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ACAD-AE-MED  October 2005

ACAD-AE-MED October 2005

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Subject:

Re: GPs triage

From:

"Brown, Ruth" <[log in to unmask]>

Reply-To:

Accident and Emergency Academic List <[log in to unmask]>

Date:

Fri, 28 Oct 2005 18:43:50 +0100

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (71 lines)

thanks, I guess the information I was after was the name of a hospital in the UK who is actually doing this, actually has a GP at the front door doing the triage, rather than having GPs in A&E or A&E nurses sending patients to GPs from triage
thanks ruth

-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]]On Behalf Of Dunn Matthew Dr. (RJC) A
& E - SwarkHosp-TR
Sent: 28 October 2005 09:38
To: [log in to unmask]
Subject: Re: GPs triage


For anyone who hasn't read it, this was one of the topics covered in Matthew
Cooke's report on Reforming Emergency Care (
www.sdo.lshtm.ac.uk/pdf/evalmodels_cooke_final.pdf  ). The (international)
studies he looked at showed that about a quarter of patients could be
triaged away of whom 40% saw someone else same day; 40% within 2 days and
20% did not seek further medical attention. Some studies showed some
patients triaged away inappropriately; some did not. No major problems with
complaints (although I think most studies gave the patient the option to
wait an be seen).
I would recommend this (rather long) paper to anyone looking at ways of
changing their systems. A lot of things being proposed have been studied
elsewhere already.
Being cynical, I have a bit of concern about the financial aspect of this:
it seems to me that once you've made sure that the condition isn't an
emergency, you've done most of the A and E treatment of it (or if it need
treatment, it seems strange for A and E to do the history and examination
and then refer the patient elsewhere). With payment by results, I'd expect
that the PCT or SHA won't be paying for these cases as A and E patients.
This could mean a drop in income of over 750,000 a year for some
departments (although I'd presume that the PCT would fund the triage nurse);
possibly significantly more if some of these patients would fall into the
60 group. With the grouping of payment by results it is clear that some
patients will cost more than you get paid for them and some you will be paid
more than they cost. This looks like a way of taking away the simplest 25%
of the 30 and 60 groups i.e. the patients that the department "makes a
profit" on.
Overall, I'd say benefits are obvious (less primary care cases in your
waiting room; your doctors can concentrate on As and Es). There is no
evidence of benefit in terms of repeat attendances. The cost to the
department as against having a primary care nurse practitioner in a large
department is 850,000 against 350,000 (assuming 11 WTE NPs, each seeing
2,500 patients a year); although there is an additional saving to the
department in that you don't need as much room as you're not seeing as many
patients. This of course translates equally well to a cost benefit to the
PCT of 850,000 minus the cost of having these patients seen in primary care
(which is pretty low as I'd expect they'd come under the GPs' core contract
in any case) and possibly minus the 350,000 it would cost them to provide
the 11 NPs. The risks are fairly low- studies of a few thousand cases showed
no major problems.
One unreported (in the literature) problem I've come across with triage from
A and E to out of hours primary care: the simplest way to do it is to send
the patients straight to the out of hours (rather than to GP next working
day). This has the advantage that if you miss an emergency the patient won't
be pleased, but at least it's likely to be picked up before it causes major
problems. The disadvantage is that the Out of Hours doctors don't like it.

Matt Dunn
Warwick


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