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Urgent care clinics may prove an important innovation, but here are some implementation challenges

Labor’s plan for 50 urgent care clinics is potentially an important innovation for Australian healthcare, but successful implementation will involve many challenges, according to heath policy analyst Charlkes Maskell-Knight.


Charles Maskell-Knight writes:

So far in this election campaign the most significant health policy announced by either of the two parties with a hope of forming government is the trial of 50 urgent care clinics proposed by Labor.

According to the announcement, the clinics “will be based in existing GP clinics and Community Health Centres and provide bulk billed services delivered by doctors and nurses. This includes treating sprains and broken bones, stitches and glue for cuts, wound care, insect bites, minor ear and eye problems, and minor burns”.

Existing GP services will receive a block grant to extend opening hours and “increase the number of doctors, nurses and allied health staff”. The clinics will receive revenue from bulk-billing for services.  They will be also able to apply for capital grants to improve equipment and facilities.

Rationale

The policy is intended to divert some demand for relatively low acuity care away from hospital emergency departments.  As the Labor policy document notes, in 2020-21 there were 4 million “semi-urgent” or “non-urgent” presentations to emergency departments. There has been debate over many years about how many of these could have been managed in general practices in the community.

The Australian Institute of Health and Welfare (AIHW) defines a “potentially avoidable GP-type presentation” to an emergency department as a semi-urgent or non-urgent presentation where the patient did not arrive by ambulance or police car and was not admitted to the hospital, referred to another hospital, or did not die.

The Royal Australian College of General Practitioners (RACGP) regularly seizes on reports using this definition to argue that GPs should be treating many of these patients. This ignores the fact that in many areas GPs are booked for a week in advance, with only a handful of same-day emergency slots available for people who ring when the practice opens. It also ignores the fact that many practices lack the diagnostic services readily available in hospital to make definitive diagnoses of many conditions, and the current expertise to deal with many conditions.

By extending opening hours and upgrading capacity, the Labor proposal will help address these potential obstacles to a greater role for GPs in treating lower-acuity patients who might otherwise have attended an emergency department.

Impact

The Labor policy announcement does not include any estimate of how many services will be treated by the new clinics. The Australian Medical Association (AMA) has sought to fill the information gap by arguing that “these centres will do little to relieve the hospital logjam”. To be fair, Labor is not claiming that the initiative will “relieve the logjam” – it is, after all, a trial.

However, there are reasons to be optimistic. The evidence from New Zealand, where urgent care clinics have been part of the health system for many years, suggests that they do reduce demand on emergency departments. NZ has a much lower rate of ED attendances per capita (230 per 1000 people) than Australia (330) and England/Canada/US (400-450). And in Auckland, which has relatively more clinics, the rate is even lower at about 200.

A trial of 50 of these clinics across Australia is unlikely to have an impact on the overall rate of emergency department presentations, but individual clinics should have a discernible impact on local hospitals.  As Stephen Duckett has written, it is important that “a rigorous evaluation study [is] developed alongside the establishment of the new centres, allowing a proper evaluation”.

Implementation challenges

On ABC TV’s Insiders program on 17 April, Shadow Minister for Health and Ageing Mark Butler stated that a Labor government would establish all 50 clinics by 1 July next year.

Unless a lot of detailed work has been carried out behind the scenes, this will be a challenging timetable.

Scope of care and accreditation

Defining the scope of care to be provided by the clinics will be crucial. At the acute end, there needs to be clear limits on what the clinics can address and what needs to be referred to an emergency department to ensure that unsafe “mission creep” is restrained.

There will need to be a shared understanding with the local hospital and its emergency department on the scope of care and the protocols for transfer – potentially from the emergency department to the clinic, as well as the other direction. In an ideal world, patients attending at either service would complete a common patient information form, which would be made available to both services.

If the clinics are to accept patients with mental illness, they will also need to have arrangements with local mental health crisis services and acute mental health services.

There also needs to be a decision about whether the clinics should provide straightforward, non-emergency GP services. If they do not have the ability to discourage patients with non-urgent needs for care, the risk is that they will turn into bulk-billing GP clinics that operate after hours.

Health service accreditation is an important tool in supporting the safety and quality of health care.  The current accreditation standards for general practice are set by the RACGP, but will need modification to reflect the more complex patient load and scope of practice the clinics are intended to manage.

It may be more appropriate for the Australian Commission on Safety and Quality in Health Care (ACSQHC) to develop standards based on its primary and community healthcare standards. Whichever route is taken, the work should be started as soon as possible.

Facilities and equipment

While there may be existing general practices with the physical capacity and fit-out to be able to operate effectively and efficiently as urgent care clinics, these are likely to be the exceptions.  Most existing practices will need to expand their footprint and fit out treatment rooms in addition to consultation rooms.

There will also need to be decisions about the range of equipment to be available at the clinics. General practices generally do not have in-house radiology and pathology equipment, and rely on specialist diagnostic imaging and pathology providers.

If urgent care clinics are to operate as a one-stop shop, they will need to acquire the equipment and the expertise to operate it, or enter into co-location arrangements with specialist providers (who will need to agree to bulk-bill all clinic patients).

Remuneration

Based on the information that is available, it appears that the model envisages that the clinics will access the Medicare Benefits Schedule (MBS) to bill for the services they deliver. This is not a problem as far as the scope of services is concerned – the MBS has items for fractures, dressing of burns, removal of foreign bodies from eyes, and so forth.

However, the level of benefits may be problematic. While the AMA has argued for years that the rate of indexation applied to MBS fees generally is inadequate, the decision a number of years ago to set the benefit for GP consultations at 100 percent of the schedule fee resulted in an effective boost in addition to the indexation rate. This has played a part in the very high level of bulk-billing for these services.

Benefits for the procedural items likely to be claimed by the clinics were not boosted in the same way, with the result that these services are rarely bulk-billed and often involve a patient gap. Requiring clinics to bulk-bill these services will offer a real-world test of whether the benefits for these services are set at a financially viable level.

Workforce

Some media outlets have persisted in asking Labor to quantify the workforce requirements of the clinics.

While demand is likely to outstrip supply across the entire health workforce in coming years, Labor is probably right in arguing that the clinics will find it easy to attract staff as they will offer interesting work across the full scope of practice of employees

Next steps

If Labor is successful at the election there is a lot to be done if clinics are to be up and running by 1 July next year.

The Department of Health will need to establish a dedicated team to take the policy forward, and establish an advisory group including the RACGP, the Australasian College for Emergency Medicine, the Australian Nursing and Midwifery Federation, the Consumers Health Forum, the ACSQHC, diagnostic imaging and pathology groups, and states and territories. It would also be worthwhile to seek advice from the New Zealand Ministry of Health and the Royal New Zealand College of Urgent Care on lessons to be learnt from the New Zealand experience.

Urgent care clinics are potentially an important innovation in the Australian healthcare landscape, though many issues will need to be addressed. Successful implementation by 1 July 2023 will need a concerted effort.

Charles Maskell-Knight PSM was a senior public servant in the Commonwealth Department of Health for over 25 years before retiring earlier this year.  He worked as a senior adviser to the Aged Care Royal Commission in 2019-20.


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