GPs lighten the load for casualty doctors

Nicholas Timmins reports on a hospital that is cutting emergency admissions

Family doctors working in hospital casualty departments provide less expensive care and could even help to stem the tide of unnecessary attendances at accident and emergency departments, new studies have shown.

The evidence comes as A&E departments are facing repeated staffing crises because of changes to junior doctors' training and shortages of doctors while hospitals have faced a rising tide of emergency admissions in recent years.

A study in London at King's College Hospital in south London, where GPs have been used for more than six years to provide a primary care service in its A&E, shows that when they see patients with less serious conditions, the family doctors order fewer tests and X-rays, admit fewer patients and refer fewer to on-call teams than hospital doctors working in the same department.

Overall, the cost of treating each patient was between 35 and 40 per cent lower for GPs than for the usual casualty staff of junior doctors still in training.

Patients, however, were just as satisfied with the care they received, appeared to have equally good outcomes, and when followed up were more likely than those seen by the hospital doctors to say that in future they would treat themselves or visit a GP.

The results published in the British Medical Journal "support a new role for general practitioners" in casualty departments, according to Dr Edward Glucksman, the A&E consultant at King's College Hospital.

The findings broadly match those from a similar study of more than 4,500 patients at St James's Hospital in Dublin, which has also been published in the BMJ. The GPs "managed non-emergency A&E attenders safely and used fewer resources than the usual accident and emergency staff", according to George Bury, Professor of General Practice at University College, Dublin.

At least in theory, they freed beds for waiting-list cases by admitting fewer patients, and on the measures available the patients they saw did just as well as those who received more intensive investigation from the usual casualty staff.

"Inappropriate use of accident and emergency departments has defied solution throughout the world," Professor Bury says. All the measures that have been tried safely to reduce the numbers have failed. These have included giving frequent attenders advisory letters, allocating a GP to patients when they do not have one, and even changing the name "casualty department" to "accident and emergency" to make its purpose clear.

Using GPs might just have the potential to "break the cycle", the professor said, reducing inappropriate visits and over-use of hospital resources. If fewer unnecessary tests and X-rays were done, patients would no longer appear to have their need for a hospital visit confirmed.

That, he stressed, remained "speculation" and both he and Dr Glucksman warn that the overall impact of using GPs may be better quality and more cost-effective care rather than real overall savings.

CASE STUDY

'We are more

used to these

problems'

Paul Stacey, 30, an unemployed steel fixer, is in the A&E department at King's College Hospital in south London, writes Nicholas Timmins.

He has a pain in his groin which developed overnight and is refusing to go away. But at King's, Mr Stacey is being seen not by a senior house officer or one of the other casualty doctors, but by a local GP, Dr Thamer Chabuk. He is one of 13 who between them provide a service from 10am to 10pm, seeing patients classified as non-urgent, most of whom could have been dealt with by their family doctor.

Mr Stacey tried that - but was put off by being told he would have to wait a fortnight for an appointment. He is far from an extreme case. The junior doctors in the department say that they have people coming in at four in the morning after waking up with sore throats - or people who arrive at night with lumps they have had for months but which they have suddenly decided they want looking at. Some have no GP.

Mr Stacey does need to see a doctor. Dr Chabuk prescribes an anti-inflammatory drug, gives him a letter for his family doctor and advises him to visit his GP if his condition does not improve with the treatment. Mr Stacey departs, a satisfied customer, saying he will do just that.

This GP-in-a-hospital service has just been shown by a study of 4,500 patients at King's to produce more cost-effective treatment for primary- care cases than the department's usual casualty officers, who on average order more tests, use more X-rays and admit more patients.

Dr Chabuk, 45, and his colleagues can only guess why. Probably, he says, experience. "In this case," he said, "a senior house officer might have ordered a urine sample and perhaps a blood test. But I was happy to provide the treatment without the need for that. We are more used to these types of problems, from our experience in general practice."

A fully trained surgeon before he became a GP, Dr Chabuk is inevitably more experienced that the senior house officers who are only a year or two out of medical school.

The set-up has other advantages. The GPs help to train the junior doctors and students. They builds closer links with consultants at the hospital. They provide a service that is plainly needed. And they can advise patients on how to use their GP.

In follow-up interviews, more of the patients seen by the GPs say that in future they would go to their family doctor rather than return to casualty, and more without a GP find themselves one. But Dr Edward Glucksman, the department's consultant, is cautious about whether the load on his department will be reduced.

"The problem is that there's a very high turnover in the local population and most of those who come here when they could go to a GP are one-offs. We don't have large numbers of people repetitively using A&E for primary- care problems, so we haven't been able to show that using GPs changes patient's behaviour. But it is possible that in an area with a less transient population you may have that kind of effect."