Paying the price for nowhere else to go

Brayden sat in the emergency department (ED) waiting room, eyes fixed on the floor. He’d checked the clock three times in the last ten minutes. Around him were coughing toddlers, older couples speaking in hushed voices, and a paramedic wheeling someone straight past the queue.

“I don’t want to be here,” he said quietly. “I understand there’s a backlog. If I’m just sitting here, burning people’s time, I don’t want to take time away from someone who needs it more.”

Brayden knew his condition wasn’t life-threatening. But in his town, the local GP clinic had told him to go to ED. There were no appointments available for weeks.

His experience is common. Rural Australians attend EDs at much higher rates than people in cities, and within rural areas there is a stark social gradient: people living in poorer neighbourhoods are three to seven times more likely to end up in ED than those in more advantaged areas.

Despite this, the dominant narrative is one of “inappropriate attendance”, suggesting people misuse emergency services. This overlooks how little choice many people have.

Isabel, the mother of a four-year-old boy living hours from a city, knows this well. When her son became unwell, she went to the ED because there were no alternatives.

“Accessibility to care is the most important thing,” she said. “It’s so hard to get an appointment. I would go to the GP if they were available, but that’s unlikely. It usually takes two weeks.”

Like many rural parents, Isabel made a practical decision shaped by concern that something might go wrong if her son was not assessed. The ED was the only door open.

These experiences matter not only for rural Australians, but for the health system itself. An ED presentation costs the government, on average, more than $690. A GP visit costs closer to $80 — a difference of more than $600 each time someone ends up in ED for a problem that could potentially have been managed in primary care.

Across thousands of presentations annually, these costs accumulate rapidly, with little added benefit for patients whose conditions are not emergencies.

This is bad economics, and bad for trust. Brayden and Isabel do not feel entitled when they arrive at ED. They feel guilty. They worry they are taking resources from someone who “needs it more”, even when the system has funnelled them there. EDs become crowded, staff burn out, and rural hospitals are increasingly required to provide primary care, after-hours care, and crisis response simultaneously — often constantly re-prioritising limited resources.

Importantly, the solution to crowding is unlikely to sit within the ED. Our extensive review of global evidence on ED crowding showed that the main drivers lie outside the ED: who attends, why they attend, and whether they can leave hospital safely. Yet most initiatives focus on moving people through ED faster and don’t work.

What the evidence suggests are whole-of-system solutions: services designed around local needs, better coordination between clinics, hospitals and community care, and approaches grounded in understanding why local people end up in ED. This means investing in prevention, early intervention, and accessible care close to home. It means supporting a sustainable workforce rather than relying on EDs to fill every gap. And it means recognising that when people choose ED, it is rarely a choice at all.

Back in the waiting room, Brayden’s name is finally called. He is relieved but uneasy. He shouldn’t be there — and neither should the system have to pay the highest possible price for the only option left open to him. We can, and should, do better.

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