Tag Archives: CHSA

Emergencies & GP after hours

Well there’s an interesting article this week from Emergency Medicine Australia (Nagree et al 2012 ‘Telephone triage is not the answer to ED overcrowding’ EMA 24 123-126) as well as a media release from the Australasian College of Emergency Medicine regarding triage.

Before rural medicine I was an EM trainee. I’m pretty passionate about emergency medicine – sadly one of the reasons I got out of the specialty was frustration with things I could not control, not least the phenomenon of ‘access block’ – too many people in the ED, waiting for beds on the ward. I must admit that as a junior doctor I would bemoan ‘GP-type’ patients clogging up the ED…but as time went on and I matured clinically, I realised that:

(a) these low acuity problems were quick and easy to fix
(b) they were not a burden on time or resources
(c) often even the low acuity patients had complex health needs that required admission to a hospital for sorting out.

As a rural doctor I do my utmost to avoid turfing patients unnecessarily to my overworked colleagues in the ED, trying to smooth my patients’ admission to the appropriate unit without them having to be stuck on a trolley in the ED awaiting review.

Whilst it is tempting to imaging the ED clogged up with non-urgent problems, the reality is that such presentations are easily dealt with (even the most junior of resident medical officers can treat a UTI or reassure parents of a child with otitis media). What clogs up the ED are complex patients requiring investigation and admission, as well as the labour and resource-intensive presentations such as critical illness.

It’s also relevant to the ongoing issue of what is and what isn’t an emergency – with a blatant cost-shift between State and Federal funds trying to classify many ED attendees as ‘inappropriate GP-type attendances’.

But there is a problem.

Politicians need to be seen to ‘do something’. They have latched onto the concept of the idea of triage 4 and 5 patients as being GP-type attendees and in a non-evidence based approach have poured hundreds of millions into schemes such as GP after hours, co-located clinics and the disastrous healthdirect phone line.

Phone triage sounds good. But it doesn’t work – experience from overseas (not least the ill-fated NHS-direct in the UK proves this). Put simply, a nurse or a GP following a protocol will not be able to diagnose over the phone 100% reliably. It may be a sop to the worried well, but my grandmother can do this job just as well and won’t cost the estimated $200 million that healthdirect costs the taxpayer.

The Health Minister has stated that healthdirect has deterred 30,000 patients from a million calls from visiting the ED. Sounds good…but that’s only 3% of calls…surely better to spend that money on beds and more clinical staff…not a phone service.

We don’t do phone triage in the ED, instead advising patients to present to the ED for a face-to-face assessment – because it is a safe approach – history and examination cannot be done reliably over a phone. In fact, the more medicine I do the more I realise how medicine doesn’t fall into neat protocols or boxes. The skill of a good Emergency Physician or GP is to spot the severely abnormal amongst the morass of mostly normal. A protocol (or my grandmother) will get things right most of the time – but will miss the more unusual or atypical presentations. The UK’s NHS-direct has learnt this, with several lawsuits after missed diagnosis – the headache that was a subarachnoid, the febrile child with meningitis etc.

So Prof Nagree’s paper neatly debunks the idea that phone triage alleviates pressure on Emergency Departments. What then of triage as a measure of ED vs GP-type attendances?

Triage is a score of urgency of treatment – not complexity. Many triage 4 or 5 patients have been sent to the ED by GPs. To then proclaim that they are ‘GP-type’ attendances misses the point that such patients are complex, require extensive investigation (usually using facilities not present in a GP surgery, such as X-ray, bloods etc) and often require admission.

This may not sound like a big deal – but it is an issue in the country where patients who are not admitted are charged a fee for attending the ED, on the spurious basis that they represent routine General Practice.

Which then raises the issue of GP After Hours services – what is the appropriate level of service needed after hours and will pumping money into GPAH alleviate pressure on EDs?

The Government clearly thinks so and is throwing around money like a drunken sailor. We met with the Medicare Locals mob last month on Kangaroo Island (formerly they were the Southern Division of General Practice in Adelaide, then GP-Network South, and now the unwieldy Southern Adelaide-Fleurieu-Kangaroo Island Medicare Local). They were canvassing opinion on GPAH services but seemed to have no grasp of the issues locally nor how to address them.

I always think of GPs like plumbers – you need us during working hours for scheduled things like routine maintenance…but we might have to deal with the occasional urgent job like a dripping tap. However you don’t really need these things fixing at 3am. On the other hand, if the hot water service blows up or a water main bursts, this needs to be dealt with. These are the medical equivalent of an emergency medicine service and as rural GPs we provide this too. However is this routine GP or is this an emergency?

I’m a simple chap – I think that primary care generally deals with most things…but if it cannot wait 12 hours or needs the services of a hospital then the problem is ipso facto an emergency.

Nagree’s paper establishes that phone triage does not alleviate pressure on EDs – the issue is access block, not inappropriate attendees. The corollary is that most patients are in ED because they belong there – throwing money at afterhours services by GPs doesn’t really address their complex health needs requiring hospital services (imaging, same day bloods etc)

However the issue of non-admitted emergency patients remains unaddressed. I can cite numerous examples (not least from the current busy Easter weekend oncall as I type) of people presenting appropriately to the ED – but being forced to pay for their attendance because they are not admitted (State Govt cost shifts to Medicare)

Examples include

– fall from a roof, 25 cm incisional wound requiring formal debridement under local anaesthesia and repair taking 90 minutes

– fall from a horse with possible cervical spine injury

– four tourists in a medium speed (60kph) rollover on unsealed road, presenting to hospital for forensic blood alchohol, assessment of injuries

– 13 year old fall from skateboard with angulated Colles fracture requiring manipulation and casting

– mental health patient brought in by Police for assessment

– 45 yo with ?fracture-dislocation shoulder requiring analgesia, X-ray and reduction

All of these patients chew up a few hours of time. I think they were appropriately seen within the ED and not deferred for a routine 15 min GP appointment in the week.

However the false reliance on triage as a marker of GP vs ED attendance will continue to encourage misguided strategies to reduce ED overcrowding that are doomed to fail. It also allows cost-shifting from State (emergency) to Medicare (GP) budgets.

As ACEM say “it is in the political interest of State governments to ensure that any definition of general practice patients seen in EDs yields high numbers. This helps perpetuate the myth that EDs have too many GP patients’


What do others think?

Had a gutful

Well, it’s kind of ironic that over the weekend there’s been a small flurry of interest in the issue of non-admitted hospital patients being charged a fee in South Australian country hospitals (see The Australian p7 24/3/12)…and yet at the same time this issue arose locally.

I understand that the Minister of Health is not a happy bunny currently – being the Health Minister must be an unforgiveable job, especially when the budget is squeezed tight. 

And I’ve recently been criticised for raising this issue – on the basis that it’s been going on for a while and may impact on doctor’s hip pockets (some rural docs are doing OK charging a $50 gap for non-admitted patients and may be reluctant to see a change in the status quo). 

It’s also a fairly intense time at the moment – the contract between Country Health SA and rural doctors remains ‘in negotiation’ – even though a finalised deal was supposed to have been in place by 30/11/11…and we are on our second 3 month extension. There may be anxiety that politicising this issue will affect negotiations.

I agree and think this issue transcends whichever party is currently in power.

Anyhow I was on for anaesthetics this weekend and was called in by the hospital for a ‘cardiac arrest’. I arrived ahead of the A&E oncall doctor and the patient, who was transported by ambulance.  

Suffice it to say that when they arrived at the hospital, the patient was very much alive and indeed combative from another cause. 

After a quick ABC assessment I was stood down and left the patient in the capable hands of my A&E colleague. I understand that the patient left the ED some time later, discharged to the care of a capable adult.

Today I emailed the head of Country Health fee-for-service, asking how this attendance should be billed.

The response? Well, as the patient was not admitted, it is apparently ‘a private matter between the patient and the doctor and CHSA is not liable

I’ve had a gutful of this. I really don’t mind being called in, whatever the hour, whatever the reason. If the hospital feels they need my services, and I am oncall, then I am available and will come in.

But to then turn around and say they won’t pay?

Now, this will no doubt be sorted out after the usual barrage of emails to-and-fro until someone (usually the CHSA medical advisor) makes a determination. I will expend many hours chasing the debt, my BP will climb…but ultimately I will get paid.

But it is all so tedious and mind-mumbingly unnecessary. I am fed up with having to chase payment from a health service that seems to apply rules inflexibly and illogically.

I sure as hell am not going to charge the patient – they arrived by ambulance with four paramedics in attendance, two doctors, extra nursing staff etc and were transported to the appropriate place – a nice shiny hospital.

My expectation is that if the hospital feels a matter is urgent, and calls a doctor, then they should pay that doctor regardless of outcome, of subsequent diagnosis or of triage score. I think most common sense people would agree. However the wording of current arrangements opens the door to cost-shifting from State funds (public hospital) to the patient (Medicare reimbursement if compensable).

I don’t care, I just want to get paid without fighting every bloody time!

Is this really so unreasonable or hard to understand?

Open Letter to the Minister

Well, it’s finally happened. I’ve succumbed to the urge to fire off Victor Meldrew-like letters of indignant fury to the Health Minister over the recent exchange of press releases between Liberal and Labor Health Ministers regarding the issue of country patients being charged fees for A&E services.

Grumpy old doctor aside, I really believe this is an issue that is important. Rural Australians are disadvantaged enough, without having to face fees for A&E services.

I should note that this is not an issue of self interest – as a rural doctor, I derive part of my income from charging fees to attend a patient at 3am. And I am comfortable with charging a fee where it is fair. But when the same patient would get the same service for free in a metro ED, I have to question the process. And when patients are afraid to attend the A&E because they fear a fee, something is very very wrong.

It is true that a private fee can be charged as part of a continuing care episode or by prior arrangement for a patient to see a particular doctor privately. Fair enough.

But the people who attend EDs usually have urgent issues that cannot be dealt with in GP private rooms. They often require services that cannot be delivered in rooms (X-rays, anaesthetic, plaster etc). They haven’t asked for a particular private doctor to see them – they have correctly self-presented to the emergency department and the hospital has in turn decided to call in the doctor.

Rural health outcomes are already bad – to charge people just makes this worse.

So – I’d be a lot happier if I was paid by the hospital for attending patients who the hospital feels need to see a doctor urgently, through my contract to provide A&E services. I may be poorer if paid by the hospital, but it would be a fairer system

I am pretty sure patients would prefer it!

Anyway, here’s my latest missive.


Dear Minister

I read your latest Press Release re: country hospitals charging fees in response to the Press Release of Martin Hamilton-Smith. Regardless of whichever party is in power, I remain perplexed.

The fact remains, country people are charged fees for non-admitted A&E attendances in rural hospitals,  for services that are provided for free in metropolitan areas.

These are not, as you suggest, charges for routine GP services – your 2010 contract with rural doctors is very clear – non-admitted patients in the ED are considered to be private patients of the GP

Examples of non-admitted A&E attendances include

– forensic medical examination of a rape victim
– assessment including X-ray, reduction & plastering of a fractured limb
– repair of a complex laceration
– assessment of victims of a vehicle rollover
– urgent assessment of a complex mental health crisis
– administration of a neuroleptic agent for reduction of a dislocated shoulder

These are not routine GP services. These services are appropriately provided through an Emergency Department and are provided for free everyday in metro EDs.

When the Hospital calls the oncall doctor, it is through his/her contract with CHSA to provide A&E services, not as a private arrangement betwixt GP and patient. 

Many patients are rightly fed up with being charged fees for services in an emergency. Sadly some patients do not seek medical attention with urgent problems that SHOULD be seen in an ED, for fear of cost. I have recently been told of a patient who delayed seeking medical attention for fear of fees…then presented in extremis several days later and died.

Your press release intimates that the only alternatives are for either GPs not to charge patients their gap fees, or for CHSA to put in salaried medical officers and ‘put rural doctors out of business’

You neglect to mention the third option – simply to pay the oncall doctor for the work he or she does, regardless of admission status. Existing fee-for-service arrangements would be more than adequate and would be in line with conditions interstate.

Surely it’s not that hard to grasp? If a patient presents to a CHSA hospital with a problem that is deemed urgent, the hospital needs to call a doctor as part of the A&E roster, and the service cannot be provided in routine GP rooms….then the patient should receive the service for free and the doctor be paid by CHSA.

The matter has been needless obfuscated by lack of confusion over what is and what isn’t an admitted service..and a continuing reference to provision for private patients to be treated by their own doctor when they request as part of a prior arrangement or as part of continuing care. None of these apply for the patients I am called to see when on your A&E roster.

I rang Medicare last week. They reckoned it was illegal for me to be charging patients for services provided in the A&E department and referred me to the National Healthcare Agreement which states that:

States and Territories will provide health and emergency services through the public hospital system, based on the following Medicare principles:

(a) eligible persons are to be given the choice to receive, free of charge as public patients, health and emergency services of a kind or kinds that are currently, or were historically provided by hospitals;
(b) access to such services by public patients free of charge is to be on the basis of clinical
need and within a clinically appropriate period; and
(c) arrangements are to be in place to ensure equitable access to such services for all eligible
persons, regardless of their geographic location.

As far as I am aware there is no section 19 exemption between SA and the Commonwealth.

How then can CHSA continue insist that doctors on the A&E roster charge patients for A&E services in CHSA EDs for conditions that are certainly serious but may not require admission for the requisite four hours to satisfy admission criteria?

I look forward to your response. These questions have been asked by me previously to CHSA CEO’s George Beltchev and Clare Douglas without response.

I hope you can finally answer this, not with political spin, but in the interests of rural patients who deserve a better deal.

Kind regards

tim leeuwenburg (dr)
kangaroo island
south australia