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I'm just not quite sure what your concern is Jonathan. If it's true that some 50% of your patients are primary care-type patients, then wouldn't it make sense to get some of them "sieved" off to primary care before they get into your ED proper? And the cost is none of your direct concern, I should imagine, as the PCT will fund it (using all the money they've saved from effectively stopping GPs doing on-call work), although there may be some implications for staffing in your department if you lose a huge chunk of your "customers". That is not such a concern these days, however, as your resources are to some extent "protected" by the four-hour targets. At the end of the day, I'm sure we'd all be willing to trade some of our resources if it also meant trading away our primary care patients. But I get the impression it's really the admissions that you're more concerned about. I think you're saying that some 75% of your admitted patients are directed to you from primary care anyway (which seems a huge percentage, but never mind), so putting a PC person on the front door is hardly going to make a big impact on admissions, is that right? I suppose I agree with you there, but they may make a huge difference to the number of non-admitted patients, redirecting them back to PC instead of ED. I also agree that it's going to be difficult even for an experienced GP to "offset" an admission when the patient - that they have never met before - is at the front doorstep of the hospital. I think the only way GPs can avoid admissions in such borderline cases is when they see the patient - whom they already know well - in their own home or in their surgery. But that "model" of primary care is increasingly rare these days. I would suggest let the PCT play with a pilot and see what happens. Either way, you're not going to lose on this, are you? AF ----- Original Message ----- From: "Jonathan Benger" <[log in to unmask]> To: <[log in to unmask]> Sent: Saturday, March 04, 2006 12:18 PM 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] > > 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. >