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Successful urgent care services need collaboration between levels of government, consultation, co-design, population health modelling, and uplifting of primary care.
In brief
- Urgent care services can help address the challenges facing emergency departments and general practice.
- Urgent care services should be tailored to local needs and build upon existing services, infrastructure and workforce across general practices and the healthcare neighbourhood.
- Targeted investment is needed in clinical governance, workforce upskilling and supporting digital technologies.
The federal and state governments have announced significant investments in urgent care services with the stated aims of reducing emergence department (ED) presentations while being free at point of care.¹ ² ³
The joint announcement by the governments of Victoria and NSW says that their urgent care services will be jointly commissioned with primary health networks (PHNs), building on the collaborative commissioning model which has already been deployed in NSW.²
A system under pressure
Hospital and community health services in Australia are showing numerous strains following a tough couple of years through the COVID-19 pandemic. EDs and hospitals are reporting burnt-out clinical staff, difficulties admitting patients and overcrowding. The problems appear most acute for emergency presentations, with reports of patients spending up to 24 hours in EDs due to high demand and a lack of available beds to admit patients to hospital. Even prior to entry to ED, patients are being “ramped”, or waiting in ambulances outside, which continues to illustrate how demand is outstripping service capacity. These high and growing ED waiting times have been subject to numerous state parliamentary inquiries.⁴ ⁵ ⁶
The pandemic arguably exposed pre-existing underlying weaknesses. The Australian Institute of Health and Welfare (AIHW) monitors lower urgency care presentations in EDs as a proxy measure of lack of access to general practice, where those patients should present for care. Their analysis of lower urgency care found that in 2018−19, nearly half of all ED presentations (by type of visit) were classified as category 4 or semi-urgent (39% or 3.2 million presentations) or category 5 or non-urgent (7.5% or 613,000 presentations).⁷ The Australasian College of Emergency Medicine (ACEM) responded to the AIHW report by stating that the raw numbers do not provide the complete picture of patient complexity.⁸ Notwithstanding, the most recent Australian Bureau of Statistics (ABS) patient experience survey delved further into the reasons why patients attended ED, finding that in 2019, 21% of patients reported attending ED because they could not get an appointment with their GP.⁹
General practice is also reporting significant pressure, with patients struggling to access bulk-billed appointments, particularly outside metropolitan centres, and GPs also reporting high levels of burnout.¹⁰ Concerningly, fewer medical graduates are choosing a career in general practice and the RACGP is reporting unsustainable workloads and increasing numbers of GPs expressing an intention to retire or change careers in the next 10 years.⁶ These issues are also attracting national attention with the federal government committing to “strengthen” Medicare by investing in general practice.¹¹ Too many patients are showing up at ED due to a lack of accessible services in the community, demand other countries have met through services called “urgent care”.
Introducing urgent care
Urgent care services are intended to serve urgent, but neither serious nor critical, medical conditions for patients who would previously have presented either to general practice or emergency medicine. “Urgent” typically means medical care is required within 24 hours and continuing care is not provided.¹² ¹³ ¹⁴ ¹⁵ Some countries, like the USA and New Zealand, provide urgent care in standalone centres accepting walk-in patients who present with specific conditions or symptoms. In countries where urgent care services are relatively mature, such as the USA, New Zealand and parts of Europe, service appraisals have found that they:
- Reduce ED presentations in postcodes near urgent care centres¹⁶ ¹⁷ ¹⁸ ¹⁹
- Are generally well received by consumers due to shorter waiting times, but²⁰
- Deliver no overall cost reduction for the system (mainly due to expense of running parallel infrastructure)²¹
Urgent care services are being introduced to an already mature, complex, and overlapping Australian health ecosystem providing routine to emergency care. This includes general practice, other primary care clinicians, ambulance services, emergency departments, virtual ED and hospital in the home. All of these have their own distinct entry points and associated criteria, which may or may not be subjected to triage and scheduling (by organisations like HealthDirect) or patients reporting an emergency via triple zero (000).
Design services not centres
Substantial capital investment would be needed to build new physical facilities, and international experience has found that the expense of running parallel facilities can erode the systemwide benefits of urgent care. The focus instead should be on urgent care “services” leveraging existing local infrastructure, primary care providers and supporting workforce, integrated with targeted acute service interventions alongside investment in clinical governance, workforce upskilling and supporting digital technologies. Services should also be designed to improve utilisation and equity across the broad health ecosystem, as the benefits can be realised beyond geographic boundaries.
Clinical governance for urgent care services would comprise pathway design; modification of triage and referral protocols; clinical upskilling aligned to the desired service profile; continuity of care and correspondence with patient’s usual GP and/or ED; and application of practice standards and payer requirements, such as from Medicare.
Consumer information materials and proactive educational initiatives are needed to build familiarity with services for urgent but not serious medical conditions, and how and when to access them. Ongoing support will also be required for consumers, particularly if the service profile for urgent care varies across and within jurisdictions.
By their nature, urgent care services involve a high degree of clinical uncertainty stemming from the potential for more serious differential diagnoses.²² It is imperative to factor this into clinician education and upskilling and to embed clinical decision-support into the clinical workflow from day one (principally for radiology and pathology). Otherwise, governments run the risk of further increasing demand for and spend on diagnostics, driving up overall health system costs.²³ ²⁴ ²⁵ ²⁶ ²⁷ ²⁸
But where to put them?
Determining the location of any health infrastructure involves finely balancing population health, the existing service provider ecosystem, and local capabilities. It will also require acknowledgement and response to the political imperatives of different levels of government.
In relation to urgent care services, the ideal starting point is an objective assessment and modelling of local population health needs, taking into consideration the area’s demographic profile, impact of social determinants of health, patterns of behaviour and the incidence and nature of ED presentations in the hospitals in the area. Coordination between those responsible for the area’s primary care and hospital services in highly recommended, the nexus where urgent care services are positioned.
The involvement of the relevant health governing bodies in the areas is another key factor for success, requiring commitment to a co-designed model and pathways that integrate care across transitions and centre support around the patient. Collective insights can be drawn by appropriately sharing data, coupled with extensive knowledge of local characteristics (particularly consumer needs, preferences and behaviours) and how local bodies have guided the implementation of other new services – a joined-up approach that is consumer-centred and clinically led.
Viability and funding
Once potential locations are evident from an objective assessment, the next major consideration is the availability of enablers to build from and coordinate with.
Figure 1: Enablers of successful urgent care services
More than one urgent care service configuration or model can be made to work. Federal and state-level policymakers should be comfortable trialling and testing a variety of models and some tailoring based on local population health needs and the availability and readiness of key enablers.
The federal government initially allocated funding of $235m to commence roll out of 50 Medicare “Urgent Care Clinics” (UCCs), including $100m to co-develop and pilot innovative models with states and territories.²⁹ The federal budget in May 2023 committed to a further eight UCCs, raising its overall commitment to $358.5 million over five years.³ Adequate funding is necessary for these new services to get established and become sustainable, while bulk-billed services are important to incentivise patients to present to urgent care rather than ED. Within a few years, urgent care services should have transitioned to run without making a loss. Partnership between federal and state governments on funding and design is critical for success and should extend further to involve local health districts, primary health networks and stakeholders who possess an in-depth knowledge of care pathways, service design and implementation.
Signs of success
Urgent care services should play a central role in the delivery of sustainable public health systems. To do so, governments need to guide the establishment of a viable environment for urgent care through careful design, selection of service locations based on demonstrated population needs and availability of key enablers, and input from local health governing bodies. Furthermore, outcomes data will need to be captured that monitors progress, builds an evidence base and facilitates evaluation.
Figure 2: Short-term signs of success of urgent care
In the medium term and aligned to the Federal Government’s funding allocation over the next four years, urgent care needs to be established as a cost effective and sustainable alternative for urgent but not critical care. This would be demonstrated by reducing growth in low acuity demand for ED and in-hospital services and contributing to a more sustainable primary care model and improved patient satisfaction.
Irrespective, local health needs and service configurations will continue to evolve, building on success stories from the pilots and achieving sustainability through ongoing review, analysis, evaluation, refinement and collaboration.
The success of urgent care will hinge on collaboration between levels of government, stakeholder consultation and co-design informed by population health modelling, aligned with existing local services, and uplifting of primary care.
Summary
Underlying fragilities in health services have been exposed by the pandemic. Urgent care services can help meet local demand via a strengthened and uplifted primary care and integrated care setting. The focus should be on designing services which build upon existing local services, infrastructure and workforce, with investments in clinical governance, workforce upskilling, and digital health. Locations should be chosen based on objective analysis of data, availability of key enablers and collaboration between levels of government and stakeholders. Signs of successful implementation include community behavioural shifts, timely access within local service ecosystem – right care in the right place, and positive feedback from consumers and health professionals.