Implementing primary care services in or alongside EDs: qualitative analysis of a policy initiative.

Problem

Attempts to address increasing demand on emergency departments (EDs) include the use of general practitioners (GPs) in or alongside the ED (GPED). It has been estimated that between 15% and 40% of patients attending EDs in the United Kingdom could be treated in primary care, particularly those aged between 16–44. The 2015 ‘Keogh review’ of urgent and emergency care in England recommended co-locating primary care services alongside the ED and “streaming” of patients attending with primary-care problems to this alternative provision. At that time it was estimated that 43% of UK EDs already had some form of co-location.In March 2017 £100m of Capital funding was allocated by the UK Chancellor to support the development of GPED in England. NHS hospital trusts could bid for funds to support the implementation of GPED, which was a mandated healthcare policy. However, there is limited data on the benefits of introducing such a model; its effectiveness, potential risks and possible unintended consequences.The aim of this study was to explore whether NHS Trust leaders’ expectations of GPED were realised a year after introduction, and how the policy was implemented in practice.

Approach

Semi-structured telephone interviews were conducted with managerial and clinical leaders in 59 NHS Trusts that received capital funding to support the implementation of GPED, to explore their expectations. 26 repeat interviews were conducted one year later to discover whether their plans have been realised successfully.

Findings

Interviewees expected that streaming to a GP in the ED would result in improved management of patients presenting with primary-care problems and a reduction in associated resource use. Expected impacts included improvements in: ED performance against the “four-hour standard”; waiting times; quality of care; patient-safety; patient satisfaction. The actual experience of introducing GPED for both system-leaders and front-line staff, including GPs, was varied. Success of implementation was based on operational, structural and organisational factors. Some reported the introduction of GPED had realised their expectations resulting in positive outcomes. Others reported several challenges, particularly with governance, recruitment and retention of staff (especially GPs), and little impact on patient waits or performance. Some abandoned GPED altogether. Reported concerns included the possibility that introducing GPED increased attendances, but such increases were rarely explained by GPED. The impact on surrounding primary and community healthcare providers was difficult to establish.

Consequences

Rapid introduction of health policy supported by the offer of capital funding does not always result in the intended outcomes. National policy is implemented by, and in response to, local actors and influences; the result can be a service that is more complex than anticipated. Focusing on a single area of provision may fail to take account of potential impacts on the wider health and care system.