The Federal Government is implementing Urgent Care Clinics (UCCs), in conjunction with the states and territories, as part of a broader strategy to improve access to primary healthcare and reduce pressure on hospital emergency departments.
In the article below, Croakey editor Jennifer Doggett, in consultation with Croakey contributors Dr Lesley Russell and Charles Maskell-Knight, investigates the state of play with UCCs, and highlights some challenges facing governments in their implementation.
Edited 2/3/23 to include information provided by the Department of Health
Jennifer Doggett writes:
A key health election commitment of the Federal Government was to establish “at least” 50 urgent care clinics (UCCs) around Australia to improve community access to primary healthcare and take pressure off hospital emergency departments.
UCCs were described in the ALP policy platform as follows:
“Medicare Urgent Care Clinics will be based in existing GP clinics and Community Health Centres and provide bulk billed services delivered by doctors and nurses – in every state and territory.
This includes treating sprains and broken bones, stitches and glue for cuts, wound care, insect bites, minor ear and eye problems, and minor burns. All important and time-critical treatments that don’t need a hospital emergency department.”
In the October 2022 Budget, $235 million (over four years) was allocated to fund this commitment. This is considerably more than the $135 million that was part of the election commitment and includes $100 million over two years from 2022-2023 to co-develop and pilot innovative models with states and territories to “improve care pathways and inform the urgent care program rollout”.
The current funding level is equivalent to $4.7 million over four years for each of the promised 50 UCCs. On this basis it must be assumed that further funding will be needed over the forward estimates.
Since the Budget there have been specific announcements and media reports of UCCs being planned in individual states, with some indication of their locations, including in South Australia, NSW, Victoria, Queensland and Tasmania.
The Department of Health told Croakey that locations for UCCs have been confirmed and expression of interest processes opened in Tasmania, Western Australia, South Australia, Queensland and New South Wales. Locations include:
- Tasmania – North west region, Launceston and Hobart.
- Western Australia – Perth City area, Joondalup, Rockingham, Murdoch, Midland, Bunbury and Broome
- South Australia – Adelaide City, Mount Gambier, Outer Northern Adelaide Metro, Outer Southern Adelaide Metro and Southern Adelaide Metro
- Queensland – Bundaberg, Ipswich, Rockhampton, Cairns, Southern Brisbane, Northern Brisbane, Gold Coast, Redcliffe, Logan, Townsville, and Toowoomba.
- New South Wales – Albury, Batemans Bay, Blacktown, Campbelltown, Cessnock, Coffs Harbour, Gosford, Lismore, Penrith, Randwick, Tamworth, Westmead, Wollongong and Wyong.
The Department also stated that announcements for the remaining jurisdictions are expected over the coming weeks and that some Medicare UCCs will be open by July this year, with all 50 to be established before the end of 2023.
The state of play
The Health and Aged Care Minister Mark Butler and the Prime Minister have clearly stated that UCCs are not designed as a substitute for traditional general practice but rather to provide services not typically available at GPs and which would otherwise require a hospital visit.
In a recent interview Butler stated that UCCs are “not for the care you would normally be getting from your GP”.
“At the moment,” he said, ” if you bust your arm or you have a very deep cut, the overwhelming likelihood is you can’t get into your GP within two hours, the overwhelming likelihood, particularly if that happens after hours or on the weekend and at the moment because of that, people are going to the hospital…
“In America, there are more of these centres – more urgent care centres than there are Starbucks – we’ve got hardly any here in Australia, and it means that just translates into more pressure on our emergency departments.”
The Prime Minister has stated the trials will be based on models from Aotearoa/New Zealand, which has one of the lowest rates of emergency department attendance in the developed world.
He has also promised the UCCs will bulkbill and will be open from 8am-10pm, saying in a statement:
“They will treat sprains and broken bones, stitches and glue for cuts, wound care, insect bites, minor ear and eye problems and minor burns. Care will be bulk billed, meaning families won’t be out-of-pocket for having a loved one attended to, just like if they’d gone to a public hospital. They’ll be open seven days a week from at least 8am to 10pm – the time when the majority of non-life-threatening injuries occur.”
The Department also clarified for Croakey that UCCs aim to ease the pressure on our hospitals and give Australian families more options to see a healthcare professional when they have an urgent, but not life threatening, need for care, including for conditions that would not require a hospital admission such as closed fractures, wounds, and minor burns.
It stated that the Government has committed to properly resourcing the clinics and is working closely with state and territory governments, Primary Health Networks, peak bodies and the health sector to ensure that the clinics meet the needs of the local community and are integrated with existing emergency diversion initiatives.
In response to a question about workforce availability, the Department said that it recognises there are significant existing challenges in securing health workforce and is working with stakeholders on options to leverage the available workforce while building capability in urgent care.
It also informed Croakey that an evaluation framework for the UCC program has been jointly developed and agreed by the Department of Health and Aged Care and state and territory governments.
Emergency care
There’s no doubt that reducing pressure on hospital emergency departments (EDs) should be a high priority for federal and state/territory governments.
Over the past two decades Australia, like many developed countries, has experienced a significant increase in demand for ED services.
Over this time, ED activity has grown faster than population growth both in terms of the number of presentations to EDs and the length of time each person spends in ED.
Data from the last three years has been impacted by the COVID-19 pandemic, which makes comparisons difficult, but in the five years prior to this, the rate of presentations to ED per 1,000 population steadily increased from 310 in 2014–15 to 329 in 2018–19, an increase of 3.2 percent per year on average.
There are many possible reasons for the rising demand for ED services including: the ageing of the population; the rising incidence of chronic illness; decreased availability of general practitioners/primary health care services, especially for after-hours and urgent visits; the expansion of diagnostic and therapeutic choices; and changes in consumer preferences and behaviours for accessing health services. Insufficient inpatient beds has also been identified as a major cause of ED overcrowding.
The increase in demand for ED services has not been matched by a similar increase in resourcing, leading to a situation in which EDs are frequently under pressure and not able to meet demand, as reflected regularly in headlines like these: New pressure on buckling health system as urgent patients flood EDs (Courier Mail, Queensland); Linen shortage hits South Australian hospitals as report shows ambulance waiting times worst nationally (ABC, SA); Hospital bed blocks, ambulance ramping: Here’s six suggestions to fix them (The Age, Victoria).
Over-burdened EDs have a range of adverse consequences for patients, ED staff and the health system more broadly, including:
- increased morbidity and excess deaths (one 2009 study estimated that ED and hospital overcrowding caused at least 1500 deaths per annum in Australia)
- delays in treatment, in particular delayed time-critical care
- more walkouts by patients prior to treatment (particularly common among Aboriginal and Torres Strait Islander patients)
- adverse events and errors
- more ambulance diversion and delays to offloading ambulance patients
- more preventable re-admissions and hospitalisations
- increased costs per stay and higher overall healthcare costs
- reduced patient satisfaction
- less frequent and less adequate pain control
- prolonged hospital length of stay
- more legal actions and patient complaints
- severe problems with staff turnover and burnout
- increased stress and exposure to violence for ED staff.
Diverting demand for ED services to UCCs could therefore deliver significant benefits.
But in practice this might prove more difficult than it seems.
Evaluations of previous Australian and international primary healthcare strategies aimed at reducing pressures on EDs do not provide solid evidence for their success. There are many examples in the literature of unsuccessful attempts at reducing ED attendance through primary health care and reviews of the literature in this area have found that many evaluations conducted on these initiatives are flawed. Even studies which identify an impact on ED presentations make clear that evidence for this effect low.
Learning from these experiences is essential if the UCCs are to avoid the mistakes made in the past.
Some of the other challenges that the Government will need to address if the UCCs are to be successful in achieving their goals are outlined below.
Understanding the problem
Clearly defining the problem which UCCs are supposed to solve is important in order to design and implement the UCCs to maximise their chance of success. This involves understanding the reasons why people might choose to attend an ED rather than a general practice, which is not an issue well understood within the Australian health system.
Charles Maskell-Knight has previously written about the lack of Australian research on why people present at an emergency department. He identified only two recent reports: a 2017 meta-analysis which identified two Australian studies published over the twenty years to 2016; and a 2014 survey of 1,000 patients in a large hospital in northern Queensland.
He suggests that there are likely to be three main groups of reasons why “GP-type patients” may present to EDs rather than general practices. These are: access barriers (for example, time or distance); cost barriers (likely to be exacerbated when bulkbilling rates decline); and the limited scope of services provided in most general practices.
“Patients who expect their care will require radiology or pathology services may attend an emergency department knowing the hospital will provide a one-stop shop, avoiding the need to travel elsewhere to receive diagnostic services before returning to the GP. In the absence of rapid access to these services many GPs will refer patients to emergency departments. Indeed, the north Queensland study found that over 25 per cent of patients meeting the AIHW definition of potentially avoidable presentations had been referred to the emergency department by a health professional.”
Clarifying target groups
It’s also important to be clear about the target groups for the UCCs and to evaluate their outcomes in relation to their impact on these target groups.
Butler has described the aim of UCCs as diverting “GP-type patients” from EDs. This sounds straightforward in theory but it is complicated in practice to know who exactly this refers to.
Even the experts can’t agree on how a ‘GP-type patient’ should be defined in the Australian health system.
Currently at least six different definitions of a “GP-type patient” are being used, some of which vary significantly. For example, four of the definitions use Australian Triage Scale (ATS) categories 4 & 5 to define a “GP-type patient”, but one includes category 3 and another (the definition developed by the Australasian College for Emergency Medicine) does not use the ATS scale at all.
It is important to remember that the ATS categories focus on urgency not acuity. The Department of Health Emergency Triage Education Kit states that “patients may be triaged to a lower urgency rating because it is safe for them to wait for an emergency assessment, even though they may still eventually require a hospital admission for their condition or have significant morbidity and attendant mortality”.
If the aim of UCCs is to increase access to primary healthcare for other groups in the community whose needs may not be met by traditional general practice (these include people with drug and alcohol addictions, people from diverse cultural and linguistic backgrounds, people experiencing homelessness and Aboriginal and Torres Strait Islander people), then there will need to be explicit focus on accommodating these groups.
For example, for UUCs to provide culturally safe and responsive care for Aboriginal and Torres Strait Islander Australians they will need to be underpinned by the National Agreement on Closing the Gap and the National Aboriginal and Torres Strait Islander Health Plan 2021-2031. If they simply replicate the services provided by mainstream health care then they are unlikely to see many First Nations peoples.
Dr Lesley Russell nominates mental health urgent care as one possible role for UCCs, given the high numbers of people with mental health concerns presenting at EDs. But she also acknowledges the complexity of providing mental health services and the need for specific expertise and resources to target this group.
Without a clear and agreed understanding of the patient groups being targeted by UCCs, it will be impossible to determine whether and to what extent they have been successful or whether they have simply (as has occurred previously) diverted patients from traditional general practices.
It will also make it easier for governments to bow to political and interest group pressures to locate UCCs in areas favourable to them rather than in locations that will best meet the need of the target groups.
Provide additional services and supports
If one reason why patients present to EDs is to receive a “one stop shop” service, then UCCs will need to also provide this level of care to prevent them from attending hospitals.
Maskell-Knight suggests that this includes the capacity to provide onsite diagnostic imaging (at a minimum X-ray and possibly also CT) and a quick turnaround on blood chemistry and microbiology to aid diagnostics. Pharmacy dispensing either onsite or nearby may also be important.
Evidence from one similar service (Balmain Hospital General Practice Casualty) suggests that this is an important factor in attracting patients.
Without these additional services, UCCs are unlikely to attract the group of patients attending EDs in order to avoid having to visit multiple different locations and services to access the care they need.
Build collaborative relationships with other sectors
Russell stresses the importance of establishing links between UCCs and other sectors of the health system, in particular hospitals and community-based specialists, to facilitate rapid referral of patients when required. This will involve cooperation from state and territory governments and a systematic and agreed approach to communications and data sharing.
Maskell-Knight agrees and highlights the need to agree on role delineation and their respective scopes of service.
He warns that without this, patients may end up receiving duplicated services if, for example, the hospital can’t access (or doesn’t trust) data from tests performed at the UCC and decides to repeat them. This includes agreeing on when a patient needs specialist input which is only available in the hospital setting.
Integrating with other primary healthcare policies, processes and services
It is also important that the UCCs are considered in the context of other current processes and initiatives with similar or related aims to the UUCs.
These include:
- The Strengthening Medicare Taskforce, which has a brief to develop options to improve access to primary health care and integrate services at the local level
- Primary Healthcare Networks whose role is to address gaps in primary health care, build capacity among general practice and integrate services at the local level
- Current trials of pharmacist prescribing and increased roles for nurse practitioners which are designed to increase access to primary health care services and take pressure of hospital EDs.
- Existing co-located nurse led clinics, GP casualty and urgent care clinics.
To give UCCs the best chance of success, it is important that they learn from the experiences of these existing services, work with existing infrastructure such as the PHNs and support the broader policy directions of government.
Ensure adequate workforce
The UCCs will only be successful if there is an adequate workforce available to fill required positions.
Russell suggests that this will include a range of health professionals such as nurses, doctors, physician assistants, nurse practitioners and possibly also paramedics and mental health staff. Where imaging services are provided radiographers and pathology will need to be available, along with links to pharmacy.
Given widespread workforce shortages in many of these professional areas, it is important that governments ensure there are enough health professionals available now to staff the UCCs (without leaving other services, such as aged care, understaffed) and also undertake workforce planning to ensure there will be sufficient numbers of health professionals for the UCCs (and other areas of health services) of the future.
Negotiate sustainable financing arrangements
The Government has stated that UCCs will be bulkbilling clinics but has not provided information about whether this will be mandated.
It is also not clear whether other services provided in conjunction with a GP consult at the UCCs (such as imaging) will also be bulkbilled and, if not, if there will be any requirements for limiting the number and level of out-of-pocket costs that could be experienced by consumers using UCCs.
A range of different financing models could be used to fund UCCs and it is important that the most appropriate one is used to maximise their impact (for example by reducing cost barriers for consumers) and ensure their sustainability. This is likely to involve negotiations with a range of different parties, including state governments and provider groups.
Deal with opposition
While there has been support for UCCs from a range of health stakeholders, there has also been opposition from some quarters.
Some of the issues being raised are clearly politically motived and do not address genuine policy concerns but these will still need to be managed as part of the Government’s implementation process.
Other genuine issues being raised by stakeholders – such as whether UCCs are the best way of reducing the pressure on hospital EDs – should be addressed through consultation with the relevant stakeholder groups, with sufficient input from consumers and the community to ensure their implementation is driven by consumer rather than provider interests.
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