Introduction

Why develop general practitioner services in the emergency department?

The urgent and emergency care (UEC) system includes emergency departments (EDs), ambulance services, NHS 111 and urgent GP appointments.1 Currently, there is a significant mismatch between capacity and demand, with attendances at Type 1 EDs increasing year on year and reaching record levels.1,2 This increasing demand, together with high hospital bed occupancy, leads to ‘exit block’ in the ED, creating crowded EDs and delays to treatment.3 These challenging conditions make it difficult to provide safe care and contribute to staff burnout and failure to retain highly skilled professionals.2,3

To meet demand, we need to ensure that patients can see the right person at the right time to meet their needs. A proportion of patients attends the ED with problems that could be effectively managed in community primary care.2 Some EDs deal with this group by redirecting patients from the ED back to their own general practitioner (GP). Other hospitals have employed GPs to work in or alongside the ED to see these patients.

There has been growing international interest in using members of the primary care team in or alongside EDs.4 Urgent and emergency care services are highly variable and have often been described using inconsistent terminology.5 The 2010 Primary Care Foundation report identified three main GP-ED models used in the UK: GPs working geographically ‘adjacent’ to EDs; GPs serving in a triage and screening capacity; and GPs fully ‘integrated’ into ED service provision.6 Ablard et al.7 later highlighted additional models including ‘co-located’ urgent care centres and GP out-of-hours (OOH) services.

The 2014 NHS Five Year Forward view8 suggested UEC services should be redesigned to integrate EDs with primary care and in 2017 a significant NHS England funding initiative allowed EDs to apply for one-off payments to develop new or existing services to support streaming patients to GPs.9 However, the evidence base for these interventions is underdeveloped. A 2018 Cochrane review identified only four studies for inclusion, concluding there was insufficient evidence to conclude whether primary care services in the ED (referred to as GP-ED models in this report) were effective or safe, with the impact on patient flow and waiting times remaining uncertain.10 Due to the paucity of evidence available, NICE chose not to make any recommendations for practice regarding GP-ED models.11

Important concerns about potentially negative impacts of GP-ED models include causing an unintended increase in ED attendances due to ‘provider-induced demand’,12 or because the primary care workforce is finite and already struggling to manage increasing workload and GP-ED models may lead to decreased community primary care capacity.13 The training needs of staff working in GP-ED models to ensure safe care and the cost effectiveness of these services are also unknown.

The commissioning brief

This study was designed and conducted in response to a commissioning call from the National Institute of Health and Care Research (NIHR) to evaluate the effectiveness, safety, patient experience and system implications of the different models of GPs working in or alongside EDs.

While the commissioning brief focused on the role of GPs in EDs, during the course of the study it became apparent that primary care services in EDs are being delivered by a range of staff including GPs and both nursing and paramedic advanced clinical practitioners (ACPs). While the specific role for GPs in EDs remained a focus of the project, where our findings were also relevant to the wider primary care teamworking within/alongside the ED, we indicate this within the report.4

Aims of the study

Four key research questions were identified:

1. What models are in place? How are they staffed/funded/operationally managed/performance managed? On what scale are they delivered?
2. How do the models work (in comparison with standard practice)? Is the way they work in line with the intentions of those who set them up?
3. What are the outcomes of each model in terms of: percentages of ED attendances seen; admissions; reattendance rates; waiting times; costs; patient safety; patient experience; team impact and sustainability?
4. What are the relationships between these contexts, mechanisms and outcomes, and is the evidence base transferable to commissioning, service improvement and cost-effective delivery in other settings?

The research approach

The study used a realist evaluation approach collecting mixed-methods data across three phases (see Figure 1 for summary). Realist evaluation (described in detail in Chapter 2) is an iterative approach, in which theories about how, why, where and for whom interventions work are developed, tested and refined.

FIGURE 1 Three phases of data collection and analysis. (Figure not reproduced here; see the original article.)

Preliminary preparatory activities in the pre-funding period (Phase 0) included: identifying ‘marker conditions’ which could be used to focus the later data collection and analysis (see Chapter 6); analysing existing patient safety incident reports from the National Reporting and Learning System (NRLS) which related to GP-ED models;14 analysing Coroners avoiding future deaths reports relating to GP-ED models.14

Phase 1 activities focused on developing theories about how and why different GP-ED models worked for testing in the later phases. Theory development activities included:

• a rapid realist review (RRR) of the existing literature (including 96 studies, Chapter 3)15
• a service evaluation of current GP-ED models [including a national survey and follow-up interviews with selected clinical directors (CDs); Chapter 3].

In Phase 2, we collected and analysed mixed-methods data at 13 case study sites (10 with a GP ED model and 3 without GPs) to test our theories, including:

• qualitative data from case study sites (observations, interviews with patients and staff, local patient safety incident reports; see Chapter 4)
• centrally held routinely collected ED data for each site accessed via NHS Digital/Digital Health and Care Wales (DHCW) (for interrupted time series and cost–consequence analyses, see Chapter 5)
• additional data for health economic analysis at a selected exemplar site (see Chapter 6).

Phase 3 involved the triangulation of each data set to refine our theories and develop our programme theory along with a toolkit for stakeholders based on our findings (see Chapter 7).

Deviations from the original protocol

Limitations in the availability of data necessitated some changes to the original protocol:

1. Emergency care data set (ECDS) data were not available for the case sites. Routine data were therefore collected from hospital episode statistics [accident and emergency (HES-AE) and admitted patient care (HES-APC), via NHS digital] for case study sites in England and emergency department data set (EDDS) and patient episode database for Wales (PEDW) data sets [via secure anonymised information linkage (SAIL)] for one study site in Wales.
2. The planned medical record reviews for marker condition analysis were found to be too time consuming with hard-to-decipher handwritten medical notes. The co-applicants opted for local case site data collection as an alternative. Pandemic and other constraints meant only one site was able to share these data for analysis.
3. The health economic analysis was changed from activity-based costing methods to cost–consequences analysis (CCA) following consultation with the steering committee with an awareness of data quality.
4. To improve patient recruitment for interviews, we added another ‘marker condition’ and recruited patients onsite as well as via mail.
5. Our second stakeholder conference was well attended in December 2019 by a wide range of stakeholders. This was used for some validation of findings since the planned second survey was not conducted due to the COVID pandemic.

Public involvement

Two experienced public contributors (JH and BH) were recruited from the Health and Care Research Wales Public Involvement Network to join the research development group to plan the study. They took part in all discussions about the research questions and proposed methods and drafted the plain English summary for the proposal. They shared responsibility for the bid sections about proposed public involvement, including reviewing the proposed budget (total and for public involvement). They were named co-applicants in the outline and full applications. After funding confirmation, two further public contributors were appointed to the Steering Committee, responsible for independent oversight of the study.

We were committed to continuing our relationship with the two public contributor co-applicants throughout the study as equal members among all co-applicants within the research management team. We named an academic co-applicant in the funded post of Public Involvement Lead and tasked her with supporting and facilitating public involvement.

This team developed a detailed role description at study outset, approved by the research management team. This set out how public involvement, summarised in the research application, would be undertaken in practice. Throughout the study, the team communicated regularly and met annually to review the activities carried out and update documentation on public involvement roles and responsibilities.

We describe below public involvement roles and activities in each phase of the study and compare these to our original public involvement plan developed in our project proposal (Table 1). A paper describing our involvement processes, impacts and learning has been published (see Project web page).16

Phase 1

Public co-applicants were involved in all aspects of work in this phase including:

• reviewing all participant information and data collection tools and processes which were submitted for Research Ethics Committee approval.
• membership of working groups, helping to plan and undertake:
  • the rapid review of evidence including forming initial theories; a survey of hospitals and preparing data collection tools; selection of case study sites (see Chapter 3)
  • case site data collection and analysis (see Chapter 4)
  • overall management and scrutiny
• planning and delivering the first stakeholder event including recruiting public participants (n = 6 attended), designing elements of delivery and materials, facilitating workshop discussions and presenting results alongside researchers (see Chapter 3)
• proposing additional marker conditions based on feedback from stakeholder event.

During Phase 1, public co-applicants also undertook a Public Involvement audit to assess activity in line with the recently published UK Public Involvement Standards.17 Changes to improve practice related to:

• recruiting more diverse public participants at stakeholder events
• improving communication
• undertaking training reviews
• strengthening involvement in dissemination.

To improve communication and current awareness of study activity, public co-applicants requested monthly updates from the Project Team. These regular, succinct reports kept them informed of actions and discussions between management meetings.

Following the audit, the public co-applicants proposed recording impact of public contributors as the study progressed. Co-applicants agreed that the regular Public Involvement agenda item (at Study Management Group meetings) should also include a ‘Public Involvement Impact’ box where all co-applicants could regularly record evidence of impact.

Phase 2

During this phase, the public co-applicants were particularly involved in discussions regarding patient interviews and identified ways to address poor response rates, including rewording patient information sheets and recruitment letters, using hospital letterheads and offering gift tokens to respondents.18 These were implemented and resulted in an improved acceptance rate.

Public co-applicants reviewed transcripts of interviews with patients and CDs.19,20 They identified themes, which they discussed with qualitative researchers and contributed to data synthesis. They contributed ideas about why patients might have responded the way they did and possible reasons for not participating in interviews. The themes they identified were in line with those put forward by the researchers. The public co-applicants reported that this exercise gave them a real feel for the research on the ground and greater insight into data quality, patient experience and complexity of the models which helped inform their involvement. In turn, the researchers found it useful to have their initial theories confirmed by the public co-applicants.

Public co-applicants were actively involved in planning the second Stakeholder Event. Changes implemented after contributions by public co-applicants at planning meetings included:

• written clarification of the scope of the event and the meaningful role of the patient attendees
• amendment to the recruitment method, letter, instructions for attendees and timetable
• membership of discussion groups to include a mix of researchers and public contributors.

Barbara Harrington and Julie Hepburn co-presented and co-facilitated a workshop based on findings relating to patients’ acceptability of primary care streaming on the day. Eleven public contributors also attended, alongside other stakeholders.

Phase 3

This phase included the submission and publication of papers relating to study findings and public involvement. The public co-applicants co-conceived and co-authored papers about public involvement and drafted this section of the final report. They also contributed as co-authors on other publications. The public co-applicants were particularly keen to ensure that the findings of this study are accessible to a lay audience. To support this, they wrote lay summaries for each of the published papers. These are listed with the full papers on the website and in the study ‘newsletter’ [see GPs in EDs (PRIME Centre Wales)].

To ensure that study results will be disseminated to the public, public co-applicants recommended widening the Dissemination and Publication Strategy to include Engagement. To identify ways of improving public dissemination, one of the public co-applicants (JH) collected views from a public and patient group linked to Primary and Emergency Care Research (PRIME) Centre Wales21 and used their feedback to produce an outline plan. This co-applicant also approached the Communications experts within Health and Care Research Wales Public Involvement and Engagement them, who agreed to facilitate media engagement.

The public co-applicants contributed to the design and development of a toolkit (see Chapter 8) offering practical suggestions on improvements EDs can make based on findings from this research.

Finally, the public co-applicants initiated, planned and conducted a group interview of study co-applicants to reflect on experiences of public involvement in the project. This was transcribed and analysed using thematic analysis. These findings, plus records of public involvement activity and impact, have been published.16

Conclusion

Public contributors were actively involved in data collection, analysis and dissemination. They attended management, scrutiny, planning and task meetings. In addition to their role in study management, delivery and dissemination, the public co-applicants developed and facilitated public involvement in the study identifying further opportunities for them to contribute and critically reviewing the effectiveness of their involvement as the study progressed.

The public co-applicants contributed directly to the management and delivery of the study and helped maintain awareness of patients’ perspectives among the whole co-applicant team. In addition, we have reflected on public involvement in this project to identify factors enabling effective involvement so that other studies can learn from our experience.16

Collaboration with University of West England general practitioner–emergency department study

The NIHR funded two separate projects following the commissioning call. The GP-ED study was led by Professor Jonathan Benger, University of West England (UWE).22

The two study teams identified the value of collaboration across the two projects to maximise learning by sharing information across two projects, minimise unnecessary duplication and ensure consistent terminology across GP-ED research was used by both projects.

Joint activities conducted included:

• initial survey (Cardiff Team led) supplemented by additional national data collection (UWE led) to form a single data set describing current GP-ED models in place at UWE 22 March 2018
• taxonomy development (Cardiff-led)
• stakeholder events – Cardiff-led events attended by UWE team (27 February 2018 and 3 December 2019) and UWE-led events attended by Cardiff team (16 November 2018 and 20 October 2020).

Changes in health care following the COVID-19 pandemic

Most data collection for this study was completed in April 2019, before the global COVID-19 pandemic. The pandemic hugely impacted all areas of health and social care. In response, new models of working were rapidly introduced, including a move to telephone consultation before or instead of face-to-face assessment, in community primary care and at some EDs. Despite the changes in healthcare delivery since the study was conducted, our findings remain highly relevant and can usefully inform new ways of working including:

• how to safely and effectively redirect the right patients away from ED care and towards primary care
• how patients experience alternative models of delivering urgent care
• ensuring new service models do not drive additional demand
• understanding what primary care staff working in ED settings need to practice safely and effectively.

Structure of the report

Chapter 2 describes the realist methodology and its application in this study. It also describes the preparatory activities undertaken as part of Phase 0.

Chapter 3 describes the Phase 1 activities including the RRR and service evaluation. It also includes information about the Phase 1 stakeholder event and the production of an agreed taxonomy of GP-ED models as a key Phase 1 output.

Chapter 4 describes the methods used for qualitative data collection in Phase 2 at the case study sites. It includes the realist analysis of these data, which develops the Phase 1 theories further.

Chapters 5 and 6 cover the methods and findings from the quantitative data analysis of the routinely collected data obtained for Phase 2 sites. They also include the ‘marker condition’ analysis completed for a single site.

Chapter 7 describes Phase 3 of the project in which the qualitative and quantitative results were triangulated to further refine our theories.

In Chapter 8, we discuss our findings and describe the toolkit produced.