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Integrated Urgent Care

The GP-led Accident and Medical (from this point will be referred to as an Urgent Care) provided acute care services to the Franklin and South Auckland region for 20-25 years. Unfortunately, due to an inability to retain GP physicians, the decision was made by the shareholders to close the service in July 2017. The original goal of ‘Urgent Care-Franklin’ was to run a service that did not rely on GMS funding that comes from the patient’s GP capitation funding. Capitation is money that is given to the General practice that that the patient enrols. When the enrolled patient presents to another practice outside of the public hospital, a portion of the capitation money if forfeited to the practice providing care to the patient even if the patient’s enrolled practice did not refer the patient to the service. This can cause financial stress to General Practice as capitation has not kept pace with inflation and can cause financial stress

This brief discussion paper:

“Integrated” Urgent Care would start as a duplicate urgent care service to the previous West Street Urgent Care at Pukekohe Family Healthcare. The main reason for this would be to have a service up and running quickly so that patients can get use to coming back to West Street for their acute care needs. The West Street site is the only location currently available in Franklin that would be capable of meeting the new Urgent Care Standard (UCS). The main need is covered access to radiology services; in preliminary discussions, ARG has indicated that they would be keen to return to providing services to the new Urgent Care to meet the needs of the community. While the new UCS is much more burdensome in comparison to the previous ACC standard that was require, there is nothing in the new UCS that would keep a resurrected West Street service from becoming accredited under that standard.

While there were problems around wait times and staffing that particularly stressed PFHC providing its GP service, the Urgent Care provided reasonably high level of service even to the sickest patients.  The skills accumulated over the last 20 years was reflected in many aspects of care including getting recognition from the specialty services at Middlemore that a high level of service was being provided in Pukekohe as reflected in the appropriateness and treatment of referred patients. Because of the burden of providing after-hours care, the long-term goal would be to get physicians dedicated to only working Urgent Care. This would allow the local GPs to enjoy a much better lifestyle while maintaining their actual requirements of providing after-hours services to their enrolled patients. Wait times difficulties would eventually be solved by staffing at a slightly higher level (hopefully starting within 6-12 months after reopening). Also, educational efforts around training both emergency and urgent care house officers and registrars may allow the acute care service to become more efficient.

One of the bigger reasons to reopen West Street is to provide a ‘safety valve’ for the GP services. There is a requirement in most of the PHO contracts to have an after-hour service available for the patients of each practice. This requirement is currently met by referring to UCF (signs up at most practices) and Healthline. Given the 45-minute (or more depending on time of day) transport time just from Pukekohe to Middlemore (and more time further south of Pukekohe), a proper Urgent Care service is desperately needed in the Franklin region with the goal of attracting patients from the Karaka and South Auckland. PFHC (and other GP practices) have struggled to provide ‘on-the-day’ services especially as they are expensive and a redundant expense for most practices. The ‘Acute Demand’ service provided by general practice is clearly NOT the same level of acute care services that had been provided previously.

Discussions with General Practitioners about acute presentations indicate a large level of comfort with ‘bread-and-butter’ GP services (coughs, cold, bumps and bruises) but little interest in providing services for the sicker presentation. Since July 2017, there has been a definite drop-off in the more serious presentations at many GP services. Many of these patients go straight to hospital. There are similar acute care service challenges at other GP practices with the patients ‘worked-in’ to the normal GP flows. This causes stress within the Practice and has the potential to put the GP behind in their daily patient list providing a ‘less than desired’ level of customer service.

By having an Integrated EM/Urgent Care (IUC) reopen, then GPs should feel comfortable referring their patients to a tightly run service. This should be especially appealing if there was no GMS ‘claw back’ that is costing most practices significant amounts of revenue each month (and possibly jeopardising their ability to provide service going into the future). The ‘Integrated’ portion of IUC would hope to make use of a new resource called Healthone (a program similar to Testsafe (Auckland’s region portal) that allows patients from various medical practices to be centralised) currently being utilised in Canterbury or by possibly virtualising participating GP databases/medical records. Letting the treating doctors at IUC have the patient’s medical information would ensure that the patients are treated with more safety and with much better continuity. Virtualisation of GP databases is another possibility that may allow GP record to be available to optimise patient care. Part of the ‘cost’ to provide remote access to their patient records (of course with appropriate privacy controls) would be recovered by not having GMS taken from the practice by non-ACC patients.

Integrated Urgent Care’s biggest challenge to start providing services is staffing. When UCF opened, PFHC lost one of its best Urgent Care doctors. Besides the previous medical director at PFHC, there are 1-3 other doctors that have indicated in the past that they still have an interest in providing Urgent Care services. While it would be most ideal to reopen the West Street site as soon as possible, then initial staffing would have to be available at a minimum 4-5 FTE (just to provide adequate single coverage and little flexibility in ‘surge’ time). The ultimate goal would be to have a group of physicians (even more ideally Urgent Care AND emergency medicine doctors) that would cover all the sessions to provide patient care with double coverage and adequate nursing staff to enable IUC to provide emergency level service. This would eliminate the stresses on the GP services. While some GP services would continue to provide some acute care services, they would always have the ‘back up’ of IUC. Once more EM and UC physicians are available, there are additional studies including sedation, fracture reduction, cosmetic wound closures and eventually observational medical services (if/when 24-hr services are provided).

Another long-term goal of IUC would be becoming an educational facility for both Urgent Care trainees and a community EM training location. The Medical Council now has a community requirement for House Officers in their first 2 years. A location near Auckland could appeal to large number of trainees looking to train in this region. Instead of having inexperienced doctors working by themselves, they would have access to consultant physicians that could provide learning in real time as well as serving as a role model and back up to help the training doctors. Since IUC would be looking to train Emergency Medicine trainees as well, didactic learning could be combined with Middlemore (or other public hospital emergency services) and/or RNZCUC to help optimise the learning experience for trainees and provide timely review for the consultant doctors.

Given the importance of point-of-care ultrasound, there would be plans to provide training and to utilise this modality in the treatment of patients. While meeting the UCS would be sufficient in general to allow Urgent Care trainees, IUC would need to team up with Emergency Medicine at one or more of the public hospitals (Middlemore or Waikato ideally) to meet the standards needed for Emergency Medicine trainees. Given that both supervised trainees and consultant doctors would be on site together, the level of services provided at IUC would be high enough to have the potential to make some headway in off loading Middlemore (currently the busiest Emergency Department in Australasia) if IUC was located in the South Auckland region.

IUC would also be developing ‘pathways’ to allow nursing staff to work to their highest skill levels. Some GP practices have had such pathways for UTIs (women 16-65). There are several areas that of both Urgent Care AND GP practices that would benefit from standardised pathways that allow for easier data collection and improved care in the region. IUC would hope that other practices could contribute to the development of these pathways as this integration would allow for better care especially if the patient experienced an unexpected return visit. The Auckland Regional Health Pathways as they currently exist are not user friendly in many ways but they continue to improve. IUC could also work at distilling the information and help expedite patients in the community to avoid hospital admission as well as bridging care to get the patient back to their registered GP.

St John has noted both and increase in call outs to UCF as well as needing to transport more patients up to Middlemore Hospital. St Johns has specifically mentioned that the previous Urgent Care was more than capable of handling those slightly higher acuities and being able to keep those patients away from Middlemore. This allowed St Johns to keep their ambulances local and allowed ambulance services to be more readily available to the Franklin Area. Maybe not initially, but eventually, IUC would expect to take all but the most critically ill patients (especially if IUC was able to be open 24 hours.). St John has also indicated that they would be more than happy to support a ‘full service’ Urgent Care facility.

By avoiding the ‘GMS clawback’ that would discourage referrals by the local GPs to IUC would make funding more challenging. As the volume of presentations increases, it would be hoped that 2-3 doctors (plus trainees) could be available during the busiest portion of the day. This would allow IUC to keep nursing and other ancillary staff busy and distribute the fixed costs of running IUC over a larger number of patients. Without the GMS funding, then cost structures for all patients including ‘over 65’ and ‘under-13’ would have to be carefully considered. The new Labour Government has stated they are more interested in funding healthcare services. The current government has also indicated they are not willing to consider public-private partnerships. Ideally, the appeal of an integrated emergency service with the potential to partially off-load Middlemore would encourage seed funding if not a longer period of support. Recent budget deficits at the Counties Manukau DHB level have discouraged taking this discussion to either the Locality (subgroup of the Middlemore DHB) or the DHB level. Current financial models looking at how an ‘integrated’ service would run would be much more profitable with higher patient volumes that could hopefully be referred or supported from the GP services if appropriate. While there is no ‘funding model’ to provide acute care outside of the public hospitals in NZ, an efficient Integrated EM/Urgent Care could take stress off both Middlemore and local GP services and allow patient care to remain local. If the Healthcare Trust structure was adopted, any excess operating funds could be directed towards other healthcare needs within the South Auckland community.

Long-term, West Street is likely not the ultimate service location as there is no room for expansion or parking for high patient volumes. There are discussions currently being undertaken by several private groups keen to develop private hospitals (similar to Anglesea in Hamilton or Ormiston). Timeframes here are unclear as to when a purpose-built location might become available. These private hospitals have plans for a full radiology suite with the possible inclusion of both CT and MRI as well as laboratory services. This would alleviate many referrals to hospital especially with patients with chest or abdominal pain. Having both services on site could also compact the patient’s length of stay as well as avoiding unnecessary referrals to Middlemore.

Details on development and provision of the healthcare trust are here. If the healthcare trust cannot be supported by the community, it would be impossible for 2-3 years to develop this service by a private service. Integrated Healthcare Trust will be looking to the generosity of the South Auckland community to both form the Trust and develop the acute care services. Once the Trust is established, then the Trust can apply for grants to support educational efforts as well as deal with social determinants that can impact on the health of certain populations.

Integrated Healthcare Trust is still looking for Maori Kaumatua to help address specific needs of the Maori and Pacific Island communities in the South Auckland region.