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Jonathan, this all sounds very familiar! However, we are being asked to integrate our ED with the local Walk in Centre and the GP OOH service and for the new service to have a "primary care focus" whatever that is! Our PCT have actually stopped making noises about how we admit too many in order to make money (although they contiune with this approach where children are concerned) and indeed accept that there is likely to be a 2% increase in unscheduled demand yearly. From the clinical side we have quite a good relationship with the GP's and WIC staff and at the moment are working together on the project. We are not in a situation where GP's have been imposed at the "front door" which as you say would be an absolute disaster and cost a lot of money. steve Dr Steven Crane FFAEM Consultant in A&E York Hospital -----Original Message----- From: Accident and Emergency Academic List [mailto:[log in to unmask]]On Behalf Of Jonathan Benger Sent: 04 March 2006 12:18 To: [log in to unmask] Subject: Primary care front door Dear Colleagues, I would value your assistance with an issue that has arisen locally, but which may have implications across the UK. In common with everywhere else, our local health community is under substantial financial pressure, and this will only worsen with the additional savings and imperative to achieve financial balance that are being imposed during 06/07. In an effort to reduce costs, our local PCTs have decided that patients are increasingly bypassing primary care and attending the ED because this is an easy option. From the ED they are being unnecessarily admitted to hospital because this is also an easy option, and makes more money for the acute trust under the payment by results system. I am informed that 50% of the patients in my emergency department could be dealt with in primary care (does anybody have any evidence to support this?). In response, the four PCTs in our region have decided that they will institute a "primary care front door" to all local emergency departments. Nobody will be allowed to attend an ED unless they have first been seen and "triaged" by a primary care practitioner. I have pointed out the costs, problems and potentially negative publicity that may result from this, and have even undertaken research to show that only 25% of acutely ill patients admitted to hospital come to the ED directly, with the vast majority contacting primary care first, from where they are often directed to the ED (some of you have kindly helped me with this, and I will be presenting the results at the BAEM conference later this month). Nevertheless, the PCT tell me that this revolutionary idea is currently sweeping the country and is being successfully instituted all over the place. My main question is, does anybody have a primary care front door to their ED? If so, does it work? Has it been suggested and dropped: if so, why? I recall corresponding with Ruth on this subject a few months ago, and thought the whole thing had been laid to rest, but round here it just refuses to lie down. As usual, please feel free to contact me off list: [log in to unmask] <mailto:[log in to unmask]> Best regards, Jonathan. PS: It will come as no surprise to many that the PCT's thinking around this issue is very woolly: Obviously the cost of placing a GP in the ED 24/7 is phenomenal, and when I pointed this out it was suggested that perhaps a nurse could do it with GP back-up, or maybe a GP could spend a few hours in the ED during weekday afternoons. Interestingly, the PCT actually paid to put a GP in our ED about four years ago to screen and reduce acute medical admissions (the GAMA project: GPs avoiding medical admissions). This showed that GPs had a marginal effect (<5% reduction) at best, and really only worked well when they encountered their own patients in the ED. Sadly, the local PCTs have a very short memory, and are desperate for some sort of "magic bullet" that will save immense amounts of cash in a very short space of time. This e-mail is confidential to the addressee and may contain privileged information. If you are not the addressee you are not permitted to use or copy this e-mail or its attachments nor disclose same to any third party. If this has been sent to you in error please notify us as soon as possible. We reserve the right to intercept and read e-mails sent or received by our employees. If you do not wish for your communications to be subjected to such scrutiny, you should not communicate via this e-mail system. We endeavour to exclude viruses from our data but it is the responsibility of the recipient to check any attachments for viruses.