Helen Salisbury: GPs aren’t to blame for delays in emergency departments

If you’ve been reading the popular press, you’ll have been told that the problem of long waits in emergency departments (EDs) is partly caused by snowflake patients (who don’t know how to look after themselves when they have a sore throat) but is mostly the fault of lazy GPs who can’t be bothered to offer them an appointment, leaving them with no choice but to attend to their nearest ED.

However, a study by NHS England, recently reported in the Health Service Journal, shows that this just isn’t true.1 The study was devised to pilot a new way of categorising the urgency (“acuity”) of each case presenting to an ED, which was partly in response to tragic deaths of patients who had waited long hours for medical attention after inadequate triage.23 The study sorted patients into five groups, ranging from life threatening emergencies right down to low acuity patients who could more suitably have been seen in another setting, such as an urgent care centre or a GP surgery. The expectation, based on previous studies in the UK and abroad, was that 20-40% of patients would fall into the low acuity group. The actual figure was just 4%.

Part of the reason for the difference between these results and previous estimates may be that this was a prospective study, looking at the outcome of triaging patients on arrival. Other studies have been retrospective, judging acuity on the basis of what treatment, tests, or follow-up the patient needed after medical assessment.4 This makes sense: until you’ve taken a proper history and examined the patient, you don’t know for certain how ill they might be. To be safe, any triage system is likely to categorise patients as possibly higher acuity, which can then be downgraded when more information is available.

Anyone who actually works in an ED could have told you that low acuity patients are not the issue. Yes, there are unacceptable waits for medical care, but the main problem is that departments are overwhelmed with sick patients lined up on trolleys waiting to be admitted. It’s very hard to offer safe and dignified care in a corridor with minimal facilities and no privacy. In this situation, the patients waiting with a headache or diarrhoea who should have seen a GP are the least of your problems, although the delays are unwelcome for them too.

The need to stem the flow of unnecessary ED attendances is one of the factors assumed to be behind the push for same day access hubs. The argument is that, if patients have easy access to same day care in the community, they won’t clog up EDs and the waiting times will all improve. Unfortunately, from this study it seems that this would make very little difference—we still need more beds and more social care. We also need more GPs who can offer proactive care and continuity to keep patients well and prevent their emergency admissions.