The Essence of Urgent Care

Those of us who work in urgent care know exactly what it is and the value it brings. Yet despite the Royal New Zealand College of Urgent Care (RNZCUC) being in operation for more than 30 years, awareness remains limited—both among the public and even among some hospital colleagues.

The Royal New Zealand College of Urgent Care (RNZCUC) defines urgent care as: the specialty that provides care for patients with acute injuries and illnesses that are not immediately life-threatening, but that require treatment within 24 hours. It is one of New Zealand’s four recognised frontline specialties, alongside General Practice, Emergency Medicine, and Rural Hospital Medicine.

The Reality on the Ground

Urgent care is not simply a midpoint between general practice and emergency medicine; it is a discipline in its own right. On any given shift, the breadth of presentations can be wide and unpredictable, and this is under-recognised. We can go from dealing with something very minor to a life threatening emergency in a heart beat without any warning. There is no ambulance pre-alert as happens in the ED; no time to prepare. We are straight into it.

In my own practice, I have seen cases as varied as finger amputations, children in DKA, ventricular tachycardia, STEMIs, massive PEs, septic arthritis, cardiac arrests, spinal injuries, and open fractures. Some colleagues have dealt with paediatric arrests and gunshot wounds. I once treated a patient with a circular saw injury to the face that transected the mandible and facial artery; another presented with a spontaneous coronary artery dissection (SCAD). These aren’t everyday occurrences, but they exemplify the acuity that can and does walk through our doors. We have to ready for anything.

A common misconception is that serious cases are simply handed over to ambulance services. In reality, delays in ambulance response are frequent, and urgent care doctors have to act decisively. In the past I have for example had to chemically cardiovert a broad complex tachycardia with amiodarone and have started an adrenaline infusion for profound bradycardia while awaiting transfer.

Alongside these higher-acuity presentations is a steady flow of upper and lower limb trauma: shoulder dislocations, ankle fractures, Achilles tendon ruptures, Colle's fractures. We find that most shoulder dislocations can be reduced with entonox or a low impact technique such as the Cunningham technique. We manage a lot of Colles fractures conservatively and sometimes I will do a reduction under haematoma block. In my clinic we usually manage Achilles tendon ruptures conservatively via a visiting orthopaedic specialist. We also manage a significant volume of other fractures conservatively, providing immobilisation, follow-up, and ongoing care, keeping many patients out of hospital fracture clinics.

Many presentations we see are very vague and undifferentiated. The patients are often unaware how serious things are. These "grey cases" are where the real skill comes in. If we can make a good early diagnosis and expedite treatment this can sometimes have a significant impact on outcome.

Over the years I have come to see and experience how different specialities are influenced and change as result of external factors. Change is inevitable. The main forces that shape the frontline are (1) political and system forces, (2) advances in medicine and (3) patients themsleves.

Political and System Forces

Government health policy, funding models, and local resources influence not only patient flow but also the scope of practice.

An illustrative example comes from my time working in Queenstown, designated as “rural” at the time. On site we had X-ray and occasionally ultrasound. There was no CT scanning or surgical services locally. There was a lab which could do basic tests but something more complicated like a serum β-hCG tests would have to be sent to Dunedin. In that environment, necessity expanded our practice. The GP-urgent care clinic managed approximately 90% of ski-related trauma. We performed Colles fracture reductions under Bier’s block, and managed most lower limb injuries in-house. Referral to Dunedin or Invercargill was reserved for those who truly needed higher-level care, because the alternative was a significant travel burden for patients.

At the same time, urban urgent care clinics face their own pressures: voucher systems to offload EDs, funding incentives for children, and seasonal surges when general practices close over the summer break. Ambulance services in Auckland are stretched and under constant pressure to offload patients at urgent care clinics.

In ED, the growth of nurse practitioners handling minor trauma and procedures (Colles fracture reductions, shoulder dislocations, Bier’s blocks) has shifted the experience base for junior and senior doctors alike.

Advances in Medicine

New treatments and pathways constantly redraw boundaries. ST-elevation myocardial infarction (STEMI) for example used to be the domain of emergency physicians and medical registrars, deciding on thrombolysis. Now, interventional cardiology and PCI dominate. Similarly, acute stroke pathways increasingly bypass ED doctors in favour of neurology-led interventions.

General practice, particularly in urban areas, has also shifted. Appointment-based models and the sheer burden of chronic disease mean GPs do fewer acute procedures. By contrast, urgent care has retained and expanded much of this practical skill base.

General Medicine has changed a lot since I was a medical registrar. In those days it was unofficially expected that you could do the full range of practical procedures by the time you had completed the MRCP. We placed central venous lines using only landmarks(yikes!) and there was the not infrequent drama of temporary pacing wire insertion with the patient often arresting mid procedure. These procedures made the job more fun. Now though with advent of POCUS it would be considered negligent to not use ultrasound for CVL insertion and temporary pacing has become the domain of cardiology. Most medical registrars and consultants have become de-skilled at these procedures. More than this the rise of Emergency Medicine as a speciality has taken away a lot of acute experience from General Medicine trainees. In days gone by the medical registrar had a prime role in the ED particularly with arrhythmia management and cardiac arrests. All specialities change!

Patients Themselves

Patients play a critical role in shaping urgent care. They make choices based on access, cost, and expectations. General practice in Auckland is under significant manpower pressures and many patients cannot obtain timely appointments.

Patients with acute injuries or illness are often not prepared to wait weeks to see their GP, nor are they willing to endure prolonged waits in an ED for conditions they perceive as urgent but not immediately life-threatening.

A recent case highlights the importance of this pathway. A teenager developed urosepsis due to an unusual renal abnormality. She attended an ED but left after learning about the wait time. She then presented to urgent care, where she was correctly diagnosed and referred to the appropriate acute specialty. Without urgent care as an alternative, the outcome might have been very different.

Urgent care also provides access for patients who are new to the country or otherwise not enrolled in general practice. Just recently, I saw an elderly woman who had newly arrived from overseas with undiagnosed type 2 diabetes who needed full input. I started appropriate medications and arranged a private specialist appointment.

Care at all times

The case mix that we see at urgent care clinics is not within our control. It is shaped by multiple forces. This makes it difficult to capture the true essence of urgent care in any formal definition.

What is clear is the scale of the contribution: every day, urgent care absorbs a workload that would otherwise land in EDs and orthopaedic services. Yet this contribution remains largely invisible outside the specialty.

Having worked across multiple specialties in both the UK and NZ, I can say with confidence that urgent care is vital to the New Zealand health system. Patients need an alternative to GP and ED. Urgent care provides that; timely, safe, effective care for those who might otherwise fall through the cracks.

But urgent care is more than a safety-net. It is a standalone specialty demanding a broad skill set, confidence across diverse presentations, and the flexibility to work with whatever resources are at hand. That readiness is our defining feature.

The RNZCUC motto, Semper sanamus — “care at all times” — captures both the mindset and the mission of urgent care. It emphasises readiness, reliability, and the enduring purpose of our work: to provide care and support patients whenever, wherever and however they present. This is urgent care medicine.