Phase 1

Overview of Phase 1 work

This chapter describes the work undertaken in Phase 1 of the project, which were later used to inform data collection in Phase 2. We summarise five key pieces of work: a rapid realist literature review, a service evaluation of current GP-ED models (undertaken via online survey and key informant interviews), development of a taxonomy of GP-ED models, selection of a set of potential marker conditions and an analysis of existing safety reports relating to GP-ED models.

Rapid realist review

Rationale for rapid realist review

The focus of our review was to develop initial theories about the contexts within and mechanisms by which the different GP-ED models produce the intended and unintended outcomes. Although there had been several systematic reviews undertaken exploring GP-ED models, their narrow inclusion criteria limited the evidence included and their conclusions. We sought to glean explanatory information from a wider range of data sources including policy documents, case study reports and opinion pieces to contribute to our theory building process. We used the previous recent reviews12,49,50 as a starting point for a RRR that focused on theory development. We did not seek to use the realist review for theory testing because we planned to collect primary data in Phase 2.

Methods

A detailed description of the methods used for the review is published elsewhere.15 In brief, we followed the steps for RRR outlined by Saul et al.51 in which we used our co-applicants as an expert reference group. Our review was registered on the PROSPERO database.15 The review was carried out between April and September 2017. An initial scoping exercise of four UK papers52–55 identified in a previous systematic review12 and two policy documents6,56 was used to generate a set of 27 initial theories (grouped into themes) which were developed and refined following discussions with our expert group. To further develop these initial theories, we then sourced the papers included in the earlier reviews and combined the search terms used in these reviews to identify more recent studies (see search strategy in Report Supplementary Material 1).15 We performed forward and backward citation tracking of included studies and asked our expert group to contribute papers.

There were no restrictions on the type of study included. Data were judged at the level of the individual extracts based on their relevance to the developing theories and the rigour of the methods used to generate the data.26 Papers were excluded if they lacked explanatory power or were unavailable in English. Two authors extracted data into NVivo 11 (QSR International, Warrington, UK) and met weekly to discuss their interpretation. A co-applicant working group (AP, PA, BAE, BH, JD and ACS) met 6-weekly to discuss review progress and guide priority areas of focus for further searches and data extraction. As the review progressed, limitations of the available evidence were recognised, with notable gaps in some areas (e.g. impact of GP-ED models on the wider healthcare system). The expert group considered this was more likely to represent a lack of available evidence rather than a deficiency in the search strategy used. As such, at the end of the review process, many of the candidate theories remained untested or only weakly supported by the available evidence. We published our findings in a paper entitled ‘The impact of general practitioners working in or alongside emergency departments: a rapid realist review’15 (published via CC BY 4.0.), extracts from which are reproduced in part in the section below.

Results

The sources of papers contributing to the review are outlined in Figure 2.

FIGURE 2 Sources of papers contributing to RRR from Cooper et al.15 published via CC BY 4.0. (Figure not reproduced here; see the original article.)

Most of the included papers were British (n = 44), and a significant proportion were Dutch (n = 17). Other studies included came from Ireland, Belgium, Switzerland, Sweden, Italy, Finland, Australia, USA, Canada, Singapore and New Zealand.

Included articles were largely observational studies (n = 74) but also included organisational reports (n = 7), controlled studies (n = 5), qualitative studies (n = 5), opinion pieces (n = 3) and modelling studies (n = 2).

Results of the review

The initial scoping work and subsequent expert group discussion identified 27 candidate theories, categorised into five themes: streaming and flow, the GP role, patient satisfaction, patient safety implications and wider system implications.

Those which we were able to refine, or were supported by the review data, are discussed below, together with the CMOC developed. The remaining candidate theories stayed on file for the research team to refer to during the Phase 2 data collection.

Streaming and flow

Candidate theories about streaming and flow explored ideas about how staff made streaming decisions, who was the best person to perform streaming and how streaming might lead to duplicate assessments.

Using the literature, the CMOC developed was:

General practitioners and ED staff use their own personal experience and expectation (C) when interpreting streaming guidance (M) to influence which patients are streamed to GPs (O).6,53,54,57,58

The process of streaming patients to the GP service was observed to influence service effectiveness. Variable streaming rates were described due to differences in guidelines and also how the guidance was interpreted by ED clinical and non-clinical staff of varying experience.7,58–61 Staff were sometimes described as being unclear which patients GPs could deal with,7,55,54,59,62–64 or being more familiar with ED work so favouring ED referral,7,58,59,63,65,66 even over-ruling the guidelines if they felt that the patient would require specific investigations63 or admission.58 When there was a good relationship between the GPs and ED nurses,62 and when the GPs were directly involved in the streaming process, increased streaming rates were reported.67,68 GPs were also noted to over-ride nurse decisions to select patients that suited their own interests or perceived skills.69

The role of the general practitioner

Our candidate theories about the roles GPs undertook in EDs explored how the characteristics of individual clinicians and the way in which they were expected to work could influence their approach.

Using the literature, the following CMOC was developed:

When GPs working in the ED maintain a ‘traditional role’ using the same approach taken in the primary care setting (M) to treat patients with primary care problems (C),7,66,70–73 investigations, admissions and process times will reduce (O).54–56,61,72–78 However, if GPs adopt an ‘emergency clinician role’ working as another pair of hands (‘going native’) because of their personal interest or experience or because they feel this is the correct way to work in this setting (M), there will be no difference in the rate of investigations and admissions (O).7,62,66,79

Material in this section has been reproduced from Cooper et al.15 This is an open access article distributed under the terms of the Creative Commons CC-BY licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.

The traditional GP approach was described by many authors as a different approach to risk management and diagnostic uncertainty, with less reliance on acute investigations.7,66,71–73 This approach was maintained in a variety of different settings including when GPs worked in parallel to the ED in their own room54,55 and also when GPs worked in a more integrated model, alongside ED clinicians.61,72,73 There were multiple examples of GPs managing non-urgent patients using this approach to divert attendances from ED staff.59,64,67,68,80–93 Several services used GPs specifically to see ‘non-urgent’ paediatric patients.67,74,81,94 In some settings where the GPs were less experienced, this was associated with increased antibiotic prescribing.61,79

Data indicating that GPs took on an ‘emergency clinician’ role were more limited.7 There was evidence that GPs working in or alongside EDs saw more acutely unwell patients7,95 and minor injuries7,54,59,63,64,96 than when working in community primary care. The implications of this on their required skillset and learning needs were not explored. One Irish study suggested inexperienced GPs working in a setting without a robust triage process appeared to adopt a more ‘diagnosis-driven’ emergency clinician approach.79 Other articles described GPs at the front door of the ED redirecting patients to other services.97,98 The wider literature provided examples of both good practice (e.g. a comprehensive assessment with vital signs recorded)99–103 and potential concerns (e.g. low sensitivity of triage criteria in infants)104 relating to redirection. The influence of GPs’ special interests, experience in emergency medicine or the effect of staff shortages on the roles GPs adopted were not described.

Patient satisfaction

Our candidate theories described how satisfaction could be linked to the expectations that patients attend with (e.g. relating to waiting times and investigations required). Following the review, we developed the following CMOC:

Patients with primary care problems that present to EDs (C) and are seen by GPs, are more satisfied with the care they receive (O) if the experience exceeds expectation (M), but if they do not perceive any difference in the care they received compared with what they expected (M), there is no difference in satisfaction (O).56,61,66,72,105–109

Data to support this theory were limited, with an increase in satisfaction for patients seen by GPs generally associated with shorter waiting times,72,105 rather than expectation of investigation and treatment.66 The GPs were sometimes supernumerary which may have contributed towards this.56,72 Other studies demonstrated that GPs focused more on patient education and counselling than ED clinicians with some improvement in satisfaction rates.110,111 In more fully integrated models, the patient was often unaware that they had seen a GP rather than an ED clinician and there was no difference in patient satisfaction.66,70,56,106

Patient safety implications

Our candidate theories about patient safety discussed the potential differences between patients presenting to EDs and community primary care, how communication within and between services could impact on safety and how a GP service might improve safety in the ED for the sickest patients.

Following our review, we developed the following CMOC:

In EDs, where there are delayed patient transfers to wards or inadequate staffing (C), GPs seeing patients with primary care type problems (M) may not free up ED staff to care for the sickest patients (O).67,112–118

There was a lack of evidence that GPs working in or alongside EDs directly or indirectly improved care and safety for the sickest patients. An Australian study reported a reduced mean time taken to see more seriously ill patients,113 and a Canadian study of over 4 million attendances reported that low-complexity ED patients did not increase time to first physician contact for high-complexity patients.114 Other studies also described how diverting non-urgent patients did not improve the high-level care required by others, and that influences such as delayed transfer of patients to the ward were more likely to contribute to overcrowding.71,115–117

There were minimal data on the safety implications of GPs working in ED settings. Several studies used ED reattendance as a marker of safety, with no increase among patients seen by GPs compared with the usual ED staff.53,56,61,119,120 For GPs working inside the ED, good communication and integration were described in some studies,7,54,56,95 with anecdotal reports of poor communication negatively affecting care quality in others.80

Wider system implications

We developed several candidate theories relating to a range of implications of GP-ED models on the wider system. These considered the cost effectiveness of the approach and whether it would act to create additional demand. We also considered how the models might impact on ED staff as well as on the primary care workforce. Although we drafted candidate theories around other potential broader impacts (e.g. widening access to primary care for homeless people), some of these were subsequently shelved as they were too far beyond the scope of our project.

Cost effectiveness

If there is a demand for patients with primary care problems presenting to EDs (C), and they are streamed to onsite GPs and managed using a traditional GP approach (M), the service is cost-effective due to fewer referrals, admissions, investigations and better outcomes compared with usual services (O).56,60,77

Data to support this theory were limited, but supported by three economic evaluations (UK, Ireland and the Netherlands) where non-urgent patients were streamed to GPs during normal daytime hours.56,60,77 The comparator was ‘business as usual’ with no GP service. The UK and Irish studies were published in 1996 and may not represent current ED staffing models.

Three other studies of ‘out-of-hours’ patients did not find the addition of a primary care service to be cost-saving as patients and staff were not comfortable with redirection,58 preferred to attend another convenient location62 or because minimum staffing levels had to be maintained at the ED.93

Risk of provider-induced demand

If patients with primary care-type problems present to EDs (C) and are streamed to indistinct primary care services, without patient awareness or choice (M), there is no provider-induced demand (O).53,54,82,83 However, distinct urgent primary care services may offer convenient access to primary care (M), resulting in provider-induced demand (O).84,103,121–127

Four articles described fully integrated models, where non-urgent patients were streamed directly to GPs inside the ED without provider-induced demand.53,54,82,83 Here, there was no patient choice offered and often a lack of patient awareness. Another 10 articles described distinct urgent primary care services, often in separate buildings outside the EDs, as duplicating services and creating their own demand, increasing patient presentation rates directly or at nearby services, rather than relieving pressure on the ED.103,121–131

Impact on staff

Limited evidence from the included studies prevented us from refining theories on the implications on ED staff or the wider primary care system.

Two articles did highlight the potential reduction in learning opportunities for junior doctors in EDs.78,95 There were no reports of ED clinicians changing their approach as a result of working alongside GPs, but some reports of GPs in management positions influencing system changes.132,133

There was limited evidence that working in an ED setting led to increased job satisfaction for some UK GPs with a special interest in emergency care.7,133 However, reduced satisfaction was also described because the job was outside the scope of the usual general practice,7,76 possibly contributing towards recruitment problems.7,134

Summary of rapid realist review findings

The review demonstrated that GPs are working in a variety of ways in and alongside EDs. Important influences on the way in which these models operate at the level of individual clinicians (level of experience, personal interests) and wider service design (e.g. visibility of the service) were identified.

We found evidence describing ED staff uncertainty about the role of GPs impacting on streaming to primary care services, GPs being able to maintain a traditional GP role while working in EDs, and how highly visible services generate their own demand. Less evidence was available around safety implications and whether these services represent value for money.

The review has highlighted the importance of understanding local context, including how the GP-ED model sits within the wider provision of urgent care locally when trying to understand outcome patterns, which we now explore further in key informant interviews, and later in Phase 2. It also emphasises the need to represent complexity in any categorisation of GP models while also allowing for meaningful comparison across sites, which informed the development of our taxonomy described later in this chapter.

Service evaluation

To understand what GP-ED models were currently being used, and how they were working, we undertook a service evaluation in two parts, firstly a national survey, followed by telephone interviews with key informants identified from the survey.

National online survey

Methods

We carried out a national online survey of all Type 1 EDs in England and Wales in 2017 (see Project web page) to gather information including:

• the aims of their GP-ED service; the extent to which the EDs consider these aims are being achieved in practice; perceived successes or failures of GP-ED services; date(s) of changes to their GP models; patient volume, case mix, funding, governance and training processes
• where there was no GP service, to identify the reasons for this.

The survey was developed in collaboration with our co-applicants and the GP-ED study team from University of West England, informed also by our initial scoping of the literature (influenced particularly by a previous survey conducted by the Primary Care Foundation).6 We used a combination of fixed-response multiple-choice questions and open-ended questions with free-text responses. The survey was delivered to ED CDs using Online Surveys. Research and Development departments for all EDs were provided with details of the study. We obtained ethical approval for the survey and follow-up interviews as a service evaluation from Cardiff University School of Medicine Ethics Committee (17/45). We obtained contact details for CDs through networks of contacts (co-applicants, UWE collaborators) and internet searches. We sent invitations to all CDs of Type 1 EDs in England (n = 171) and Wales (n = 13) by post and e-mail. Initial invitations were sent in September 2017, with follow-up invitations 2 weeks later. We recontacted non-responders to encourage participation until the survey closed in February 2018.

Results

We received 77 responses out of 184 invitees (41.3%). Fifty-one (66%) respondents used a GP model in their ED, and 26 (34%) did not. At 21 sites (27%), GPs were integrated within the ED, at 23 sites they operated inside the ED but in parallel to the ED service (e.g. seeing patients in a separate room), at 7 (9%) sites the GP service was located outside the ED elsewhere on the hospital site.

Aims of services

We asked respondents to indicate the aims of introducing GPs in or alongside their ED. Among those who had introduced GPs, the most common aims selected were reduce ED waiting times (n = 40; 78%), reduce ED patient volume (n = 36; 71%) and better use of available ED resources (n = 35; 69%), improve the quality of care for specific cases (n = 31; 61%) and improve patient experience (n = 29, 57%). Less frequently cited aims included to ‘educate’ patients by sending them to the right place, to meet a national or other directive, to reduce admissions or to save costs. Free-text responses related to a change in OOHs GP service, tariff applied to patients seen in urgent care centre and difficulties in recruiting ED doctors.

Respondents were also asked to what extent various pre-selected aims were achieved. Most frequently reported aims achieved were improved quality of care for certain groups (all, most or some of the time n = 40/46, 86%), improved patient experience (n = 38/46, 82%), reduced ED patient volume (n = 38/47, 81%), better use of available ED resources (n = 39/47, 79%) and reduced ED waiting times (n = 39/50, 78%). Those aims least commonly achieved were reducing hospital admissions (rarely or never n = 29/47, 62%) and saving costs (n = 23/42, 55%).

Workforce

The number of GPs working in the surveyed EDs each week ranged from 1 to over 15, with most EDs using 1–3 GPs per week. EDs reported using a variety of primary care clinicians including using sessional locum GPs working ad hoc shifts (n = 41; 80%); salaried GPs working fixed shifts (n = 22; 43%); advanced nurse practitioners (ANPs) working ad hoc shifts (n = 15; 29%); ANPs working fixed shifts (n = 15; 29%); other nurses working ad hoc shifts (n = 4; 8%) and other nurses working fixed shifts (n = 8; 16%).

General practitioner workload

At some EDs, up to 40% of patients (average 13% across all sites) were reported as being seen by a GP or primary care clinician in ED. The types of patients seen by GPs varied both across and within sites and included patients with primary care problems (n = 47; 92%); low-acuity patients including minor trauma (n = 26; 50%) and undifferentiated patients, that is, same case mix as ED clinicians (n = 6; 12%).

A range of staff members selected which patients should be seen by a GP, most commonly ED nurses (n = 34; 67%), GPs themselves (n = 24; 47%) and ED doctors (n = 14, 27%). Others involved included primary care nurses, telephone triage services, paramedics and patients themselves. Decisions about selecting patients to be seen by a GP were informed by clinical judgement (n = 36; 71%), locally developed criteria (n = 35; 69%) and national triage/streaming tools (n = 11; 22%) including Manchester triage tool, NEWS, Luton Streaming Tool or adaptations of these.

Training

Induction and training for GPs working in or alongside EDs were provided by a range of organisations including the hospital (n = 21; 41%), the primary care provider (n = 16; 31%) and as a shared responsibility between the hospital and primary care provider (n = 10; 20%).

Marker conditions

Conditions the survey respondents felt that the GPs managed well included chronic pain/illness (n = 18; 35%), non-urgent paediatric patients (n = 15; 29%), dermatology problems (n = 12; 24%), ear, nose and throat problems (n = 7; 14%) and gynaecological problems (n = 6; 12%).

Conditions the respondents felt that GPs did not manage so well included trauma (n = 23; 45%), chest pain (n = 16; 31%), injuries (n = 12; 24%) and sepsis (n = 6; 12%).

Using findings from free-text survey responses

The survey included a free-text response question about barriers and enablers identified in relation to setting up the service and achieving the intended aims. We coded the responses to these questions into key themes and used our analysis to purposively select ED CDs to interview for maximum variation.

Key themes that emerged included:

• motivations for setting up service (staffing shortages, policy directive, increasing demand)
• providing a consistent service (issues obtaining funding for GPs, finding staff to provide a consistent service)
• variation in GPs skillset (scope of practice, number of patients they see, risk taking)
• agreeing governance structures
• space for GPs to work from (physical structure of the department, capacity to create work areas for GPs)
• variation in demand for primary care and concerns about creating additional demand
• variation in streaming methods.

Key informant interviews

We identified a purposive sample of 30 EDs as potential case study sites. We looked for sites with a GP-ED model implemented since 2010 (required for case site time series analysis) spread across England and Wales representing a variety of settings (urban and rural, smaller and larger EDs), GP-ED models (location of GPs, access to investigations, range of patients seen) and experiences of the GP-ED model. We invited the CDs of all 30 EDs for a follow-up interview; 9 declined to take part or did not respond.

We included participants from 21 EDs (19 England, 2 Wales). Eleven had GPs working in separate primary care services (seven within the ED and four outside), five EDs had GPs integrated in the ED and three EDs did not employ GPs (two in Wales).

Interview guide

We developed individualised interview guides informed by our survey responses and the initial theories derived from our RRR (see Project web page).15 We aimed to:

• obtain more detail about participants’ survey responses relating to the aims of the primary care service; enablers and barriers to implementing and delivering a service; GPs’ roles; streaming; patient demand and flow
• gain a better understanding of the local context and explore ideas about what factors impacted on way their service worked and their perceptions of the outcomes of the GP-ED model to contribute to later theory refinement.

Data collection and analysis

We interviewed 18 CDs by telephone and three in person (March 2018 to March 2019). All signed a consent form before interview. Interviews were audio-recorded and transcribed verbatim. In our first stage of analysis, we created an initial thematic coding framework in NVivo 11 based on the research aims, findings from the RRR and the survey responses. We coded themes and subthemes within the thematic framework (ME/DP), also allowing for new themes to be identified. When it was established, there were no additional concepts observed, then sampling was terminated. This initial analysis was used to inform case site selection and orientated the researchers to important local contextual factors for further exploration during the Phase 2 case site visits. It also fed into the development of a taxonomy of GP-ED models (see below).5 The interview data were then incorporated into the data set for each of the case sites for further realist analysis alongside the other qualitative data collected at each site in Phase 2.

Results of initial analysis

The full set of findings from the interviews can be found in a published paper.15 Three main themes were identified, described in turn below.

Achieving the aims of implementing and delivering a general practitioner–emergency department service

Sites with separate primary care services (either within or alongside the ED) aimed to reduce waiting times and improve flow, by streaming patients identified to have primary care needs away from the main area of the ED. Some CDs perceived that they had reduced waiting times and improved flow in the ED, enabling primary care patients to be seen quickly without investigations and enabling ED doctors to focus on more acutely unwell patients.

Sites with integrated primary care services aimed to: (1) improve waiting times and flow by focusing on primary care patients and sometimes also patients with minor injury or more acutely unwell patients; (2) reduce admissions by focusing on frail/elderly patients or (3) work in the ED as a middle-grade ED doctor seeing undifferentiated patients (if experienced in emergency care) to fill gaps in ED staff recruitment. GPs caseloads sometimes included a wide range of acuity and primary care streaming was not always used. However, having GPs with skills, experience and special interests and a multidisciplinary team of staff with a range of skills helped manage demand; provided opportunities for sharing advice and learning between GPs and ED clinicians; and was perceived as potentially better value.

Challenges in implementing and delivering a general practitioner–emergency department service

Some factors preventing implementation were a lack of space for GPs and a potential reduction in ED space, which might negatively impact ED flow; competing funding priorities for extended community primary care services; and previously unsuccessful pilot services. Some participants were concerned that if GPs worked inside the ED, they might be tempted to work beyond their expected role and see emergency care patients, potentially leading to quality and safety concerns. In Wales, there were no policy or funding initiatives for primary care services in EDs; two departments had ED staff with previous experience of working as GPs but who were employed in a middle grade ED doctor role. These hospitals had previously piloted models with GPs to focus on primary care type patients but there was no longer funding available.

Some participants commented that the ‘Luton and Dunstable model’135 promoted by NHS England (where suitable patients are streamed by a nurse to a separate GP service within the ED) was not appropriate for their service. Low demand for primary care was attributed to local demographics or easily accessible and good-quality community-based primary care and ambulatory care services. Some ED primary care services were reported not to be cost-effective due to the high costs of GPs, low demand and little or no impact on waiting times, flow or use of investigations. Consequently, some primary care services were scaled down or discontinued.

There were concerns that implementing a new primary care service could cause ‘provider-induced demand’ by attracting additional ED attendances (see Chapter 4 for further analysis of findings relating to demand).

Material in this section has been reproduced from Edwards et al.19 This is an open access article distributed under the terms of the Creative Commons CC-BY license, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.

Facilitators and barriers to primary care streaming

Facilitators to primary care streaming were described as consistent demand from primary care patients; experienced and confident nurses; clear guidelines and protocols (CD interview sites 4, 6, 10, 11, 13, 16 and 20); NHS or shared clinical governance (CD interview site 3); training, evaluation and improvement workshops (CD interview sites 6 and 20) mentoring and support from senior ED staff was perceived to improve streaming (CD interview sites 4, 10 and 16). The monitoring and supervision of streaming by senior ED clinicians also facilitated more patients to be streamed to a GP (CD interview sites 3, 4, 15 and 20).

Establishing governance pathways and policies and reaching an agreement on which types of patients a GP should see was reported as a key challenge (CD interview sites 4, 6, 18). Sometimes, the working relationships and teamworking between NHS commissioned ED service and a primary care service operated by an independent contractor were not well established and presented a barrier to setting assessment time targets and developing streaming criteria (CD interview sites 6 and 18), meaning that primary care patients were seen by ED clinicians or moved across streams. Where primary care demand was low, streaming was difficult to implement and sustain (CD interview sites 4 and 14).

Stakeholder event

Our Phase 1 stakeholder event was held in Bristol in February 2018. We presented findings from our RRR and the national survey which highlighted the complexity of service models. This event then focused on gathering stakeholder feedback on two main topics; the development of a taxonomy of GP-ED models and identifying appropriate ‘marker conditions’ to guide data collection at Phase 2 case sites.

Attendees were commissioners and policy-makers (n = 6); clinical leads and ED clinicians (n = 8); GPs and nurse practitioners (n = 6); public contributors (n = 8) and research team members (n = 14) from England and Wales.

Taxonomy of general practitioner–emergency department models

The need for taxonomy

An array of different terminology describing the ways in which GPs work in EDs was identified during our realist review and service evaluation. Sometimes, different terms were used to describe the same model, while on other occasions the same term was used to mean different things.

As researchers, we needed clear definitions to be able to make useful comparisons and ensure that we grouped services together appropriately. As described earlier, the NIHR funded two projects simultaneously to examine the role of GPs in EDs (NIHR HS&DR 15/145/04 and 15/145/06). It was important that these did not cause further confusion by using different terminology. The two teams therefore agreed to develop a shared taxonomy for characterising the ways in which primary care services worked in or alongside EDs.

Development process

The development of our shared taxonomy of GP-ED models has been described in a publication (see Project web page).5

We contributed data from our Phase 1 activities described above (RRR, national survey and telephone interviews), as well as early data from the first five case sites selected for Phase 2. The role of a taxonomy and what it should include was also discussed at our stakeholder event.

Additional data from the UWE GP-ED team informing the taxonomy development included: 38 telephone interviews conducted with senior staff at sites which had applied for capital funding for GP streaming in 2017, findings from 5 early case study sites and results of searches of routinely collected data and publicly available documents. This collaboration enabled us to obtain data for 41 English EDs from additional sources [NHS England, Care Quality Commission (CQC) reports] totalling information on 62% of (n = 118/189) all Type 1 EDs in England and Wales.5

The data demonstrated the complexity of models in use and inconsistency in the language being used to describe the service models. Stakeholders recognised the importance of any taxonomy being able to effectively represent the complexity of GP-ED models. A key concept identified was the difficulty of defining GP-ED models using distinct categories when there was a wide spectrum of how well integrated GPs were into EDs and the level of integration of different processes could vary within individual sites.

The two research teams used the data to collaboratively develop a taxonomy with two parts, the first describing the ‘form’ of the GP-ED model in terms of where patients were seen, and the second describing a spectrum of integration across a variety of constructs which could influence how the model ‘functioned’.5

Taxonomy produced

Part 1 describes the form of GP-ED models:

First, the GP-ED model was classified as being either inside or outside the ED. These categories were then subdivided into the following groups:

• Inside–integrated: GPs are fully integrated with the emergency medicine service.
• Inside–parallel: GPs provide a separate service within the ED, for patients with primary care type problems.
• Outside–onsite: The GP service is elsewhere on the hospital site.
• Outside–offsite: The primary care service is off-site and may include telephone advice via 111, or pharmacies, dentists, opticians, urgent care centres or registered in-hours or OOHs primary care services. As these services are distinct from ED provision, they were not represented further in the study.5

Part 2 describes several constructs which influence how GP-ED models function, represented on a spectrum of integration with a typical ED service at one end and a typical primary care service at the other, outlined in Figure 3.

FIGURE 3 Conceptual model identifying constructs that influence the function of primary care services in or alongside EDs from Cooper et al.5 published via CC BY 4.0. (Figure not reproduced here; see the original article.)

We used this taxonomy to categorise our case study sites (though position on some elements of the spectrum may vary day to day), inform case site sampling and to develop a toolkit for EDs (see Chapter 8).

Marker conditions

As outlined in Chapter 2, our early scoping of the literature identified nine groups of conditions that could potentially be used as ‘marker conditions’ during Phase 2. Before our stakeholder meeting, we discussed the findings of the scoping review and survey within our co-applicant team exploring the pros and cons of including individual conditions. Three additional conditions identified by the survey respondents were added (menorrhagia, chest pain and ankle injury). Following the discussions, the co-applicants independently selected their top five conditions. The ACSC work focused on diagnosis rather than presenting complaint. The team considered it important to view the clinician’s management of undifferentiated patients; therefore, the presenting complaint was equally important. The top 10 presenting complaints with associated exemplar diagnoses following the co-applicant ranking were presented at the stakeholder conference for discussion in a modified nominal group technique exercise.136 The list had been circulated before the event with explanatory information following input from the co-applicant public contributors. Attendees were invited to complete their top five rankings at registration. The results were presented and discussed, with some conditions then added as a result of the discussions (e.g. abdominal pain). Attendees independently ranked the conditions again at the end (32 ranked forms collected). Conditions were given a score out of 5 based on the perceived likelihood of providing useful data to test our theories about potential management differences between GPs and ED doctors with the highest scoring conditions being: child with a fever; adult with cough/shortness of breath, abdominal pain, back pain or chest pain. These were selected for use in Phase 2 data collection. Due to difficulties in patient recruitment, a sixth condition was added at a co-applicant meeting in November 2018 (while all case sites were still open to patient recruitment). Headache (one of the conditions ranked next highest by the stakeholders) was chosen as, if not investigated appropriately, it could lead to a missed serious diagnosis.137

Learning from previous patient safety incidents

The final activity undertaken in Phase 1 focused on the safety of GP-ED models. Our rapid review had identified limited data specific to patient safety. Several members of our research team have significant expertise in patient safety research and identified two sources of additional data which could be used to develop further theories for testing in Phase 2. This process has been fully described in our published paper (see Project web page)14 and is summarised briefly below.

Data sources

Coroners’ reports

The Chief Coroner publishes Reports to Prevent Future Deaths made by coroners as part of their statutory duty when they believe future action should be taken.138 We searched those published between 2013 and August 2018 and identified 9 of the 1347 reports identified related to a GP-ED service.

National Reporting and Learning System patient safety incident reports

This database holds over 18 million incident reports, usually completed by healthcare staff in England and Wales. These anonymised reports include structured sections (e.g. demographics) and unstructured sections (descriptions of what happened, potential contributors, ideas about future prevention). We searched reports from 3 January 2005 to 30 November 2015 to identify reports relating to diagnostic errors made in GP-ED services.14 We focused our search on diagnostic errors as these were a common theme among the Coroner’s reports. We identified 217 relevant reports from the 1878 reports screened.

Data analysis

We used the PISA framework for classifying patient safety incident reports as a first step to code the data139 and summarised the findings using descriptive statistics. We then thematically analysed reports, grouped by features identified by this classification process, to identify key themes and potential learning. We used the realist process of retroduction140 to infer why incidents may have occurred when this was not explicit in the reports and developed CMOCs from these data. These CMOCs were validated through discussions within our co-applicant group.

Results

Three CMOs were developed using these reports, described in turn below.

Difficulty with triage and streaming processes

If patients presenting to the ED (C) are assessed for streaming but the streaming nurse is unclear which patients are appropriate (due to unclear guidance or inexperience) (M) or the initial assessment is inadequate (limited history or lack of physiological observations) (M), then higher-risk patients may be streamed to the GP service (O).

Data from one Coroner’s Report and 29 NRLS reports were used to develop this theory which expands our RRR theory about how clinicians use their own personal experience and expectations when interpreting streaming guidance. They highlighted a lack of understanding of which patients were appropriate for the GP service (n = 7), delays in the initial assessment of patients streamed to the GP service (n = 14) and inadequate assessment including basic observations (n = 13), as contributing to safety events. Common presentations included patients presenting with chest pain (n = 10) and unwell children (n = 7).

Material in this chapter/section has been reproduced from Edwards et al.19 This is an open access article distributed under the terms of the Creative Commons CC-BY license, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.

Errors in clinical decision-making

If patients present to the ED with a condition not usually dealt with in primary care (C) and are seen by a GP who may have inadequate knowledge or skillset for the condition (M), the patient may be at risk of a mismanagement (O).

This new theory was developed directly from these data. Six Coroners’ reports and 59 NRLS reports described under-investigation of patients with serious conditions who were seen in GP-ED models. Fractures were the most reported condition in this group (n = 27), followed by headache (n = 10), deep-vein thrombosis (n = 5), acute coronary syndrome (n = 4) and unwell infants (n = 4). Eighty-seven NRLS reports related to GPs interpreting X-rays incorrectly (a task outside their usual role in the community) when the fractures were subsequently identified through radiology reporting systems at a later date. Five NRLS reports highlighted specific concerns about a lack of knowledge of ED child safeguarding procedures.

Inadequate referral pathways and communication between services

If there is poor communication between the GP service and the ED service (C) because of a lack of awareness about capacity (M), a lack of awareness that investigations have already been requested (M) or inadequate referral pathways (M), then patient assessment and treatment may be delayed (O).

One study identified in the RRR described a lack of communication between the GP and ED services delaying patient assessment and treatment.7 One Coroner’s report and 21 NRLS reports described inadequate referral pathways from community or ED GP services as contributing towards diagnostic errors. Five other NRLS reports described miscommunication between services about capacity (sometimes caused by incompatible IT systems) causing patients to get ‘lost’ in the system, sometimes leading to treatment delays. One Coroner’s and one NRLS report identified understaffing as contributing towards delayed assessment and diagnosis. Another Coroner’s report described how a lack of communication with the patient’s usual GP about attendances at a walk-in centre may have contributed towards the death of a baby. Inferences were made that some patients may choose these settings as a first point of call rather than their registered GP, affecting communication between services and continuity of care.

Summary of Phase 1 findings

Our RRR of 96 papers developed 6 key theories for further testing relating to the effectiveness of streaming, role of the GP, patient satisfaction, safety, cost effectiveness and provider-induced demand. Our service evaluation described how GP-ED models were being used (or not) at 77 EDs across England and Wales, with our follow-up interviews providing additional detail about 21 sites. These data informed the development of a taxonomy of GP-ED models and a list of ‘marker conditions’ which might be managed differently by GPs and ED doctors. Analysis of Coroners’ and NRLS reports enabled us to develop three additional theories about the safety of GP ED models. Chapter 4 describes how case study sites were selected and qualitative data collected to further test the theories from Phase 1.