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| Journal of the New Zealand Medical Association,
02-May-2003, Vol 116 No 1173
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Is the PRIME (Primary Response In Medical Emergencies) scheme
acceptable to rural general practitioners in New Zealand?
Todd Hore, Gregor Coster and Janne Bills
Before the development of a nationally consistent plan to
manage medical emergencies in the pre-hospital setting, the provision of
emergency services in rural New Zealand was often dependent on finding the best
local solutions through the knowledge and goodwill of concerned rural community
members and local health professionals. In many areas, a strong collegial
relationship developed between the emergency services, in particular volunteers
and the rural general practice team, who provided advanced resuscitation skills.
However, this produced inconsistencies in standards and practices between
different regions.1
The 1993 health reforms introduced competitive contracting
that began to undermine the cohesiveness and goodwill of the rural emergency
team. The contracting process did not take into consideration the important role
played by rural GPs and, in some areas, advanced rural nurses. Centralised
emergency communication centres, familiar with the urban model, using paramedics
for advanced skills, generally did not see a role for GPs. They also did not see
a need to notify rural GPs of an emergency in their local community, despite the
absence of paramedics in rural areas. Dedicated rural GPs were isolated from the
new communication systems, which perpetuated poor communication between the
local emergency services and rural GPs, although this was often not the wish of
the local ambulance services. Inconsistency of training, knowledge and skills in
the emergency situation played some part in the reluctance of the ambulance
services to acknowledge the GP role.
The PRIME (Primary Response In Medical Emergencies) scheme
was developed in 1995, the objectives being to provide both a coordinated
response and consistent, appropriate management of trauma and medical
emergencies in rural locations. The Southern Regional Health Authority (SRHA)
funded the creation and development of the scheme as Stage One of their regional
Trauma Service Plan. The scheme embraced the pre-hospital emergency care
recommendations of the Royal Australasian College of Surgeons Trauma
Committee.2 This scheme would incorporate the
rural GP (and, in some areas, advanced rural nurses) with standardized training
into the pre-hospital emergency team. The scheme was trialled in 1998 in the
SRHA region, funded jointly by the Accident Compensation Corporation (ACC) and
SRHA with the support of Hon. Bill English (then Minister of Health); it was
extended to the rest of the nation in 1999.
The PRIME scheme was incorporated into the Ministry of
Health ‘Roadside to bedside’ strategy published in 1999. This
document highlighted a concern regarding the integration of health services,
stating:
‘It is also important that
integration does not inhibit flexibility in the approach and mode of service
delivery, especially in rural areas where there are special challenges caused by
distance, geography and population
size.’3
The PRIME service provider is required to have undertaken a
PRIME training course (approved by ACC), within a maximum of two years after
signing up with the scheme, followed by a two-day refresher training course for
trauma and medical emergencies (approved by ACC) at least once every two years.
The PRIME service provider is also required to have access to the PRIME medical
kit and a form of communication (eg, pager, cellular phone or ambulance radio).
The PRIME scheme requires the service provider to respond within a local roster
system that provides cover 24 hours a day, 365 days of the year. The key
objectives of PRIME are primary assessment, essential resuscitation, and the
rapid and safe delivery of patients to the appropriate place of definitive
care.
The PRIME scheme utilises the skills of rural GPs and/or
rural nurses (RNs) in areas where an ambulance crew (two ambulance officers,
where one is a paramedic) is more than 20 minutes away (40 minutes in the South
Island). There are currently 266 PRIME service providers in New Zealand
(including both rural GPs and RNs). The PRIME network is activated via a pager,
in most cases, by the regional communications centre (RCC) following a 111 call,
where the nearest paramedic response is more than 20 minutes away. Remuneration
for call-outs is dependent upon whether the call results from trauma or a
medical condition. PRIME providers receive a monthly retainer for medical
call-outs, while trauma call-outs are covered by an ACC claim.
This paper presents the findings of our research, which aims
to ascertain the level of acceptance of the PRIME scheme by rural GPs in New
Zealand.
MethodsAn anonymous postal
questionnaire was sent to New Zealand rural GPs inquiring as to their level of
involvement in and opinions of emergency care. Questionnaire design and content
were the result of consensus among a panel comprising rural GPs, executive
members of the Institute of Rural Health and the NZ Rural GP Network Inc. The
questionnaire contained a mixture of tick boxes, Likert scales and open-ended
questions, designed using Microsoft Forms™. Likert scales ranged from 1 to
5. A ranking of 1 was equivalent to a ranking of ‘excellent’ or
‘strong agreement’ with the statement, while a ranking of 5 was
equivalent to a ranking of ‘poor’ or ‘strong
disagreement’ with the statement. The resulting averages were then
compared between groups for statistical significance where possible.
Ethical approval was obtained from the University of Auckland Ethics Committee. Rural and semi-rural GPs were identified using a database provided by the Department of General Practice and Public Health, Christchurch School of Medicine and Health Sciences, University of Otago. Questionnaires were sent to 536 rural/semi-rural GPs; 105 GPs received the electronic questionnaire via email and the remaining 431 GPs received the questionnaire via normal post. Questionnaires were sent out during mid to late December 2001 and a reminder notice was sent out to non-respondents in mid January 2002. In compensation for the time taken to complete the questionnaire, a letter of acknowledgement for Maintenance of Professional Standards (MOPS) accreditation was sent to those GPs who responded. This letter allowed the respondents to claim one MOPS point from the Royal New Zealand College of General Practitioners (RNZCGP). To maintain anonymity, the GPs were asked to confirm/provide return address details on a slip with the completed questionnaire. A third party (not involved with the research) then separated the completed questionnaire from the return address slip. Questionnaires returned via email were stored separately from their email addresses so that no association could be made between the questionnaire and the respondent. The questionnaire sought demographic information, previous experience in emergency medicine, opinions regarding emergency resources/services, and level of involvement in emergency healthcare in the respondents’ respective regions. PRIME GPs’ opinions were canvassed as to their experience and satisfaction with various aspects of the PRIME scheme. Non-PRIME GPs were asked to clarify their reason(s) for not signing a contract to be involved in PRIME. ResultsFigure 1. Summary of results from
questionnaire
Overall, 290 replies were received. Completed questionnaires
were received from 224 rural/semi-rural GPs (24 via email, 200 via normal post),
providing an overall response rate of 42%. Eight were late/incomplete
questionnaires, and 58 were returned stating relocation or retirement (9 via
email, 49 via normal post). Of the completed questionnaires, 91 (41%) were from
PRIME GPs (P group) and 133 (59%) from non-PRIME GPs (NP group). Currently,
there are 266 registered PRIME providers (196 GPs and 70 Registered Practice
Nurses); therefore, we were able to sample 46% of PRIME
GPs.4 The majority of rural GPs were male
(74.6%) with no gender difference between the two groups. Mean age of rural GPs
was 45.6 years, with P group significantly younger than NP group. The
overwhelming majority of rural GPs were NZ European for both groups. The average
Rural Ranking Scale (RRS) was 47.3 points, with a higher RRS for P
group.
Table 1. Demographic profile of rural/semi-rural GPs
who completed the questionnaire
*number of respondents varies due to non-response to
some questions.
†statistically significant, p = <0.001 A significantly greater proportion of NP group (22%) are
reliant on work experience as their only source of emergency medical training
compared with P group (2%). Other sources of emergency medical training included
the Rural Trauma and Emergency Care Roadshow, RNZCGP courses, Goodfellow Unit
courses and training courses in anaesthesia. NP group contained 4% who had
trained as PRIME GPs and since left the scheme. The PRIME training courses were
distributed throughout New Zealand and were regarded as outstanding by the
majority of P group (1.7 on five-point Likert scale). P group (1.7) also
regarded PRIME retraining as highly desirable. Almost all rural GPs carried some
form of basic medical emergency equipment, such as a stethoscope,
sphygmomanometer, gloves, bandages, analgesia and inotropes. However, there were
some marked differences between both groups regarding the carriage of advanced
medical emergency equipment. For instance, a significantly greater proportion of
P group (82.3%) carried a chest drain than NP group (19.5%). The majority of P
group (93.7%) carried a laryngoscope; fewer carried one in NP group (60.2%).
Therefore, a greater proportion of P group are able to provide advanced airway
support. Regarding advanced life support, a greater proportion of P group
(45.6%) carried a defibrillator than NP group (22.0%). Also, a greater
proportion of P group (79.7%) carried cervical collars than NP group (41.5%). In
light of these differences, P group (2.0) were slightly more confident than NP
group (2.8) regarding adequacy of medical equipment for attendance at any
emergency call-out. P group carried more equipment than NP group, as identified
from a selected list of emergency medical equipment.
The PRIME scheme is still in its infancy and some GPs are
inadequately informed to consider joining. Some are ineligible for the PRIME
scheme. Many among NP group declared they were too busy within their practice,
local rural hospital and with commitments outside of work to join. Some GPs
within NP group are willing to join but cannot do so because other doctors in
the area are not willing to be part of the PRIME scheme roster. Difficulties in
attending PRIME training courses were also quoted as being a problem. Additional
reasons included lack of communication between PRIME coordinators and GPs;
living too far away from the practice at which they would be on call; lack of
willing among other practices to share after-hours emergency cover; and
reluctance to encroach on the role of the St Johns ambulance service.
Table 2. Reasons given by non-PRIME GPs for not joining
PRIME scheme
*number of respondents varies due to non-response to
some questions
On average, both groups thought there was a good level of
communication with other emergency services. However, there was some concern by
P group (2.5) regarding the level of communication with the regional
communications centre (RCC) in the notification of the emergency. Both P group
(3.1) and NP group (2.9) were concerned by the quality of triage information
supplied to them in the event of a medical emergency. Due to poor triage
information, many GPs believed they were being called out inappropriately. GPs
in both groups regard the level of triage information to be a major concern
within the PRIME scheme. Of the NP group, 11% had been involved with the PRIME
scheme in the past, all participants having been affiliated with the scheme for
less than one year. Reasons for leaving included poor triage information and
increased workload. On average, both groups believed they had usually been of
some benefit at the last 10 emergencies they attended. P group (3.3) shared
mixed views as to the level of feedback from PRIME coordinators after a PRIME
call-out.
Remuneration was thought to be insufficient overall, however
P group believed that remuneration for equipment used and trauma call-outs is
considerably better than remuneration for time on call and medical call-outs.
This reflects a positive funding aspect of the PRIME scheme. For many of NP
group, inadequacies in remuneration for time on call, medical call-outs and
trauma call-outs are acknowledged as the reason(s) for not joining the PRIME
scheme.
Table 3. Remuneration under the PRIME scheme
*Likert scale: 1=strongly agree; 5=strongly
disagree
†number of respondents varies due to non-response to some questions ‡statistically significant, p = <0.001 The majority of P group (80.9%) have been PRIME service
providers for less than two years, with approximately one third being providers
for less than one year. GPs from P group had indifferent opinions regarding
their ability to manage both rural general practice and the PRIME scheme
effectively (2.4). The overall satisfaction with the PRIME scheme amongst P
group was mixed (2.6).
DiscussionThe involvement of rural GPs in
emergency healthcare has been proven to be crucial in improving outcome,
especially in severe emergencies in which resuscitation and stabilization are
often required before patient transfer. Less severe emergencies may also be
managed by the rural GP, therefore saving
costs.5 From the results of this study, it has
been possible to identify aspects of the PRIME scheme that are outstanding and
others that need improvement. The questionnaire response rate (42%) was lower
than expected. Several factors may have been responsible. The timing of the
questionnaire over the Christmas and New-Year period was not ideal. Also, the
demanding workload and stressful conditions placed on rural GPs today may have
contributed to the low response rate.
Demographic data are consistent with those of a recent
survey of New Zealand rural GPs.6 The groups
differed in age and rural ranking scale (RRS). The difference between the
average ages of the groups may lie in the appeal of the PRIME scheme to the
younger GP. The difference in RRS may reflect the appeal of the PRIME scheme to
the more-remote rural GP. Distance from the base hospital and/or other
colleagues may mean that the remotely situated GP has no choice but to be
involved.
The PRIME scheme provides the advantage of a high-quality
training course, which was well received by all who attended. Regular refresher
courses (ie, at least once every two years) are also welcomed by P group,
although some were unaware of when these courses would take place. Some have
found it difficult to attend the week-long training course or refresher courses
due to work commitments. Reasons given included staffing inadequacies and the
difficulty and/or expense of obtaining locum cover for the week. One suggestion
offered by a participant was to run the full training course over several
weekends. This has already been tried in the South Island, at Queenstown and
Motueka.
P group also carry more emergency medical equipment than
their NP-group colleagues, which illustrates another advantage of the scheme. In
some areas, PRIME service providers are asked to share the PRIME kit. There has
been a request that each service provider have their own PRIME kit, which they
may then carry at all times. Some amongst P group have recently been supplied
with a green emergency light for their vehicles by the ambulance service as part
of their contract. A small number of NP group have already taken the initiative
to equip themselves with a green emergency light for their own vehicle. Both
groups support the addition of an emergency light for their vehicle, as it
allows other motorists to give way to the doctor/rural nurse in the event of an
emergency.
Many GPs view the PRIME scheme as being too inflexible. Some
GPs would like to be on call from home due to family commitments; others cannot
commit to 24-hour, 365-day cover. This excludes them from joining the scheme.
Some GPs wish to join the PRIME scheme but cannot due to a lack of support from
peers. This may be partially alleviated by training rural nurses, although this
raises medicolegal issues (eg, drug administration/prescribing rights). Strict
protocols and audit procedures were a disincentive to some, whilst others were
discouraged when asked to share PRIME contracts between practices.
The PRIME contract states clearly that the PRIME GP is
required to be on call according to a roster system that provides emergency
medical cover 24 hours a day, 365 days of the year. However, this may cause
significant disruption if call-outs occur during the working hours of the
surgery. Patients waiting in the rural GP’s surgery either need to be
rescheduled or seen by another GP (if present).
P group expressed disappointment over the lack of
information supplied by the RCC during an emergency call-out. Some GPs from P
group were frustrated by inappropriate call-outs by the RCC. GPs who had left
the PRIME scheme reiterated this frustration. In contrast, P group GPs in North
Canterbury report that they can wait for further information if the distance
involved is great and/or the triage information is vague or apparently
non-urgent, especially if the GP is busy at that time. Rural GPs report that
they are extremely busy with their current workload and requests have been made
for emergency call-outs to be more focused on situations that require immediate
care.
The majority of GPs in both groups agreed that they received
acceptable levels of communication from local ambulance services. Some consider
it satisfying to support local ambulance services. However, some GPs (in both
groups) do not share this view and complained of poor coordination/cooperation
between the GP/RN and ambulance services. Regular joint exercises plus
work/social meetings may help alleviate this problem.
Some GPs believed that by being trained and employed in
emergency care through the PRIME scheme, they would remove the need for
specialist ambulance staff in their area: ‘The PRIME scheme is using GPs
to cover for reduced commitment to local St
Johns.’ This could be a view
reflected by ambulance staff and may lead to poor communication within a rural
locality. However, this was never the aim for GP involvement in the PRIME
scheme. The scheme is designed to provide a coordinated response to medical
emergencies in rural locations and utilise the advanced resuscitation skills of
the GP team to complement the volunteer ambulance staff in the absence of rural
paramedics.
All trauma call-outs are funded by ACC; however, P group are
offered increased remuneration compared with NP group. In addition, P group also
receive a retainer for making themselves available for emergency medical
call-outs, which is not available to NP
group. A strong message from rural GPs is that neither is enough, although P
group regarded remuneration for trauma call-outs as somewhat improved. It is
important to note that on average there is no difference in the time taken to
attend a medical call-out versus a trauma call-out. P group suggested that
remuneration for medical call-outs should mirror that for trauma call-outs. P
group expressed significant dissatisfaction with the inadequate on-call
remuneration, with one GP (P group) stating that remuneration for time on call
was ‘merely a token gesture’. Generally, P group did not regard the
payment for time on call as adequate and believed that it should be increased to
a more realistic amount.
In summary, the PRIME scheme has significant potential to
improve the outcome for individual patients who suffer from trauma/medical
emergencies in rural communities. The improved outcome is expected to result
from the seamless integration of a quality ambulance service and a well-prepared
rural general practice team, who can contribute advanced resuscitation skills in
the emergency situation. There is no doubt that rural GPs/nurses make a major
contribution to both the quality and quantity of emergency medical services, but
they cannot replace the specialist ambulance staff. Inclusion of rural GPs in
the emergency care team needs to be recognised and adequately remunerated. The
continued development of pre-hospital emergency service contracts should reflect
this. We must ensure that we do not overwork our rural GPs/nurses, as they are
rare and precious to New Zealand.
Author information:
Todd Hore, Medical Student, Christchurch School of Medicine and Health Sciences,
University of Otago; Gregor Coster, Professor, Department of General Practice
and Primary Health Care, University of Auckland and Trustee, Institute of Rural
Health, Waikato; Janne Bills, Rural General Practitioner and Senior Lecturer,
Department of Public Health and General Practice, Christchurch School of
Medicine and Health Sciences, University of Otago
Acknowledgements:
Todd Hore was the recipient of a summer studentship from the Medical Council of
New Zealand, which funded the research. Thanks to the Department of General
Practice and Primary Health Care, (University of Auckland) and RNZCGP for their
contribution to the research. We also thank Ron Janes, Iain Hague, Graeme
Fenton, Tim Malloy, and Raina Elley for their assistance. We are grateful to all
those who completed the questionnaire.
Correspondence:
Professor Gregor Coster, Department of General Practice and Primary Health Care,
University of Auckland, Private Bag 92019, Auckland. Fax: (09) 367 7131; email:
g.coster@auckland.ac.nz
References:
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