A SURVEY of parents who brought their children to the emergency department at the Children’s University Hospital, Temple Street has shown that the vast majority of them did not contact their GP first.
The snapshot survey, carried out by a GP working in paediatric emergency medicine at the hospital found that of 1,240 children entering the emergency department with category three and four ailments such as abdominal pain, a wheeze, a persistent ear ache or cough, and who were not there as a result of an injury, just 224 were referred by GPs. The rest came straight to A&E with ailments that were not acute.
While the findings from a 10-day period in February come from a small survey sample, they provide some interesting insight into the dynamic between patients, GPs and the AE, particularly in Dublin’s north inner city.
The survey was undertaken by Dr Robert Marsh who examined 179 of the patients surveyed. Of that 179, 133 presented without prior contact with a GP.
He concludes that hospital A&E departments are being used as an overflow service for gaps in general practice.
“The most common reason was that some of them just couldn’t get GP appointments on the same day. They would be offered an appointment for say two or three days’ time,” said Dr Marsh.
The result, he said, was that Temple Street’s emergency department had become “a walk-in service for patients who do not need to attend an acute hospital”.
Also of note, he said, was the number of patients who were unaware of D-Doc, the out-of-hours GP service for north Dublin city. Open weekdays from 6pm-8am and 24 hours on weekends and bank holidays, it has five clinics in north Dublin.
But for some, popping straight into a hospital that is right on their doorstep has long been the tradition.
“Quite a lot of patients would live within a two-mile radius of the hospital so there is that degree of convenience as well,” said Dr Marsh.
While the D-Doc service is aimed at dealing with urgent cases after normal GP services have closed, for those who say they can’t get a same-day GP appointment, waiting until 6pm for the out-of-hours service is too long.
“The bulk of them would be people like that, who just couldn’t get a GP appointment or possibly were given a later appointment with D-Doc and just decided to come down to the hospital instead.”
In nearby Mountjoy Street Family Practice, GP Austin O’Carroll agreed that while same-day appointments in the area were rarely possible, emergencies were seen.
“In our practice, we offer any adult or child an emergency appointment if they need to see a doctor urgently that day. Every day we see four to six on average extra emergencies.”
But there is no doubt that GP services in north Dublin, an area with complex health needs, are stretched, he said.
Some 70 per cent of north Dublin inner city’s electoral districts are in the bottom 10 per cent of deprivation-indexed emergency departments in the State.
Dr O’Carroll said that although mortality rates were 22 per cent higher than the eastern region and 50 per cent higher than the State as a whole, the ratio of GPs per head of population in the area is 1:2,500, versus 1:1,600 for the State as a whole and the 1:1,200 recommended as best practice.
Because of these high patient to GP ratios, he said, many GPs were just swamped with patients with 35 per cent of GMS lists now closed in north Dublin versus 25 per cent for the State as a whole.
He said another reason patients might be heading for A&E rather than the GP was that some patients entitled to a medical card cannot access one either due to slow administration or lack of GPs with open GMS lists.
The fact that non-Irish nationals are often not offered medical cards means many of them are also reverting to A&E.
The issue of finance is one worth looking at, he said.
“They are charged at A&E but they get a bill . . . at the GP they tend to have to make payment upfront.”
He said while Dr Marsh’s suggestion of putting a GP-led paediatric-only service on the Temple Street campus may help the hospital in the short term, training more GPs to work in the area and investment in local primary care centres would tackle the root causes.
The medical director of D-Doc, Dr Mel Bates, said while it was absolutely true that lots of people turn up to paediatric emergency departments with GP-treatable ailments, without going to their GP first, lack of awareness of the service was not the problem with the service seeing 80,000 patients a year, 85 per cent of them within 30 minutes of their appointment.
“But we do need to ask this question, why do people come to an emergency department and spend €100 and wait hours and hours as opposed to €60 and 30 minutes on average at D-Doc?”
With the Health Service Executive’s special delivery unit cracking down on A&E waiting times, the question has never been more pressing.
“We were supposed to invest in primary care a long time ago,” said Dr O’Carroll.
“But in inner city Dublin, we are all working separately, in isolation. Funding hasn’t gone into strategy building. From a policy perspective, we need to look at those issues.”
