David Oliver: Will the public use alternatives to emergency departments?BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1501 (Published 10 April 2018) Cite this as: BMJ 2018;361:k1501
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Emergency Departments (EDs) have over time been re-shaped into a single point of access for people with diverse health issues, a significant proportion of which is chronic and not urgent. Over reliance on our EDs threatens to negatively impact quality, access and cost for health systems, and particularly disadvantages those most in need of urgent attention. This is not at all surprising. With the ability to receive all types of diagnostic services and treatment, support mechanisms, reassurance and multiple opinions in the same location, it is little wonder that patients are attracted to EDs rather than attending their primary care physician. In addition the 24/7 availability of service means that people can fit in attending the departments at their convenience. A further appeal is that in many social health systems, there is no out of pocket cost involved at the point of care and there may also be a sense of entitlement for having contributed through general taxation to the provision of a universal health care system.
In an attempt to improve efficiency in the EDs through national emergency access targets of four hours, a potential perverse benefit is created of even better access for those that actually do not need urgent treatment. Some of our health service data suggests that up to ten percent of acute medicine admissions to hospital can manage without inpatient treatment and are discharged within 24 hours. Added risks of over diagnosis and over treatment are potentially huge and threaten to fracture the sustainability of health care.
The reality is that patients will continue to attend emergency departments for diverse health issues. Many of these health problems will not be serious and are most appropriately managed in primary care. Emergency Department physicians are experts in emergency care and are not primary care physicians. Optimised identification of patients is not only ideal but critical in ensuring that those who receive care in the Emergency Departments are truly in need of urgent attention and often hospitalisation. Greater integration of services and coordination with primary care is integral to ensuring that the most appropriate, cost effective and accessible care is provided to each patient. The uncontrolled dependence on emergency departments needs to be arrested if healthcare is to remain accessible, sustainable and efficient for the future.
Competing interests: No competing interests