Our PCT put in some extra GP shifts a while back. At enormous
cost, I would say. One South African was commendably quick,
however of the other two doctors one had never worked in A&E, and
the other was only a year one fully fledged GP. Somewhat galling to
our middle grades that these inexperienced doctors were receiving
between £80 - £100 per hour for seeing fewer patients than the See
and Treat nurses.
I would agree with Katherine. A good GP would sift out the chaff
effectively, but at a great cost to whoever was paying them, and we
would be abel to choose / direct or retain a good one should he/her
come along.
Paul Ransom
Paul Ransom
On 31 Oct 2005, at 21:27, Katherine Henderson wrote:
> Dear Ruth
>
> If you are asking the question because your Trust/PCT wants you to
> have this
> system we would be happy to share our experience. We had a PCT who
> wanted to
> force this on us but we resisted. I believe the good GPs could do a
> good job
> but the reality is that no good GP would actually want to spend his
> or her
> time doing this type of work regularly. We rejected the pressure on
> the
> grounds that we needed a 24 hour consistent system. At one point
> the Chief
> Exec was prepared to have them removed for trespassing if they
> tried to come
> in so you can see it got quite nasty. We kept being told - 'well
> the London
> has it'- which was untrue. It was tried briefly and fell apart in a
> few
> days. There are not enough GPs out there and we had to put our foot
> down
> about quality and reliability- both of which have been pretty
> variable.
> Documentation was also a nightmare. GPs are also extremely expensive!
>
> Katherine
>
> -----Original Message-----
> From: Accident and Emergency Academic List
> [mailto:[log in to unmask]] On Behalf Of Jonathan Benger
> Sent: 31 October 2005 14:31
> To: [log in to unmask]
> Subject: Re: GPs triage
>
> Dear Ruth,
>
> I am not aware of any ED in the UK that has a GP doing triage, and
> I very
> much doubt there is one. However this scheme sounds not unlike the
> sort of
> thing that a PCT or SHA will come up with from time to time,
> certainly round
> our way. The premise is that GPs are better at sorting, risk
> stratifying and
> diverting ED patients than ED staff, and therefore having a GP in
> the ED (or
> in this case doing triage) will reduce the number of patients being
> seen in,
> and admitted via, an ED.
>
> However in practice such a scheme is unworkable because:
>
> 1. GPs don't want to work outside normal office hours
> 2. GPs are more expensive than hospital staff
> 3. GPs don't want to sit in an ED doing triage all day
>
> When you start to break such schemes down they are either proposed
> for 35
> hours a week (during the period when there is often least problem) or
> ludicrously expensive (costing out a 24/7/365 GP roster is
> horrifying).
>
> When the only tool you have is a hammer, every problem becomes a nail.
> Similarly, if all you have are primary care physicians, then the
> answer to
> every problem (including four hour throughput) becomes a GP. When
> we were
> struggling with the 4 hour target, the local SHA decided that
> putting a GP
> in the ED between 9 and 4, Monday to Friday would solve the problem
> and
> avoid lots of "unnecessary" admissions. However when we actually
> tried this
> a few years ago we discovered that GPs had the same admission rate
> as junior
> medical staff.
>
> In fact, the best clinician to triage, manage and avoid admissions
> in ED
> patients is, surprise surprise, an ED consultant. Every day in my
> department
> we intercept and discharge several patients who have been referred
> by their
> GP for admission. Partly this is because we have access to
> diagnostics,
> partly because we are the specialists in emergency care. As GPs
> withdraw
> from out of hours cover they are going to become less and less
> skilled in
> this role, leaving others to manage and deliver unscheduled care.
>
> Regards,
>
> Jonathan Benger.
>
>
>
> -----Original Message-----
> From: Accident and Emergency Academic List
> [mailto:[log in to unmask]]On Behalf Of Brown, Ruth
> Sent: 28 October 2005 18:44
> To: [log in to unmask]
> Subject: Re: GPs triage
>
>
> 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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