Reverse-referral scheme for low‑acuity ED patients draws just 5% uptake after two years

The emergency department introduced a reverse-referral circuit about two years ago, approved by the government to redirect patients with primary-care complaints to their family doctors. Two years on, only around 5% of users who could be referred accept leaving the hospital without being seen, on the understanding they will be seen by their GP (or another primary-care physician) within 48 hours.

Ivette Ruiz, head of the emergency service, says the low uptake is “multifactorial”: the message may not have reached the population; patients decide based on their own perception of illness and need for immediate care; and arranging a primary-care appointment within 48 hours can be difficult given GPs’ schedules. She notes the system requires the patient to accept the referral at triage, after which staff try to arrange a GP appointment before the patient leaves.

Ruiz compares the current experience to the introduction of out-of-hours primary-care shifts, which also took time to become known and accepted but are now established. Ease of access helped: out-of-hours services are located in the hospital’s outpatient area, so patients are often directed there first because it shortens waiting times and is convenient. A similar familiarity and awareness would help the reverse-referral pathway, she says.

One common reason patients stay in hospital is that an appointment cannot be secured within the 48-hour window. Ruiz acknowledges the collaboration and willingness of primary-care doctors to operate the circuit, but also highlights pressure on primary-care consultations as a limiting factor.

Approximately two-thirds of patients who visit the emergency department are triage levels 4 and 5, indicating low urgency. Of those, about 20% would be suitable for reverse referral. Some patients at low triage levels still need emergency attendance because their condition requires complementary tests, such as X-rays.

What drives waiting times are peaks in demand—seasonal increases in winter, mid-day surges, and specific events—rather than the presence of low-complexity patients alone. The emergency department is organized to separate low-urgency and high-urgency flows, and for the past two years a dedicated mobile emergency unit (SUM) team, detached from inpatient care, has helped speed up attention for less serious cases. Ruiz says that having a separate team has reduced waiting times for these patients, who previously could be isolated in queue while the team attended other tasks.

The service plans internal work to identify improvements that could increase uptake of reverse referral. Ruiz suggests assessing whether the explanation given to patients is clear and accepted, and whether additional efforts or communication strategies could encourage more patients to use the pathway.