A firsthand look at the difficulties of continuity of care in Emergency

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.