Hospital emergency department crisis an early warning system for health overall - Dr Brian Betty

Emergency departments are not the only part of the health system under stress.

OPINION

Headline after headline highlight our hospital emergency departments are at ‘breaking points’.

I’ve been curious and throwing the question of increased demand around with many colleagues.

While we need research to confirm it, our best estimate is a 5-6 per cent reduction in access to general practice and community care could easily push a 50 per cent increase in hospital emergency department (ED) presentations.

I have a huge sympathy for my ED colleagues who face increasing stress through staff shortages, increasing patient demands and long patient wait times. I have no doubt the arguments to increasing resource in ED are justified.

We do need more, but it’s an “and-and” situation. Because over the fence in primary care we’re also feeling all those things, and more.

In many ways, ED is like an early warning system for the health system, signalling when cracks (or maybe even great chasms) exist elsewhere in the care spectrum.

I believe the long-term answer mustn’t lie solely in increasing ED capacity, because that only addresses supply which could lock us in a never-ending battle.

We need to deal with a key driver of demand.

As well as increasing resources to our emergency departments, we must also put effort and focus on fixing the broader health system by stabilising general practice and sustainably increasing capacity.

I met an emergency physician recently who was telling that she is now seeing patients who have waited in ED six to eight hours to see her because they need help with their high blood pressure.

They are there as a last resort because it is taking three to four weeks to get in to see a GP.

As she pointed out, she was never trained to do that work.

Ongoing medical care is the role of specialist general practitioners and practice nurses and should be the cornerstone of our approach to the New Zealand health system. Timely access to quality medical care in the community should be the right of every New Zealander.

If you are one of the unlucky New Zealanders who is currently not able to access a general practice or has been put on a waiting list because books are closed, your only access to care becomes acute – when something arises that needs immediate attention.

This is problematic because this type of care is transactional and single problem focused. Emergency departments are brilliant with emergencies, they were never built to provide ongoing continuous healthcare to the community.

At the moment demand for general practice services is increasing by 5-6 per cent per year. We have a shortage of specialist general practitioners and practice nurses, while at the same time we are facing increasing patient complexity.

Every study across the world shows that access to continuous general practice over time leads to less illness and less frequent hospital visits. One recent study in Norway involving two million plus patients shows people live longer if they have good access to a family doctor.

The long-term answer to the New Zealand health system issues is not only bigger emergency departments.

People need to be able to enrol with their general practice, to be able to get an appointment with their practice in a timely way, and to be able to afford an appointment when they need one.

Sadly, this is an increasingly difficult scenario for many New Zealanders, particularly some of our most vulnerable and high needs.

We need to reorient our health system towards keeping people well, as well as caring for them when they develop illness. This requires a major shift of focus and funding towards primary care, which provides most of the health and wellbeing support for people most of the time.

I don’t like the word crisis, however in a situation where one-third of general practices around the country have had to restrict access due to unmanageable demand and lack of capacity we are on a precipice.

I don’t believe general practice is broken, it is still solidly caring for thousands of New Zealanders every day, and totally up for working differently and creating new results. There are a range of pragmatic solutions already designed that can be implemented to both reduce ED presentations and create capacity in general practice.

Larger EDs are not necessarily the answer. Supporting and stabilising general practice is an essential step, it can be the rock that everything else can be built on to realise the objectives of the Pae Ora reforms.

- Dr Bryan Betty, chair of General Practice New Zealand, and the former medical director of the Royal New Zealand College of General Practitioners.