary care, in addition to the local methadone clinic, which also operates out of the same place.
Hence when an esteemed ED colleague wrote about her experience at providing primary care at her ED in northwest Tasmania some years ago, it was not that much of a revelation, more of a revealing of well-known secret in the undercurrents for years, that there are quite a few rural places where the local ED has become, by de-facto, the go-to service for certain portions of the community.
Dr Farmer’s piece is a reminder that this still exists, and frankly, given the latest GP training numbers and drastic changes to what is considered restricted areas under 19AA/AB simply meant this rural GP shortage will worsen. If the federal government didn’t realised the effect of their latest policy changes, they certainly going to wear that into the next election
Continuity of care improves the quality of the service delivered and is vastly more efficient. Patients with complex medical problems know this and doctors with complex patients know this. It can be easily argued this should be the priority for planners and decision makers. But affordability and timely access are the current priorities. The problem with dealing with these competing priorities is the absolute vacuum at the political level. The NBN, NDIS and nuclear submarine commitments are examples where a government identified a need and, despite the out of proportion cost and cool public support, forged ahead. Healthcare is in desperate need of that type of visuon and commitment but instead we have some very uninspiring reforms that must, no matter what, be cost neutral or close to it. Primary care has been mismanaged and underfunded by successive federal governments and I guess all we can do is keep hammering this home. The financial commitments so far don’t even scratch the surface.
A wonderful article Jillann, I agree with everything you’ve written.
Medicare homes and headline articles about ‘tripling bulk billing incentives’*** (read the extensive fine print) are not solutions, and possibly harmful to the perception of ‘greedy GP’s charging gap-fees’.
Is there any research into what the marginalised/vulnerable population want or need? Whatever it is, I’m sure it cannot be met by current medicare fee for service or ‘medicare homes’, with neither encouraging or remunerating the time these people need from the right GP.
Continuing to see ED as the back-stop to gaps in every other health and social service is “killing” EDs – both literally and metaphorically. For both patient safety/quality and as a workplace, this is becoming increasingly unsustainable. Having transitioned to Emergency Telemedicine after decades of specialist-level emergency medicine, I can now see these issues with greater perspective.
I come across many patients who get worried about a new symptom or complication and have no good source of non-risk-averse advice than ambulance or ED. They might try calling an advice line – most of which use algorithms that often result in ED referral or calling an ambulance. For many patients – especially at both extremes of age – the transport to ED and the wait in an unfamiliar, cold, noisy place is counter-productive.
Our health and social services systems are designed to default to ED when all else fails. We have tacitly agreed to concentrate excess workload and risk in EDs. Combine this with access block to the wards and ICU, and the intense scrutiny of everyone else’s hindsight, and you have a perfect storm. As a workplace, EDs are brutal. Mental health units have abandoned their intake services – highly disturbed people can spend days locked in an ED, patients with critical illness can be held for hours to days in ED beds while newly undiagnosed people continue to arrive, and these priorities continue to compete with the medically and socially needy. The service cannot continue to deliver safe emergency care and remain a safe workplace while (i) the service is seen as the backstop for every other service; and (ii) patients admitted from ED are blocked from going to the wards.
If every other service – from wound care to psychiatry to housing to aged care to drug and alcohol to primary care – doesn’t work to plug gaps in their own services, there will be no functional ED service to default to.
Creating a myriad of clinics linked to ED only drives further people to “the hospital” as the solution for everything, and creates an easy pathway to default to ED for more complex problems.
There are two crucial solutions – both of which preserve the core acute roles of ED:
1. Create a “default” clinic off the hospital campus, where the service does not compete with time-critical acute illness and injury. UCCs could function this way if properly organised and resourced. Telemedicine can help to triage patients to the right service (if they need further care) – delivered by senior clinicians who are not risk-averse.
2. Patients admitted in ED must move out as soon as they are ready. EDs can’t have an open front door but a locked back door- workload and risk need to be shared across the institution.
I am rather tired of subsidizing the Australian Health System!
Most of my patients are bulk billed because they are pensioners, disabled, unemployed or just less fortunate.
Usually in the capital cities these patients have access to public outpatient clinics and the resources of large public hospitals.
There are just no adequate outpatient clinics in many of the rural and regional centers. The public hospitals in rural and regional areas operate increasingly in isolation to the community health provision.
Some of my specialist colleagues prefer not to have hospital outpatient clinics, so that everyone has to pay some “gap” to support the specialist’s business and lifestyle. So, there are two levels of healthcare here in the country: healthcare for those who can afford it, and no healthcare for the financially deprived.
I barely breakeven despite all the time that I give to my private practice and have to work locum’s and secondary jobs to meet my living expenses.
Given the often-complex biopsychosocial problems that I see, I am mindful that the Regulatory Authorities may not be happy with the lengths I go to, sometimes, to try and help some of the difficult patients. There just aren’t the resources here in the country to provide ‘conventional’ help. I feel that any little mistake that might come to the attention of the Regulatory Authorities could easily result in my deregistration and loss of income and career.
“We must have primary care services that are not fee-for-service based, that have a close relationship with the hospital sector and where the marginalised can regain trust in a system that has been not fit for purpose for them for a very long time”
Good luck with that…
Having been a part of several committees over several years at a National Level this issue has been repeatedly a part of the suggested solutions.
The Commonwealth/State Argy bargy just simply gets in the way of doing what is right. Some within the Profession believe that Fee for Service and Out of Pocket Gaps are morally defensible; they aren’t and were it not for the need to provide some sort of service and keep doors open this should be a sideline to the main game of expert primary care to all.
However, as State Jurisdictions increasingly take up Primary care responsibilities, it will come. The states must be funded to support primary care and not in an activity-based way (as they are for EDs and Hospitals)
Having the better part of three decades ED experience, I agree with Dr Farmer here. Some campaigns that have discouraged ED presentation and used humour as a lighthearted guilt out of presenting to emergency while funny, have made me a little nervous for our community… for the ones who really need to present but are too considerate of the demand on us, for the ones who could likely be treated by a GP but for whatever reason, can’t access that pathway right now and also for the narrative it possibly gives to some staff, which is not representative of who we are ad a whole. No doubt there are some presentations that are inappropriate- a list springs to mind… but these are often easily redirect-able especially when you take the curious and compassionate approach that Dr Farmer espouses. Noting that when you have a broader understanding of the adaptable, dynamic and complex systems of healthcare and people trying to align them with their own adaptable, dynamic, complex lives, situations and journeys… it’s just not always simple.
I thoroughly appreciated this compassionate article. A good reminder of our obligations to care for those less fortunate than ourselves with concern and dignity.
Thank you