Consumers vote with their feet – Emergency Departments are popular for a reason

The mother of a 9-year-old girl explained to me (S. D. Gill) her rationale for choosing our Emergency Department (ED) to manage her daughter’s sore wrist following a fall:

I was going to call my GP but thought I might not get an appointment until tomorrow (24-h wait and I’m working tomorrow), then the GP will send my daughter for an X-ray (another appointment at another location), then I’ll probably have to go back to the GP for a plaster (another appointment possibly a day later), so I thought I’d come here instead (wait an hour or two to be seen) and have all the investigations and treatment completed today under the one roof (so my daughter gets the care she needs when she needs it, and I won’t have to reshuffle my other commitments and drive around town looking for car parks at different venues).

So mother and daughter presented to our ED and in 90 min were assessed, X-rayed and managed for a distal radius buckle fracture (one appointment, one place, timely care and happy customers).

From a health provider’s perspective, most would agree that a distal radius buckle fracture is a non-urgent condition and ED management is not essential. GPs can manage this condition. From the consumer’s perspective, the ED was the best place to be seen: it provided efficient, convenient, integrated and free-of-charge care.

EDs are popular because they work – for consumers, a lot of the time. Publically funded EDs are free at the point of access and provide on-demand care for anyone who wants it, or needs it. Services are provided under one roof, and for major metropolitan and regional EDs, specialist services are available. It is not surprising that demand for ED services is rising in excess of population growth (Lowthian et al. 2012).

EDs are the most appropriate place for managing urgent medical conditions. However, it is contentious whether EDs are the best place for managing non-urgent conditions such as simple injuries. ‘Accident and Emergency Departments’ have been rebranded ‘Emergency Departments’ to emphasise to healthcare providers and consumers that urgent conditions are EDs’ primary business. Yet, in this age of healthcare consumerism, where power and the right to choose is transferring from healthcare providers to consumers (Berwick 2009), if consumers consider ED the best place for care (irrespective of how providers or consumers judge this), then consumers will keep coming, in increasing numbers.

Consumers with low-acuity conditions attend EDs for various reasons (Masso et al. 2007). When multiple services and interactions are required to assess, diagnose and treat a condition (e.g. simple wrist fracture), then informed consumers will often choose EDs because they provide accessible, convenient and integrated care. If, as healthcare providers and administrators we want more consumers with non-urgent conditions managed in primary care, then our challenge is to design primary care services that consumers prefer. (The Institute of Medicine’s six aims for improvement is a useful reference for creating a more responsive, integrated, and accessible health system (Institute of Medicine 2001), and GP super clinics where services such as radiology and pathology are co-located on one site is an example of integrated community-based services.) Otherwise, we must structure and resource publically funded EDs to meet increasing demand for non-urgent care.

The letter was completed within the authors’ current roles and no additional funding was received.