The case for urgent care

00:05

Jenna: Hi everybody and welcome to this webinar. I would like to acknowledge the traditional owners of the land on which this meeting is being accessed today and pay my respects to Elders past, present and future.

00:17

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00:45

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1:36

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1:52

Jenna: This webinar is proudly supported by Healius. Tonight's webinar is on the case for urgent care in Australian Integrated Primary Care Centres. We will provide information on the problem of increased emergency department presentations, the reasons behind these increases, that more of these presentations occur on the weekends, and that a percentage of these patients could be managed in primary care.

2:09

Jenna: I would like to introduce our presenters for tonight's webinar, Dr John Adie and Dr Jamie Phillips.

2:19

Dr. John Adie: Welcome to this webinar today on the case for urgent care in Australian Integrated Primary Care Centres. I am the medical director of Immediate Care for Healius and the Royal New Zealand College of Urgent Care – Australian Convener. I would especially like to welcome my colleagues from New Zealand and the Royal New Zealand College of Urgent Care, colleagues from the Sunshine Coast Morayfield and the Healius Clinics around Australia. My background is in general practice, rural and remote medicine, urgent care and emergency departments on both sides of the Tasman and the rural areas and the urban areas. I would especially like to welcome my co-presenter today Dr. Jamie Phillips. He is an urgent care clinician and rural generalist, and spends a lot of time in ED. It is good to see you, Jamie.

3:07

Dr. Jamie Phillips: Thank you everybody. Yeah.

3:08

John: I am not sure about the mo, I am hoping that is for Movember.

3:10

Jamie: Yeah, it is 100 percent for Movember, I’d be divorced if this is my normal moustache.

3:15

Jamie: So yeah, as you say, I am Jamie, I am an urgent care physician. I am a GP as well and a rural generalist and a former Pommy now proudly new Australian. I really appreciate you bringing me here actually. I am keen to actually add some kind of substance to what I do as an urgent care clinician and learn a bit from you this evening.

3:30

John: Fantastic! So, we have got a couple of polling questions to start up with. We are going to ask you these at the start and ask you these at the end as well. I would like to know yes or no. Do you feel your current model of general practice would be threatened by urgent care? So, this is the first question. And the second question is, would you be interested in that career in urgent care that complemented your core general practice. So, we are keen to know your thoughts, and we will be asking these questions at the end as well.

4:01

John: I would like to start by talking about what a non-life-threatening urgent condition is. Here is an example of one, needs to be seen now, does not necessarily need to go to an emergency department. The literature calls this health care consumer abuse, inappropriate referrals, inappropriate attendance; and low-urgency, self-referred patients better managed by other services. There was a French author. You have worked in France, have not you Jamie?

4:32

Jamie: Yeah, you know, I have, and it is definitely an interesting experience, I had a fantastic time there, but yeah, a totally different healthcare service, a totally different approach to healthcare. Patients can refer themselves to consultants without using the GP and there they really understand the value of a GP in France now.

4:53

John: So, this is a non-life-threatening urgent condition.

4:53

John: It can be seen in a number of treatment modalities.

5:08

John: Fantastic.

5:09

John: This is a life-threatening urgent condition that needs to go to a hospital emergency department and be managed appropriately.

5:17

John: The problem that we are facing in a lot of the Western countries is that patients present to ED with non-life-threatening urgent conditions. In fact, in Australia these presentations increase by 7% a year over 10 years in the countries of Australia, UK, US, Canada, New Zealand, and Switzerland. So, this is 55% in 10 years, it is not sustainable.

5:44

John: Another problem is the contributing factors to this. Limited access to primary care. GPs are not remunerated to do afterhours and weekends and walk-in cases. EDs are society’s core safety net provider. They do not close, so it does not matter what time of the day or night, patients are able to go to ED to get their solutions, whether they be GP, non-life-threatening, or life-threatening conditions.

6:12

John: Increased presentations may be partly due to the ones that we can manage in primary care.

6:18

John: In fact I found 23 studies that looked at that. Studies show for adult EDs that between 8.4 and 50% of what presents could be seen in primary care. Obviously, if it was closer to a tertiary ED, it would be more than 8.4%. If it was closer to the country, it might be up to 50%. And an interesting subset is the paediatric ED, where some studies shows that up to 82% of what goes in there could be seen by general practice.

6:45

John: Cost of healthcare is increasing as well. In 2006, the bill for Healthcare Australia was a $107 billion. In 2016, it is a $170 billion, that is a 59% increase, and it is predicted to go up to $320 billion by 2035.

7:06

John: Of those considered non-urgent, 7.6% are actually admitted. So, the decision as to whether a condition is urgent or not belongs to the patient, not the triage nurse, not the policymaker, but the patient.

7:18

Jamie: I think John, that is a really important point we see, certainly with my older patient demographic, they are acutely aware when they present to my EDs, the first thing that comes out of the mouth is, I am not sure if I should be here. The bottom line is they consider it an urgent problem, therefore at the moment, the only alternative for them is the emergency department. They equate urgency with going to the emergency department because there is no other differentiated offer for them in Australia at the moment. It was the same problem I saw in the UK, same problem I saw in the States as well.

7:52

John: Increased presentations especially on the weekend contribute to overcrowding. Is that something you have seen as well in your career?

7:59

Jamie: Oh yeah, I mean, to be honest, it is a daily problem for us. I mean overcrowding because of unscheduled care or urgent care or whatever you want to brand it, emergency care is not a complicated problem, it is a complex problem, meaning that the issues are moving and changing constantly. So, we may be, I may walk onto the floor, as I was talking about before, I may walk onto the floor, and there are 20 people to be seen when I start my shift. Now, some days, that is fine, I can be like a surfer and ride those waves, and it is quite exhilarating to be busy with that many patients waiting to be seen. Same number next day, small change, maybe a change in the staff or the change in the pressures in the hospital behind this, and then suddenly it is a stressful situation, but it is not just for us as the clinicians, it is often for us as doctors to forget that healthcare is not about us. Actually, it is incredibly stressful for the patients, and if you look at the studies certainly that have come out from the UK and the US, it is patient satisfaction has intimately linked to how long they have to wait, how overburdened they perceive the emergency department to be. It is those patients in this modern world, who get on google, who give the hospital negative reviews. It is those patients who jump online, email their MP, talk to their MP about this, complain about this, it is not really the high acuity patients, the high-acuity patients are not really impacted by overcrowding at the front end. They are impacted by overcrowding at the back end. It is those high-acuity patients we cannot move out of the department because they are bedlocked to the hospital. That does not really concern us when we are talking about urgent care. Urgent care is as we are talking about this evening, I am interested in those lower acuity patients, those priority 4s, those priority 5s, who are all waiting three, four, five, six hours to be seen because there is no alternative assistance. So, yeah, overcrowding is a real problem for me as a GP working in ED, but also as a GP referring up to ED as well.

9:57

John: And, some of the times where overcrowding is more common, is the Saturdays and the Sundays and the Mondays. Here are a couple of EDs that are in the town I was working in 2013/2014, and this pretty much shows the model in the Western world.

10:11

Jamie: Yeah, I think this is exactly and all of us know this. We know if you work in urgent care, it is the same as you work in GP. You are going to be busy Friday night, Saturday, Sunday, Monday, public holidays because that is what is going to cause the real problem, that’s when people cannot access their normal GP because our GP colleagues are not incentivised to work out of hours.

10:33

John: Another problem is the solutions, it is the slowness to embrace the solutions. Around the world, some countries have expanded their ED and put GPs in the ED, equivocal evidence for that on concurrent views, referring patients outside is one option, but as we have seen 7.6% of those who are considered non-urgent end up being admitted, and the other one is developing primary care-based solutions, and I would like to shout out to the South Australian Government because they are investing in primary care-based solutions. Right at the moment, we are doing a trial, which we will talk a little bit about later. And the sort of models that we are talking about in the Western world include minor injury units, urgent care clinics, walk-in centres, and even call-based centres. So, one of the problems that we are facing is patients presenting to ED with non-life-threatening urgent conditions.

11:28

John: We go to the literature to see what the solutions are there and there are a number of helpful points that I want to go through in the literature for helping the patient with a non-life-threatening urgent condition. They have to choose another alternative than the emergency department.

11:43

John: We found 13 non-usual GP, non-ED based models for managing non-life-threatening urgent conditions in the community, basically under three categories. There is telemedicine, which is virtual, but there is limited access to resources; house calls face-to-face interaction, but again if you’ve ever done house calls, you do not have much resources you could have taken with that, and lastly the location based when you are face-to-face and you have got access to a whole lot more. So, we found 13 models, but we found that five of them could be rolled out or developed in Australia, and I want to talk briefly about those five.

12:22

The first is the new pre-hospital practitioner community care. There are two types of new prehospital practitioners, it is the paramedic practitioner that is a paramedic that has had extra training that could manage patients in the community in their own homes, and also the emergency care practitioner, and these practitioners work in emergency settings such as the minor injury unit, the ED, the general practice, the urgent care centres alongside with GPs. And a Canadian systematic review highlighted the initiatives and the promising programs in Australia, the UK, and Canada. We have had models in Australia where these types of practitioners managed lacerations, fractures, they prescribe, they order blood tests, they order x-rays and may, even treat people in their own homes. Studies on paramedic practitioners, three randomised control trials from the UK, where paramedic practitioners treated patients in their own home with mild illness and injury, reduces admissions and admissions to hospital with favourable outcomes. Also treating the elderly with minor illnesses at home is as good as taking them to hospital. It is the minor accidents and injuries that we are talking about.

13:37

Jamie: 100%. I have got to be honest with you. My fragile ego was a little bit pensive when these guys came on the scene, you know, as a doctor we are driven by egos. When these guys came on the scene, I was one of the naysayers. I was one of the guys who said there is no way a paramedic can do this, and they proved me wrong. I have worked with these guys regularly in rural medicine in UK in free hospital care and they are fantastic. They were particularly effective with our elderly and our frail, the infective exacerbations of COPD at home, checking on the basics for the small skin lacerations. What I loved about them was their humility. They knew what they knew, but they knew what they didn’t know, and they were very very keen to work with us as urgent care emergency doctors to try and improve, they absolutely got the accordance of delivering care particularly to the elderly in their home, in their community and not taking them out of the home and to bring them to our clinic. So, you know, I absolutely had to swallow my pride with these guys. I realised they are good news.

14:33

John: So, a study from New Zealand, where I am from, shows that in a rural town, emergency care practitioners keep 59% of people at home compared to 24% normal paramedic care and in a 999 service in England, the figures were 64% were managed in their own home compared to 24% by usual care, which is a massive difference. One of the studies showed that emergency care practitioners transferred more children to hospital, but the cost was 44% in another study. That is quite a savings to the government if you can treat people in their own home.

15:12

Jamie: Yeah, that is definitely one to them and none to my ego, is not it?

15:17

John: The urgent care pharmacies is another non-GP, non-ED model for managing patients with non-life-threatening urgent conditions, and New Zealand, Australia, and Canada lead the way, and the pharmacist is a very accessible healthcare professional with medical knowledge. So, it is good to make use of that. There were four ways that the pharmacists could help. The first way was if someone comes in with a potential drug interaction or a drug question, they can help. The second is to dispense emergency supplies of medications. I remember in the days where I used to work in urgent care and people might wait sometimes 30 minutes to an hour to get a script for a month until they could see their GP, but the chemists can do that now, which I think is really good.

16:02

Jamie: Well, it is fantastic.

16:04

Jamie: I mean, we use these guys regularly in a tertiary referral to ED. So, our consultant pharmacists are part of that research team now. As we are conducting high-level research, they are there, they are advising some on medications, they are making suggestions on cost grounds, availability grounds, they are thinking interactions, and all of that does… all that does is just destress me, it gives me more headroom to focus on my patient and not worrying about the things that really are not in my specialty. So, if we could translate that to the urgent care department from the emergency department as well, I think that would be good.

16:35

John: Pharmacists are prescribing contraceptive and emergency contraceptives. In the States, there are trials going on with patients who come in and they will have STI screening and treating it in consultation with a physician as well, and in Australia, there has been screening for chlamydia in patients that come in wanting emergency contraceptive. So, all these sorts of things are happening in pharmacies now and developments as well, so I think that is a quite promising development.

17:05

John: The third is the advanced nurse enhancement of primary care. Patient satisfaction is high. Three studies show that this type of practitioner, the quality was comparable to physicians, and there was a similar outcome for those presenting with ambulatory conditions and about 90% of cases compared to GP. So, we have got nurse practitioners in Australia, we have had them since 2010. They are allowed to claim on the MBS schedule, and they are allowed to prescribe as well, and I have worked with nurse practitioners at Royal Adelaide, absolutely fantastic, I have worked with them in the community in general practice, and I have been really happy with the quality and the standard of care they provide. I think you have too Jamie.

17:48

Jamie: Yeah, yeah, absolutely, and I agree, and I am always very used to working with the NPs at the centre, and emergency nurse practitioners in the UK. I came over here, less in the urban environment, maybe occasionally at tertiary referral centres, certainly when I work rurally, nurse practitioners, RIPERN nurses, fantastic, a real element of my team, actually approach the problem differently. They all fill in those weak gaps which you know, I have always learned that actually it is good to surround yourself with people who are good at what you are not good at.

18:13

John: Yeah.

18:14

Jamie: And they have excellent interaction with the patients, and as you commented on that, in certain areas, patient satisfaction is higher. What does that mean? It means our clients are patients who go home happier because they have had better interaction in a situation which was unplanned and potentially stressful, so I’m a big fan.

18:32

John: So, a systematic review and our literature review showed that care was at least equal to that of physicians. There was a positive impact on the quality of care, patient satisfaction, and waiting times. And if you put a nurse practitioner in their room with the same consumables in the same room as a GP, for the ambulatory-type patients, similar outcomes there, not a whole lot of research her on cost effectiveness, but that is what we are all about is just finding the gaps and researching.

19:00

John: The third is designated urgent care centres and we are going to talk a little bit about that later, but urgent care is walk-in medicine, extended hours in the community. Really, it is an overflow from general practice and emergency department treating the lower acuity conditions. The sort of things that we see in urgent care, some general practice things, some medical conditions that need to be seen now, obviously accidents, we see occupational medicine, and that might include school if your occupation is going to school, sports injuries, occupational injuries, rehydration. You see here the example of White Cross St Lukes in Auckland, where I used to work. You can see the sign there, open 8am to 8pm seven days a week. On site, there is radiology, there is a pharmacy, there is dentist, there is physio, a lot of things under the same roof. So, we will talk a bit more about those later on.

19:55

John: And then there are the integrated primary care centres. So, integrated primary care centres are integrated vertically and also horizontally. They are integrated vertically with the hospital. So, urgent care centres and integrated primary care centres are related to the ED. There might be specialist clinics and integrated primary care centres from the hospital or private specialists, but they are also integrated horizontally, so you might have the x-ray, the pathology, the pharmacy, the physio, working with the general practitioner to deliver the best care. In the last decade, the Super Clinics program was launched by the government where $650 million was invested in 425 large general practices and also 60 super clinics, but unfortunately, 14 of those 60 super clinics are now non-functional, you can see that on the government website. There have been some concerns about funding models as well for those because the heads of the funding models were a little bit different, and I am hoping that it might not be so… or might not be functioning now.

21:00

John: Also in the literature, identifiable demographics and clinical characteristics of patients presenting to the emergency department with non-life-threatening urgent conditions, and what we find is that if you are single, divorced, separated, widowed, if you are a single parent, if you are of a low socio-economic status, you have not got a GP, if you are aged under 4 or aged 20-30, that you will be more likely to go to the GP for a non-life-threatening urgent condition. And interestingly, the times that you are more likely to present is between 8 and 4, also Saturdays, Sundays, and public holidays.

21:40

Jamie: So, yeah, so you are telling us that basically, it is people who are less likely to have a supportive relationship with their GP, that we know is therapeutically beneficial, it is those people who maybe are unable to access the care and bizarrely, at the times that those GPs could be open. So, they are accessing care where there are alternatives. That is interesting.

22:01

John: Also, the literature tells us the reasons for patients choosing general practice versus emergency department. One of the reasons patients like going to ED is because they can get an x-ray, they can get laboratory, they can get one or two doses of medications, and that makes all the difference. Also, they can see a specialist when they are there. Peer availability is another reason and I looked at states from all over the Western world and we pretty much found the same thing in the US, problems accessing the GP, “My primary care clinic is not open at night, I can’t get off work to go, there’s nowhere else to go for care, there’s transportation issues, the clinic’s not taking walk-in patients.” In England, problems accessing the GP, 40% of patients going to ED and walk-in centres they could not get an appointment with their GP, which is quite amazing. In France, problems accessing the GP just before he is getting the appointment. Belgium, same thing. South Africa, one of the studies I looked at said, “We don’t have primary healthcare afterhours.”

23:11

Jamie: That is exactly , Acosta et al said this, they were very clear, they have got big meta analysis where they said look, why are people coming to urgent care and look to urgent care, and it is exactly the same things that you found. It is the inability or the perceived inability to access the GP. It is this strange obsession with the hospital-based opinion must have greater value than the GP, and there is a perceived anxiety because they view it is urgent, that you must go to a hospital rather than being managed in the community. And then, there was some good work done by Acosta et al looking at the influence of friends and family, and who is more likely to be influenced. So, it is just that our female patients look more likely to listen to the opinions of their friends and their family about getting urgent care versus general practice. They found men were less likely to attend urgent care or more likely to listen to the view of their medical practitioner when encouraged to go to urgent care. And then, there is the thing that you mentioned, there is individual patient practice, it is financial, can they afford to go to a general practice setting where they are paying a gap, can they even afford the petrol. It is something I see rurally. Some of my patients say, “I certainly cannot afford to go to hospital.” So, we have to use an ambulance at that point, which we all know is inappropriate use, but the bottom line is, we have got to overcome these problems and take initiative of this. We are going to try and get our patients to see the right doctor in the right place at the right time.

24:32

John: Patient’s perception of emergency is another really interesting thing. I looked at couple of studies from the US and one showed, this is of children, despite being triaged as non-urgent, despite 95% having a GP and having medical insurance, 63% described their child’s condition as very or extremely urgent. This is the ones that have been triaged as non-urgent.

24:55

Jamie: So, they have all been triaged as non-urgent, but they still are perceived as, so we are clearly getting something wrong in emergency medicine.

25:00

John: Yep, yep. And another study in the US of 56 EDs found that those that walked in, 45% thought they had emergencies, 39% said they had urgent conditions, and 6% thought that they were too sick to go elsewhere. Interesting! Being referred or advised to attend ED by a GP is another reason why people go to ED, and we think that GP gatekeeper function is really important, but of the people that are self-referred, 79% were considered non-urgent. So, if the GPs send you in, you are more likely to be classified as urgent.

25:34

Jamie: We are affirming the role of the GP as the gatekeeper.

25:37

John: Yeah.

25:35

Jamie: Which is essential.

25:39

John: A few interesting studies that showed other reasons, the formation of bonds, which is something that we are very keen on and GP has lacked is continuity of care, not wanting to disturb the GP on call. I wish I had patients like that in the country when I was working there, alleviating pain and discomfort and also alleviating the sort of anxiety that is caused by the condition. So, these are things that you can understand. Two of the factors that were found to be most important as to whether you should have attended the ED, or the GP, were explanation by the doctor and waiting time. So, it was very interesting. And I think, looking at the literature, just some of those things we can reproduce in general practice, so that patients would choose to come to us with those non-life-threatening urgent conditions instead.

26:22

Jamie: Yeah, I understand. I think we have just shifted, so far, we as a country have lost focus of the value of the GP, that it is very important that we reiterate that the GP is the first line of care. So, certainly, in the UK, there was a wonderful campaign run by the National Health Service, which you would say, I think it is along the lines of, it is not always the ED, and it is about saying to people, hey, just have a think, is this something… is this a true emergency or is this something where actually closing the health gap can be done slowly, and should be done slowly by you GP who you trust, who knows you and is going to manage the consequences of this.

27:01

John: So, we have got five models that could be developed, including nurses, paramedics, pharmacists, urgent care clinics, and the integrated primary care centres. We have got the characteristics of patients that present, we have got the reasons why they present, but getting GPs to do this sort of work in my new role with Healius over the last several months has been an interesting dilemma.

27:24

John: So, there are reasons in the literature that GPs do provide for non-life-threatening urgent conditions as walk-ins, afterhours, and the weekends, and this has been a problem I found in New Zealand and Australia, so I presume it is the Western world as well.

27:37

Jamie: Yeah, it is. I mean, we as GPs are not incentivised to provide unscheduled care. There is no incentive. I have tried to do it with Medicare…you know, I tried to do it with Medicare to see whether I was right.

27:50

John: Yep.

27:50

Jamie: And I was completely wrong. I firmly believed it could be done with Medicare in the current Medicare structure. I do not think it can be. I have done the best and that is where I am keen to learn mainly from the audience if they have had any good experience or from other people about how we could actually do this, as I am so passionate about urgent care, and I am so passionate about it being free at point of delivery, but I just do not know how to make the money work to make it sustainable.

28:11

John: Okay, we will talk about that a little bit later on. So, GPs are happier in vertically integrated models, if they are working in a model that is separated from the ED, they like it when they are part of a gatekeeper function, so that they can manage their patients, they like it when they keep their acute skills. Some people like it just to keep their hand in general practice, so they can keep their AHPRA registration. Some of them, it is financial or some of us, it is financial incentives as well, especially when they are lined up with what we have learned about. So, these are some of the reasons why GPs will provide for non-life-threatening urgent conditions, but you know, not a whole lot of stuff and literature on this.

28:50

John: So, just to summarise, there are five non-typical GP non-ED models to manage patients with non-life-threatening urgent conditions is demographics and presentation reasons for patients to present to the ED and all patients who present to the ED, and GPs tell us what it will take for them to see non-life-threatening urgent conditions and work afterhours.

29:19

Jamie: So, pretty much what we know is that the binary approach of emergency department and GPas your only options, does not seem to work. Patients are not happy, EDs are overcrowded. So, literature, there are five options that we can go for, some of which have been tried, some of which I have experienced, maybe have not worked, some of which have not been tried, I do not know why, and then we understand, well now, why are people going to ED. We know why they chose ED over GP, and we have acknowledged that you have enough GPs to work, and that we know what would make them work. So, you have done basically what every academic does which is typically all the evidence, and then not give me a solution pretty much.

29:50

John: Well, that’s why I have got you along here tonight Jamie.

29:57

Jamie: (laughter) I am not going to give you a solution. I guess what I can do is maybe give you a perspective, maybe not a solution though.

30:03

John: So, what now?

30:05

Jamie: Here we go, yeah, right, this is my thing. Yes, it actually is my thing, and this is, for the audience, this is how John and I met in a vineyard quite appropriately, where we both really or as we were passionately agreeing about the same problem just looking at it from a different perspective.

30:22

John: over a red wine.

30:21

Jamie: Well, exactly. I am deeply passionate about urgent care and making sure people can get care when they need it, in the way they need it, with the people that may need it, and it is very easy to sit there and blame other people and push the problem down there, and it is summed up brilliantly by, you know, one of my American colleagues _____ talks about his concept of extreme ownership. He talks about, we have got a problem, it does not matter whether you are in the military which is where we both learned the concepts or whether you are in healthcare or whether you are in business, just own the problem, do not say, oh, it’s that person’s problem, it’s the government’s problem to sort out, it’s the State Government’s problem to sort out, it’s the ED’s problem to sort out, it’s the GPs problem… let us just own it and say, okay, this is my problem, these are my patients, I need to own this.

31:04

John: So, there are problems in the general practice where ____

31:07

Jamie: Yep. And ED should be, we own it as well. Actually, if we all start owning the problem and owning our own little bit of the problem and start saying, right, what can I do to fix this problem, absolutely what can I do to fix this problem, and after our conversation, I started looking, yes, I felt right, I am going to get out and try and prove that I can make this work in Medicare, and I failed, but I learned so much by failing and I learned so much by saying actually, I am going to grip this problem and fix it for my community and my people that I look after. And that is why I am very keen and what I am very passionate about, is us saying we can wait for the government to try and fix this problem or we can actually start it fixing ourselves as a group of GPs, GPs with interest in emergency medicine, GPs with interest in occupational health, public health because there has to be a solution. If we wait for the government to fix it, it will not get fixed.

31:55

John: And we want people functioning at the top of their skill set.

31:57

Jamie: Yeah, 100%.

31:57

John: We want the nurses, we want the paramedics, we want the pharmacists, we want the GP, and we want to leave for the specialists the stuff that only they can do.

32:05

Jamie: Yeah, absolutely. You know, that is what we usually do. I have said this so many times to you all, I know you are bored of me saying it, but complexity is the new acuity. Our patients are living longer, we are able to treat more. So, yeah, the acuity is still there, but where GPs who are working in primary healthcare to prevent illnesses with public health. So, actually is the acuity still there? It is, but it is different, but actually what you see in emergency medicine are the majority of what we are dealing with this complexity. And what the GPs do well, we do complexity, we do not do acuity, we manage acuity until we can handle it onto our emergency colleagues, but what we do really well is complexity, and that is where I think urgent care can really really help the system and help our patients and help our communities. As you said, the budgets are blurring out and patients are suffering. We do complexity and complexity is the new acuity in urgent care and emergency medicine.

32:53

John: Fantastic.

32:56

Jamie: I will get off my soapbox now.

32:56

John: This is great and thank you.

32:56

John: So, three ways that we could go forward, the first is research, the second is consider providing an urgent care service. I would love as many GPs in Australia that could possibly do this, especially the ones with large integrated primary care centres open extended hours as required, and also to look for public and private partners, who have some feedback on urgent care. These are ones where it is a partnership, so Medicare does not fund a lot of the stuff, but we seek partnerships, so that we can provide this sort of care because we believe that a lot of the stuff could be done in general practice, it could be done a whole lot more cost effectively if we did that. So, time to roll up our sleeves I think, and here is a few of the ways that we have done it.

33:44

John: The first is research, and I think it is great to get help from a university. I am looking at the role I have got since I have been in Australia for six years and leadership and developing things, and I do not have to read, I do not have to speak, I do not have to write articles, but if I enrol in a university, I get to do it with the help of a professor. So, I have therefore enrolled with a PhD, Prof Mary Wallace from the University of the Sunshine Coast, The School of Nursing, Midwifery and Paramedicine. She is my main supervisor and she helps me immensely. Dr Wayne Graham, same University of the Sunshine Coast from the business school. These guys have been invaluable and what they have told me about publications and presentations and all those sorts of things. It would have been so hard for me to do it by myself.

34:29

Jamie: It’s that conversation we had when you said to me, well, why don’t you just do it, and I said, well… and I don’t know, I gave you loads of excuses. You said, all I am hearing is excuses, you just need to speak about it.

34:39

Jamie: I have got to do what I say about. I have got to actually own this and say that I will need to start doing some research

34:44

Jamie: And the Australian Government, so, they pretty much pay for PSD, I cannot believe it.

34:48

John: What country I the world do you get that?

Jamie: I’m convince

34:51

John: So, I have taken a case study methodology from Krejcie & Morgan in 1970. They listed seven ways that you have to do this. First of all is getting started. So, looking at the literature I have just presented, the research problems and questions popped out.

35:06

John: So, the research problem that I am finding is that it is really unclear in the literature, whether urgent care in large general practices can provide an alternative or equal or better outcomes to ED for those lower acuity patients who walk in with non-life-threatening urgent conditions, and we want to see if it actually solves the problem of overcrowding. So, I think it does, having worked in ED, and I think you think it does as well, but it is unclear in the literature. So, we want to put it out there and add to the literature to see if that actually is the case or not.

35:40

John: A couple of research questions that have come up. What are the characteristics of what might come to an urgent care service and a general practice compared to what comes into an emergency department, and also, how do you get the patients with non-life-threatening urgent conditions to choose urgent care clinics or GP clinics instead of the emergency department?

36:01

John: So, then you select the cases. We have selected two integrated primary care centres and an ED on the Sunshine Coast on a Sunday.

36:11

John: We have collected the data, I have actually done this, where I have spent a number of hundreds of hours going through and looking at all the notes and classifying them, and then comparing them. So, hopefully, I will be publishing that in the next 6 to 12 months.

36:27

John: Then, there is the analysis, the statistics, all those fancy things that you could help with, make sure you get the numbers right. The validity and reliability to make sure that what you are actually doing as a physician out there is good, common sense, lines up with what the literature is showing. The enfolding literature is great because I have done this a number of times over the last five years and new stuff keeps coming out all the time that changes the way you think, and hopefully there will be a bit of closure in the next year. So, it would have been a six-year journey, but I am very grateful to have done that, and it is stuff that I would have done anyway, but I had to get the help of an emergency medicine professor and a business school lecturer.

37:07

Jamie: I guess that is the case, if you have this passion about it, you can infect the other people with that passion and get them to start thinking about this and doing this. That is the key thing.

37:15

John: Yeah. And this is one of the slides that I have produced, looking at what came in as an urgent care service on a Sunday, where it was just walk-ins and we looked at the top 30 non-book presentations and compared it to the Beach data, which is a 107 million consultations over 17 years by the University of New South Wales, and what we found was in the urgent care service, 54% was infection, 8% was injury. In general practice, 9% was infection and 2% was injury. So, a lot of the stuff on the left, those 30 things comes under general practice, but just in different amounts. Looking at the top there, 37 conditions was 75^th percentile, but in general practice, 102 conditions was in the 75^th percentile. So, I look at that list and one of the reasons why the list is really helpful is we are rolling out or trying to roll out urgent or immediate care centres in Healius and as many of the 96 clinics as can be, and a lot of people are worried that category 1 and 2 ambulances are going to come in with patients, but this is not the case. What we are trying to do here is take what comes into general practice normally and make it more efficient, but also have patients choose to come to general practice because we provide for that service. So, that is something that we have found so far, this is unpublished and non-peer reviewed data, hopefully this will be published in the next 6 to 12 months as well.

39:32

John: Join a collaborative as well. So, we have done a few studies on the floor there, but we have also joined a collaborative headed by Prof Gerard Fitzgerald, he is a professor, he is also an emergency physician, he is a professor of Emeritus now, it is a project with the Queensland University of Technology and also University of the Sunshine Coast with the help of Morayfield Doctors and Dr Evan Jones. So, if you are interested in being part of a large collaborative, we go for an NHMRC grant, we are looking for funding at the moment, and clinics to study would love you to contact us on that one.

39:08

John: Consider providing an urgent care service.

39:13

John: We talked a little bit about this before. Urgent care is episodic and extended hours provision for the lower acuity conditions is an overflow of general practice and also emergency department. Clinics exist in the US, who have started, Canada, the UK, Europe, Hungary, Bahrain, New Zealand. In the US, there are four levels of accreditations, so it starts off as a freestanding emergency department, you would have emergency physicians, physicians, you would have GPs, nurse practitioners. They would do lacerations, they would manage those, they would manage dislocations, fractures, rehydration, the sports injuries, the occupational type medicine. They can also do troponins. They need x-ray, ultrasound, CT available for the 12 hours a day, 365 days a year that they are available. The CTs need to be able to be reported in a timely manner, so not the next day, and also, they will be able to intubate and ventilate and they will have direct relationships with the hospital, so that they can admit transferred patients. Category 2 is 10 hours a day, similar setup. Level 3 is with GPs and nurse practitioners, open according to what the community needs, and level 4 is nurse practitioners and physician extenders. What is interesting is the studies that are coming out of the US suggest that it is a third to a fifth of the cost of a hospital ED if you see the urgent care centre rather than ED, which is quite a saving.

40:43

John: And there are two governing bodies, which is the Urgent Care Association of America and the American Academy of Urgent Care Medicine.

40:51

John: In New Zealand where I am from, we have urgent care, it is the only country we have vocational registration and a specialty standing alone in the world. Clinics are open 8 till 8, you have to be open 12 hours a day, seven days a week, 365 days a year. You need x-ray on site, and what is interesting is studies on clinics that have x-ray on-site, say that the patients that need the x-rays, there is a 62% less chance of needing to be admitted because you have got the x-ray on-site. You need a medical director that is either an urgent care fellow or trained for that fellowship, and you need the Royal New Zealand College of Urgent Care standard. So, when you walk into an urgent care clinic, you know what you are getting.

41:33

Jamie: You get a consistency.

41:33

John: You are getting consistency. We have a number of models there.

41:45

John: You can see the model at the top there, it is Ascot in Auckland, that is an urgent care centre with a private hospital on top. On the left there, White Cross St Lukes, that is a freestanding emergency department. A couple of models from Australia where we have combined urgent care services with the integrated primary care centres, and on the right a clinic at Morayfield, where not only is there a general practice and a 38-bed urgent care centre with ambulance diversion, FACEMs, and nurse practitioners, but there are also specialists and research going on as well. So, there a little, you know, a few of the different models that are in existence.

42:08

There is also the Elizabeth Medical & Dental Centre. This is a Healius clinic in Adelaide that has just been retrofit on the right with urgent care rooms. We have recently taken on a trial from the South Australian Government where ambulances, low acuity ambulances are diverted to us and patients are referred to us from ED. So, that is a clinic where there are vertical and horizontal approaches going on.

42:40

John: So, the governing body is the Royal New Zealand College of Urgent Care, it is a 4-year specialty.

42:44

John: And interestingly, we have one of the lowest rates for admission to ED in the Western world.

42:51

John: So, you look on the left there, we have US and Canada, this is the ED admission rate/1000 per annum. In the US and Canada, it is in the 400s. In Australia and UK, it is in the 300s, and in Auckland, it is 184. So, this slide was produced by Garry Clearwater, he is a FACEM I used to work for in 2014. A couple of urgent care centres in Australia that I have been associated with, this is a walk-in and afterhours clinic on the Sunshine Coast, initially open 9 to 4:30, we saw about 70 patients sometimes, and there we have a doctor on-call with x-ray. I really enjoyed working in that clinic.

43:33

John: Here is a minor injury and illness clinic open seven days a week 12 hours a day, it is a public one, Caloundra Emergency Department.

43:37

John: And also Health Hub Morayfield Doctors Minor Accident and Illness Clinic in Morayfield. You will notice that all of these, even though they are urgent care services, they label things. We do not want to attract the chest pains and have someone who do not need a stent and be delayed two hours because they came to the wrong place. So, yes, if a chest pain comes in, we will manage them appropriately, but we do not want that patient coming to us, we want the patient to go to the ED.

44:04

Jamie: Yeah, we are looking at the low acuity cases.

44:06

John: Yep.

44:07

Jamie: and that is what we are trained to do.

44:07

John: Yep. Slide on costs, this slide was done in 2016, but you will see on the right there what you get paid in Australia for an under 20-minute consultation $36.30 compared to a New Zealand urgent care centre, for an accident it might be $70. For rehydration in New Zealand, we might get paid up to $170. For rehydrating, in Australia, if we spent more than 20 minutes with the patient, we would be able to get $70, and for a non-displaced distal radius fracture, in New Zealand, if you put a cast on and managed it, you get $172 if it was an accident. In Australia, if you are not managing the whole fracture, you can only claim $36.60, this was back in 2016. So, a bit of a cost, you know, disparity between New Zealand where they provide for urgent care, they fund it, and Australia where we are not doing that.

45:00

Jamie: I guess that is… I do not know, I assume, and assume you can get double pay, assuming that, that is because New Zealand Government understands the value proposition of urgent care.

45:10

John: Absolutely, absolutely.

45:09

Jamie: Or maybe that is some of the work we need to do with our colleges, is to help the Australian Government understand the value proposition of urgent care.

45:19

John: And I think it is reflected in the fact that New Zealand have one of the lowest rates or the lowest rate of admissions to hospital in the Western world, but in Auckland where the data is from, we have one of the highest concentrations of urgent care centres.

45:33

Jamie: Yep.

45:35

John: So, we will hand it over to you, will you talk a little about what is happening in Europe?

45:40

Jamie: Yeah, I am actually no expert on this, but what I can do is I can give my lived experience when I was… as you know I lived through the new labour four-hour rule. I was an ED registrar and when that happened, I was a registrar working in ED and initially, you know we were overcrowded beyond belief, and then we saw the four-hour rule come in, and we thought that would make a difference, I think we were misguided. It actually became a flexible tool. So, it was great that somebody was taking it seriously, but it did not solve the problem, and that was why we started to introduce things like urgent care centres now, a different model to what you described in New Zealand, it was nurse-led. The evidence was less convincing than they have in New Zealand, that it was equivocal about whether it improved ED attendances i.e. reduce them. Patient satisfaction was high. We saw the same with NHS Direct and NHS 111, the telephone lines. They made no difference or possibly increased referrals to the emergency departments, but patients were happy and satisfied with the service they had received. And there is a move in the UK towards physician-led urgent care, but there does not seem to be much data apart from a small amount of data, which has been coming from the Prime Minister’s Fund in London. In terms of Israel, Israel was fascinating, working with my colleagues from Israel, and they had a very different approach. They looked at it from mid-80s, they realised they had a problem and rather than creating a solution and then trying to get the government on board, it was a bottom up solution. They had a group of GPs and ED physicians work together to create urgent care centres, but it was created with the healthcare providers with their insurers. So, the insurers were now getting worried because the insurers said to them, it is costing us too much. They had a situation like we did: ED or GP. And so the insurers said give us the cheapest solution for our patients to achieve high-quality unscheduled care for low acuity, and they came up with the urgent care centre, and just like the data you had shown for Auckland, I know in Jerusalem, where you get paid for from Zimmerman, talks about how they now have the lowest ED admission rates anywhere in Israel, but the highest concentration of urgent care centres. So, they are now trying to model this and scale that excellence that they have experienced in Jerusalem across the rest of Israel and I would be interested to see what it will show.

47:58

John: Nice. So, we thought we have presented a little bit of evidence of the primary care initiatives, here is a study on just starting up with continuity of care from 200 general practices that were linked, in London, showed a 9% fewer and lower acuity admissions. The Prime Minister’s Fund that you talked about in England. The first wave were just having weekend appointments, so all it was with GPs being open seven days a week and providing for the patients, and I am staggered with this 9% reduction in paediatric admissions, 10% reduction in A&E attendances overall, in the weekend 18%, I mean that is where we get the overcrowding and all the issues that go with that, the morbidity and the mortality, and 26% relative reduction in Manchester for minor problems because patients had another alternative. Urgent care in Chile, 10 urgent care centres were opened up in a town, there was a 3% reduction in ED visits and a 6% decrease in all same day visits to the general practice. There were some afterhours general practice studies, one in New South Wales showed an 8% reduction when you opened up a general practice that worked afterhours in category 4 and 5 patients. In the Netherlands, they did the same thing and they found a 9% total reduction in ED cases, which was really interesting.

49:11

Jamie: That showed no matter where you tried, there is a benefit, there is a signal that you are going to get about it.

49:17

John: Yeah. But what I have noticed is that there is not a whole lot of evidence out there, which is why I am doing some research myself, and while we are doing this urgent care collaborative to see if we can get funding in order to do this on a large scale in Australia.

49:30

John: So, we are going to jump through this because we are 47 minutes already, but when you have got an urgent care service up and running, and it is seven days a week, and it is 12 hours a day and the urgent care service is standardised, so people know what they can expect, and I think with their fractures and their lacerations, their rehydration and blood tests, and all that sort of thing, you can actually piggyback other initiatives, and these initiatives depend on public-private partnerships. I cannot go into too much detail about them today, but some of them that we have done, fracture clinics, where studies have shown that up to 40% of what is referred to a hospital fracture clinic could be seen in the general practice by GPs if they used protocols for that, and we are not trying to take the job of an orthopaedic surgeon, but these are fractures that do not need to see an orthopaedic surgeon because they are non-displaced.

50:24

Jamie: Low acuity, low risk.

50:27

John: Another one is hospital in the home. There are a lot of conditions like cellulitis, bronchiectasis, osteomyelitis, septic arthritis, with patients, who are non-septic because they have had some time in hospital, but we can look after them as GPs with nurses going to their house and this is a project that we did over three years on the Sunshine Coast and it was successful. Another one is the GP ambulance diversion, and this is going on in Auckland, it is going on in the West Midlands of England, in Sunshine Coast, in Morayfield, and in South Australia, we are doing a project at the moment trying to develop the IP around that, which is an absolutely fantastic thought for them. Another one that we have looked at the evidence for, but we have not worked in general practice here is the whole thing about homeless medicine. When I was in the ED, a lot of homeless people would come in, and there is not a whole lot I could do for them in the ED, but in a large general practice where there is availability and I have my psychologists there and I can refer them for cognitive disease management, and I can keep their continuity going. I think you know….

51:33

Jamie: Yeah, you can build up trust and rapport with them.

51:34

John: Absolutely.

51:37

Jamie: And use urgent care as a gateway for that.

51:36

John: Absolutely.

51:36

Jamie: And then building that relationship _____.

51:39

John: And the evidence is slowly starting to come on there.

51:44

John: So, I am just going to jump forward now to new technologies because I know this is something you are very passionate about.

51:56

Jamie: I am a geek about it, I mean it all is about it that there is a lot more now. As technology advances in terms of diagnostics, John, we can do a lot more. Now, you know, look at point-of-care ultrasound, it is a key part of my clinical practice now. I would say I ultrasound three quarters of my patients in the emergency setting. I do not think it would be that much different in the urgent care setting. What does it do? Well, it helps to make quick clinical decisions. It is not diagnostic ultrasound, it is a diagnostic aid. Ditto, the same with my using i-STAT you can see that on the left, or indeed machines like Piccolo or Butterfly. These are things that enable me to make informed decisions quickly at the point of care without referring to a hospital. You know it is simple things like managing the patient with suspected appendicitis. Although the CT and other point of care tests can give me a CRP, I wonder if that is okay, and the lactate, I can manage them safely in the community. And when I am working rurally, that is a big high-stakes decision. I do not think we really consider it in the same way when I am working suburban, and that certainly is something I have learnt thinking about the urgent care projects that I need to do.

53:02

John: You’re a doctor in the country and then also in the city.

53:04

Jamie: Exactly, but I am allowed to do more working rurally bizarrely, and I am allowed to take more risks rurally than I am in the urban environment, it is a strange proposition.

53:14

John: So, we thought we would present in the last 10 minutes some of the resources that we are using and that we have developed, it is Healius Health, a brand called SWIFTQ Immediate Care. So, we like to advertise what SWIFTQ sees, and that is minor illnesses and injuries, urgent prescriptions for up to a month, but not opioids, benzodiazepines, or amphetamines. Some vaccinations. We refer to hospital cardiac chest pain obviously, serious breathing problems, loss of consciousness, trauma, and those sorts of things. We would prefer those types of patients go to hospital, but they present to use, we manage them and refer them appropriately, and we also know that we have been working on SWIFTQ, if we are not doing general practice, in the traditional sense. So, if someone needs a mental health care plan or a care plan or continuity of care, we refer them back to the GP.

54:06

John: We have also developed a modified triage system. So, we cannot afford to have a triage nurse at the front door triaging everyone that comes in, but we want to know if you have got chest pain or problems breathing or drowsiness, especially if we are running late. We do not want you collapsing in our waiting room. So, if you have got any other symptoms or the receptionist is worried, you get sent to a treatment room, and the nurse triages you and gives you a triage score, and we see you within appropriate times.

54:31

John: We have immediate care nursing activity tool based on what are the ones we used in New Zealand from an emergency department nurse, which advises the nurse that is on duty what sorts of things we would like. So, if someone come in with abdominal pain and are of childbearing age, we would like vital signs and we would also like a urine dipstick and pregnancy test, just guidelines for them.

54:58

John: We have an item guide because Medicare does pay for some item numbers and it is good to know about those things. So, we have developed that and put the item numbers, so a doctor can have those.

55:11

John: We use the primary care clinical manual. Queensland has developed that. It is about a 900-page document. I have been here six years now, I think I have had three versions that we have printed out and used on the floor because sometimes the computer is down, and it is great to have an Australian resource that we can use, so we use that in our clinics.

55:30

John: We also use HealthPathways. Here is an example of the HealthPathways site from South Australia Health and these are pathways specific to whatever region that you are in, so getting the username and password is obviously a good thing.

55:40

John: We use the Royal New Zealand College of Urgent Care standard. This is a standard for urgent care. The Royal New Zealand College of Urgent Care went to England to get the Royal forum and the stamp to give us some legitimacy, so we use this standard.

55:55

John: We are using it in all the urgent care centres or immediate care centres that we are rolling out. In fact, most of the clinics that I have shown you use the standard.

56:02

John: There is a webpage that I wanted to talk about for registering interests in the Royal New Zealand College of Urgent Care in Australia because I would be really keen to know who is interested in there and keep a track on that, so we can keep you updated on the developments. So, there is a link there if you would like. We do CME, we do audits, we have a pay grid once a month, welcome to join that pay grid.

56:26

John: And we also have an accelerated pathway, so we have had people that are fellows with ACEM and also the ED ACRRM pathway and they are becoming urgent care physicians through the Royal New Zealand College of Urgent Care at the moment.

56:39

John: Jamie, you have had a bit of experience obviously with ACCRM, RACGP and some of the colleges from the rest of the world.

56:49

Jamie: Oh yes, _____ appraisal and revalidation as a recent IMG. It was very interesting when I came through AHPRA were very interested in my appraisals and my revalidations. I am a big fan, I was the first generation of British doctors to go through appraisal and revalidation. I was pretty spooked by it when it first came, and I learned very quickly what a useful tool it was. The bottom line was working as a GP and a free hospital emergency doctor, I had to have two separate appraisals in the UK. I had to have an appraisal as a GP, and I had to have an appraisal as a free hospital doctor. I would not be surprised in Australia, if something similar happens certainly as a GP ED, I would expect to have an appraisal as a GP, and I would expect to have an appraisal as a GP working in ED. I imagine urgent care would be the same and I think it is really important that maybe we start to professionalise this in Australia a little bit because if something goes wrong, at least you have got a peer group that you can reach out to, you can be judged by a jury of your peers, not by the college of emergency medicine, which is a different job, we know that.

57:53

John: And that is why you know we are using the standard in our clinics and we are having accountability in peer group and audits and those sorts of things.

58:02

John: Some of the websites and some of the Phone Apps, when we were talking about those, and I was very impressed, I think I might get a list of those things and download them onto my phone.

58:11

Jamie: No, it is part of a shared decision-making of patients and that is what you can do when we talk about complexity rather than acuity. We can talk about, but actually I will often use apps on my phone to stratify risk with the patients using the heart score for example, if I have got a patient with ACS in the community that has been nowhere near a hospital. We have got point-of-care troponins, we have done an x-ray, we have done serial ECGs, we are happy that there is no evidence of acute myocardial injury. I then, with the patient, develop a heart score that helps him understand if they are low, medium, or high risk. We show to them a visual representation of a surgeon’s scope, going on to have a major cardiac event in the next 30 days and then may go as an informed client back to see their GP to arrange an exercise stress testing. I do the same with PE, I do the same with mental health problems. It is fantastic.

58:56

John: Fantastic.

58:57

John: So, we have been lobbying State and Federal Government over the recent years. Obviously, it would be nice if we get other funding models because I have certainly found that Medicare…. you know, we struggle to manage the business work if we are using Medicare funding. So, we are going for the public-private partnerships.

59:16

John: We are also aware that urgent care is not 9 to 5. So, a lot of these requests that we have are for clinics open seven days a week, 12 hours a day, and 365 days a year with at least eight full-time equivalent doctors. Kind of similar to what we have got in New Zealand. If you want the extra funding, you are already squeezed up, and you are open a bit longer than your provider accredits a service. So, you know, what we have been asking for is extra item numbers for rehydration, for management of cellulitis, this is non-septic cellulitis, where patient is tried on oral antibiotics, COPD asthma, short-stay observation and also diversions from the ED, the ambulance or referral from other GPs because often these patients take longer and they are more complex.

60:00

John: We have asked for FACEM specialists to get vocationally registered rates for patients presenting to clinics because at the moment, if they are not referred by GP or a nurse practitioner, they give general registration rates, which seems a bit bizarre because they are very specialised. And for the doctors or nurse practitioners consulting by telehealth, that urgent care specialist will be able to claim the item numbers that they can for GPs in the country that are calling them.

60:25

Jamie: So that we can have FACEM, FRACGP and FACRRM, all working together on the floor approaching the problem in the same way.

60:31

John: Absolutely.

60:32

Speaker 3: Or we are just going to make money work.

60:34

John: We have asked if urgent care fellows from New Zealand could claim the non-CDM item numbers because they are going to come across and work the evenings and the afterhours and the weekends and those sorts of things and do urgent care. They are not really interested in chronic disease management, so they are not a threat to general practitioners, and we have also asked if the urgent care standard from New Zealand, which is already a JAS-ANZ standard, that is registered with JAS-ANZ, could become an Australasian standard, and I understand it would be about $30,000 to make that so, so at least we would have a standard there that we could all refer to. Absolutely.

61:01

John: So, we are kind of back to the polling questions from the start of the talk there after listening to what we have had to say about the problem of patients with non-life-threatening urgent conditions presenting to the ED and all the things that come with that. Looking at the evidence base for the different models and the reasons why patients say that they present to ED with non-life-threatening urgent conditions, the demographic of the patients, and also looking at why or how you could get GPs to work afterhours in the weekends and seeing walk-in patients.

61:44

John: We talked about rolling your sleeves up with research, trying urgent care models, and also looking for public-private partnerships in order to keep patients out of ED.

61:50

John: So, after talking all that, we are interested to ask the question again, do you feel the current model of general practice would be threatened by urgent care in Australia?

62:07

John: No. Fantastic.

62:11

Jamie: And that is absolutely important because we do not have the answers and the only way that we can fix this problem that we all know exists as GP, urgent care fellows, GP with ED FACRRM, it does not matter, we all know that there is a problem. The only way we are going to fix this is that we all roll our sleeves up, we all take ownership of this problem, and we will try and fix it, and that is really reassuring for me that our FRACGP colleagues would not feel threatened at all.

62:35

John: Not.

62:37

Jamie: Small example, but at least they are not going to feel threatened by at least advancements because we have got to work together to come up with a solution.

62:44

John: And the other question is, would you be interested in an urgent care career that complimented your core career as a GP. Interested to hear your thoughts on that. So, we are still working at general practice, but we are just providing those sorts of services for our patients, so that we could manage them in general practice rather than going to ED.

63:10

John: It is a 60% yes, thank you guys, I am really impressed with that.

63:17

John: And the last question is, are you willing to help us promote urgent care in Australia? The Royal New Zealand College of Urgent Care have a part on their website, where we are recording interests and we are getting people’s emails so that we can send your updates because they are certainly helping me as their Australian Convener to get urgent care established in Australia, serving both general practice colleges and also the Australasian College of Emergency Medicine.

63:49

John: And there is the website we would love you to record your interest on that.

63:57

John: So, just a little shout out to SWIFTQ, which is an urgent care brand that we are establishing around Australia. We are hoping to start five clinics this financial year.

64:05

John: Here are eight of the clinics that we are planning to roll out in the next sort of 18 months, in New South Wales, in Gold Coast, and also in Melbourne.

64:17

John: And we would like to open the floor up to questions for urgent care. Oh, it is fantastic, we have already got a few of these, Jamie.

64:32

Jamie: So, I have got Ken Mackay, thank you, you have got fantastic calculated questions. Okay, so the first one for you, John. About mental health conditions such as acute psychosis, alcohol intoxication, behavioural disturbances. How may it be treated in an urgent care centre in your experience?

64:46

John: So, in my experience having worked in the ED where I have got security and I have got a mental health nurse, if someone is psychotic, then he could be in hospital, so if I was to see a patient in the urgent care, I would do what I am needed to do to make sure they were safe and be able to be transferred to hospital. The lower acuity mental health conditions, I would absolutely see those in urgent care, and I do see those in urgent care, but acute psychosis is something that I would want to see not.

65:15

Jamie: So, really the decision point is not about whether it is an organic cause or a psychiatric cause, it is the acuity, is what you are going to make a decision.

65:24

John: It is the acuity. Even though I have worked in emergency departments like you have, I am a GP and I know my limitations. One of the interesting things that I found is some of the times that I have been working with FACEMS in urgent care centres, you know sometimes those FACEMS are absolutely amazing with their skill sets, but they still need to send the patient to the hospital because it is not an emergency department, you do not have the same supports as you would have in an emergency department.

65:52

Jamie: Fantastic. I am going to ask another question, Ken has asked the last question, so I will ask one of Ross’ questions. Do urgent care doctors pay higher premiums for indemnity?

66:00

John: So, at the moment in Australia, I pay the same indemnity as I do for general practice, so the answer at the moment is no, but in a lot of the initiatives that we have done, like the fracture clinic and the hospital in the home, I have actually rang my insurance to make sure that they are aware, that I am seeing a slightly different subset of general practice. So, at the moment, I do not, but perhaps in the future if urgent care becomes a subspecialty in Australia that is recognised, that might change.

66:28

Jamie: Okay, I have got a question here from one of your country-women, Lisa Edwards, she is also a fellow of your college as well, and she wants to know how far along are we are from having urgent care recognised as a specialty in Australia.

66:37

(Laughter)

66:40

Jamie: come on John, how long?

66:44

John: So, this is something that I have been working on in the last five or six years. The Royal New Zealand College of Urgent Care is very passionate about having other countries in the world recognise urgent care as a specialty. At the moment, we are working on two things, one is bringing in a standard to Australia, as you would have seen when I was talking about the different models that I have been associated with in Australia. Often, they have different names, it would be nice if people knew what urgent care was and they were named the same, they had the same opening hours, they had the same standard, so we are trying to bring that standard in, and the second thing is the funding models. So, we are working with the South Australian Government at the moment to develop public-private partnerships for ambulance and ED diversion for the lower acuity stuff. We have worked with the Sunshine Coast Hospital and Health Service with the fracture clinic, the hospital in the home, and they did an ambulance diversion project, which gave alternative resources of funding as well. But these are little pockets that are popping up around Australia. It will be nice if there was a standard, and if that standard was recognised by State and Federal governments. So, the answer is, we are working on it, and we are working on this collaborative, but I cannot give you a date as of yet.

68:01

Jamie: So, Lisa, he sized out the question there, so you are both in the same college, so you can talk with each other.

68:07

Jamie: Question here from Kate Cross, which is, how are doctors remunerated under the immediate care model?

68:12

John: Alright. So, Kate must be talking about the Healius immediate care model because Healius calls urgent care immediate care. So, what has happened with Healius at the moment is that we have gone out to the market, and we have found that it is around the $200 an hour mark, so at the moment, Healius are paying their doctors $200 an hour. They have the option of taking a percentage once the businesses build up, but at the moment, I think that is a good rate, I think it is comparable to what the same doctor might be getting in the hospital and the advantage is that you do not have to go to Broome or catch a plane or go into the country, you can get that in the city, so it is great.

68:53

Jamie: You are trying to recruit me, you are stopping my plane to Broome. [Laughter] Okay, so, I have got a question from Sam here. Is there any upcoming module or workshop for urgent care?

69:05

John: So, it is another thing that we are working on. I have been seven months at Healius, but we are working on a syllabus over three years. We will be every month doing a two-hour session on one aspect of urgent care. We are looking to film that, to edit it, and to put on our website, so that is something that we are working on, and I am hoping in the next six months we will have that started. We are hoping to have a three-year program and every three years have the specialists do some of the talks that are updated. So, that is certainly something that I am very keen on and I have got colleagues in Healius as part of the Healius Institute that want to see that happen too.

69:44

Jamie: Okay, Ken has got another question which is, are there any physician’s assistants around in Australia. If so, could they be a part of the solution _____ non-life-threatening care, I guess he is talking about physician extenders.

69:56

John: Yeah. So, you know more about physician extenders than me because you have worked with those.

69:58

Jamie: Yeah, I mean certainly PAs were very very popular for a period of time in the UK. They were very popular in Australia as well, as I understand that there is only one trial currently ongoing or has finished without physician’s assistants. At the moment, they are not common part of Australian clinical practice. Having worked in the States in urgent care and emergency care, I found physician’s assistants fantastic, and having worked with the US military extensively over the last 10 to 15 years, physician’s assistants form a key part of their unscheduled and emergency care plan. Why? Because it is cost effective is the bottom line and that is why it is driven that way. Could that model be extended to Australia? Yes. You know, I am huge advocate of physician extenders, whether they are nurses, whether they are PAs, whether they are aboriginal health workers, whether they are paramedics. So, do I think they can have a role? Yes. Are they commonplace in Australia? I do not believe so at the moment.

70:54

John: And it just brings me back to the topic of nurse practitioners because at Royal Adelaide, when I was working there, we have nurse practitioners since 2006, absolutely fantastic. In the last couple of years, I have worked with nurse practitioners but the Medicare funding for them at the moment is $17 a patient and it is not cost effective to pay nurse practitioners that for a patient, so it is a model that is in the literature, it is overseas. I would like to see it in general practice, but at the moment, it is pretty difficult.

71:27

Jamie: I am just scanning here to see there is… here we go… here is a question, so… does the Royal New Zealand College of Urgent Care allow Royal New Zealand College of GP fellows RPL for their training?

71:11

John: Sorry, the… ?

71:40

Jamie: So, the New Zealand College of GPs, can they get RPL towards urgent care training fellowship?

71:45

John: Yep. So, at the moment, there is an accelerated fellowship pathway for ACEM, in fact I was supervising a FACEM recently, and she will have their last visit in the next few weeks, and she will become a fellow of the Royal New Zealand College of Urgent Care. We also have a program where if you are ACRRM ED, it is an accelerated fellowship pathway. For other specialties, what we encourage you to do is go to the website of Royal New Zealand College of Urgent Care, register on that, put your CV in and your qualifications, and they will look at that and tell you what you need to do to get their fellowship. I think it would be a fantastic thing, especially if urgent care was established in Australia and there is funding associated with it and that the Fellowship from New Zealand is recognised. I think there would be a whole lot more people wanting to do that.

72:40

Jamie: Thanks a lot. I have got one here, which is quite a good question from Donna Ward. Are the existing urgent care centres in Australia accredited in some way or externally audited for standards of care as per hospital EDs?

72:50

John: I want that to happen, thanks Donna for that question. So, I would love to see a standard in Australia, a little bit like with McDonald’s, if I go to a McDonald’s in Perth or a McDonald’s in Darwin, or a McDonald’s in Tasmania, and I order a Big Mac and I know what a fries is I get the same thing wherever I go. It is a little bit like that with urgent care. When I go to an urgent care centre, it does not matter where it is in Australia, I want to know the opening hours, I want to know if I could get x-rayed, I can see my pharmacy, and I think it would be fantastic if the funding was tied to this accreditation. So, we need a standard, we need the funding, and I think both of those should be tied to each other. So, at the moment, there is no standard. We are using the standard in the clinics that I have been working in because if something did happen and I was called to give account, there is no standard for urgent care in Australia, but we are using the next best thing, which is the one from New Zealand, which is of Royal College, so that is one of the reasons why we are doing that, plus it is a good standard, I think it covers most of the things that come into the urgent care type cases.

73:52

Jamie: Excellent. I have got a question here, one of your country-women, I am assuming, Meg Mikala is asking, _____ New Zealander.

74:02

John: Meg is in _____ at the moment, so I will call out to Meg _____.

74:03

Jamie: So, Meg Mikala is asking, when is Healius coming to Tasmania.

74:09

John: I do not know. I will have to ask the head office there. Yeah, but we would love you to come and work for us, Meg.

74:13

(Laughter)

74:18

Jamie: I have got a few other questions here, some of them are private, so we will answer those privately, John and I. Is there anything else you wanted to cover, John?

74:30

John: Oh, really. I am certainly grateful to the Royal Australian College of GPs for giving me this opportunity and certainly for the love that has been shown around the country, especially in South Australia where you know the South Australian Government want to give urgent care a go in the general practices and GPs are rising with the challenge, and I think it is a breath of fresh air to go in where you wanted and I think that urgent care will make a difference if it is regulated, if there is a standard and if it is funded properly, and there are GPs out there that want to do it.

75:07

John: Yeah, 100%. I think that is the key thing, is we have to come up with a solution. If we stand around and wait and point a finger at other people and take a kind of inertia, the problem will get away from us.

75:20

Jamie: Because you know we have worked in ED, overcrowding is horrible, I go to ED in the summer and it is nice, I have got to find a nurse, there is a nurse there, all the consumables are there, the system works really well. In winter when there is 80 people waiting, it is hard, it is difficult, and if some of those patients that come in on those days would be able to be seen by the GP, it would make such a difference.

75:46

Jamie: This is not outside our scope, but it can rate a great point, which is a statement which is that rural ED patients just come in anyway. This is what I experience, you and I talk about this all the time, and that is where you challenged my dogma that this had to be managed by ED. And I was, say that I am GP doing ED at the moment, why, because there is no emergency specialist who wants to work rurally. Well, actually you changed my perspective of that, and you know Ken has raised a point there, when we work rurally, patients come in, I have the absolute pleasure of working in Broome. Broome is an entirely GP-led emergency department backed up by GP anaesthetists, GP obstetricians, GP led, it is fantastic, and it demonstrates that we can do it safely. We run our own fracture clinics, we run our own emergency care, and actually what it is is a mixture of a FRACGP and ACCRM fellows, who are all united by a common passion, and it certainly formed the back of what we have been discussing over the last few months. It has certainly made me change my perspective about how we could do urgent care in Australia, so that is really good. A quick question here from Meg was, where can we see the recording of the session, she missed the first half. Apparently in a week’s time, is that right?

76:55

Jenna: Yeah, so that will be available on the RACGP website, but you are free to email events@RACGP.org.au and we can get that sent to you.

77:05

Jamie: But if any of you have any private questions or any questions for John and I, if you go back through the slides, I think slide 2, both of our LinkedIn profiles are delivered there, both of our emails are on LinkedIn, and if you need to reach out to us with any questions you did not feel able to put out there or you were just thinking something else, you could just get in touch with us via our email or message us via LinkedIn.

77:24

John: Because I would love to see urgent care established in Australia and it does not matter where you work, you know, if we can help you get that going, we would like to do that.

77:32

Jamie: Fantastic.

77:34

Jamie: Thank you very much.

77:35

John: Thanks.