In a pioneering corner of south London he does not have to make that choice. As one third of the 70,000 patients who visit the accident and emergency department at King's College hospital each year really need a GP, a GP is who they see.
In Camberwell, in deciding to take the GP to the patient, they have rubbed out the firmly-drawn line between the hospital and the community.
Everyone who attends the new Accident and Emergency Primary Care Service is first seen by a specially-trained nurse who decides whether the patient is to be seen by a hospital doctor or needs 'primary care' and should be seen by a family doctor.
The man with the blister was seen by a King's GP who sought out the reasons for his condition. He had been evicted in his slippers and walked the streets for three days. The GP used his local contacts to put the man in touch with community agencies.
In the department they have stopped referring to the 'inappropriate use' of accident and emergency services by feckless patients and have started to make the service fit the patient, instead of the other way around.
Apart from the life and death emergency, there is no suggestion that the GP-designated patient is less ill or less important than the accident and emergency patient. Between 1 per cent and 2 per cent of the GP patients are admitted to the wards.
In his report on reshaping London's health services, Sir Bernard Tomlinson recommends the setting up of 'extended primary care centres' to look after the particular needs of a fluid city population. He commends the department at King's as one model.
This is despite the poor physical state of the department and the bad publicity it attracted when patients waiting for admission to wards were left on trolleys in corridors. One elderly man died. Work on a new department begins in spring.
In the department, they point out that that problem was a log-jam on the wards rather than faulty emergency care. At the time, the new system was already being tested.
Dr Jeremy Dale, a GP in Southwark, senior lecturer in primary care at King's College School of Medicine and Dentistry, and leader of the project, said: 'What we are doing is introducing the GP into the department as a specialist. GPs do have special skills and they are more experienced doctors than the senior house officers.'
They realised that junior hospital doctors were not trained in the type of primary medicine that one third of patients needed. Their research shows that the GPs were, in fact, better at treating primary care patients.
'When there is a major emergency they also come into their own, talking to relatives and making sure the department continues to run,' Dr Dale said.
Two months ago the team published its research results and immediately sold 300 copies to health authorities and hospitals. Hospitals in Brighton and Lewisham have already copied the scheme and St Mary's Hospital, London, plans to follow. Later this month King's will publish a guide to setting up a combined service.
Seven local GPs work for three hours a day, seven days week, between 1pm and 9pm, when the department is busiest. There are plans to extend the primary care project, with more innovative ideas, including a phone-in advice service staffed by a nurse and a night-duty doctors' co-operative.
The accident and emergency GPs have all received formal GP training and have their 'surgery' in the department. The GPs also train the hospital doctors once a week in 'patient-centred' skills, in which patients are encouraged to talk; the hospital doctors are encouraged to sit with the patients in the GPs' consulting room rather than stand by the beds in the accident and emergency cubicles.
The GPs are proving cost-effective. The research found that the young registrars and senior house officers called for five times as many blood tests as GPs and twice as many X-rays. When GPs asked for X-rays, they were better at picking up abnormalities. Junior hospital doctors prescribed 10 per cent more items per consultation. But there was no evidence that the GPs were 'undertreating'. Primary care patients seen by either group needed the same amounts of treatment later. The GPs at King's are paid between pounds 65 and pounds 70 for a three-hour session - not by the hospital but by the local Family Health Service Authority, which has made the 'intellectual leap' of accepting that responsibility for primary care, wherever it is provided (GP surgery or hospital), Dr Edward Glucksman, director of the department, said.
When Dr Glucksman, an American, was appointed as accident and emergency consultant 10 years ago, he amazed everyone by visiting all the GPs in the area. He is the architect of the primary care project and says that the theme of 'place' recurs. 'We saw that for many patients it was the place in which the event happened that determined whether or not they came to the emergency department. When someone has an epileptic fit at home the family knows how to cope. If it happens in a shop or in the street it becomes an A & E case. Often it is the person responsible - the teacher, an employer - who sends the person to A & E,' he said.
He also recognised that there was a traditional pattern of using emergency departments as 24-hour surgeries in cities. 'For many that is a good choice,' he said. 'Discouraging patients from using the A & E department was never going to be the complete answer.'
Primary Care in A & E; establishing the service; available later this month, Department of General Practice, King's College School of Medicine and Dentistry, Bessemer Road, London SE5 9JP.
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