Why do 'primary care' problems result in contact with the ambulance service? Findings from an ethnographic study
Pressures across the entire in-hours and out-of-hours urgent care infrastructure continue to increase, with evidence suggesting that the way people use unscheduled care services has changed significantly over the last decade. Increasingly, a substantial part of the ambulance service workload could more accurately be described as ‘urgent care’ cases, many of which could potentially be managed by timely contact with primary care expertise. With different models of urgent care provision across the UK, previous work by this team and others has sought to define what constitutes a ‘primary care sensitive’ contact with ambulance services. The complex reasons driving the increase in such potentially inefficient contacts remain unclear.
Drawing upon an ethnographic approach, this study used a range of complementary qualitative methods to explore ‘primary care sensitive’ contacts with a UK NHS Ambulance Service. Fifty exemplar cases were identified by an experienced GP accompanying front-line ambulance crews to calls across a range of shifts times and locations. Detailed ethnographic field notes and reflexive diaries supplemented semi-structured interviews with patients, carers and ‘in-the-moment’ focussed interviews with ambulance staff. The subsequent thematic analysis was triangulated with the findings from semi-structured interviews with the patients’ GPs and other health providers. The teachniques of Document Analysis informed a complementary analysis of healthcare records, and the original ‘999’ call-recordings were analysed according to the conventions and theories of Conversation Analysis to provide additional perspectives on the resulting healthcare encounters.
With such a rich variety of complementary data providing multiple perspectives on the same healthcare encounter, a detailed typology of triggers and circumstances that result in primary care cases receiving ambulance care has been developed. Data suggests that the process of seeking unscheduled care on behalf of someone else can change the way uncertainty is handled and projected. We explore how conversational ‘trouble’ in the initial 999-call can result in more acute outcomes from the telephone-triage process. We also explore how elements of the care provided by the ambulance crews are highly valued by patients, and how these valued aspects may offset the practical limitations that the ambulance service faces in fully resolving the clinial situation.
The findings have implications for primary care, urgent care and ambulance service providers with respect to the ways patients and their carers can be supported to access appropriate services. As urgent care is increasingly being delivered in a range of novel settings, patients may be viewing their ‘route in’ to acute services as less important than the eventual outcome. Additionally, we offer recommendations for how triage processes might be developed to become more sensitive to primary care conditions.