Phase 2 qualitative results

Overview of Phase 2 qualitative work

This chapter describes the collection and analysis of qualitative data from 13 ED case sites and how these data were used to further develop and refine our theories.

Data collection methods

Case site selection

Phase 1 data (survey and interviews) were used to identify potential case sites from the three different GP-ED models described in our taxonomy and potential control sites with no GP-ED model. We selected 13 of the 21 potential sites for maximum diversity looking to represent a variety of geographical locations, size of ED and experiences of the GP-ED service resulting in our sample of 3 inside–integrated sites, 4 inside–parallel sites (1 was reclassified following the visit), 3 outside–onsite sites and 3 control sites (with no GP-ED model).5

Data collection at case sites

Two researchers (AC, ME) visited each site (2–4 days) with a GP-ED model to complete fieldwork (see Appendix 1 for researcher characteristics). One researcher attended the control sites for a 1-day visit (ME). Ahead of visits, we provided sites with information leaflets and posters for staff to inform them about the study and planned research activities. We requested to review relevant patient safety incident reports regarding the associated GP service during our visit. Before the visit, the two researchers familiarised themselves with the survey and CD interview data already held on that ED, also the most recent CQC report if available, to consider which of our theories might be useful to test and refine at each site.

Observations

We met the CD on arrival for an introductory tour to orientate us to the department and meet key staff members. We then independently observed various areas of the ED (e.g. triage and streaming areas) and spoke informally to a wide variety of staff, making field-notes and documenting key findings. Discussion topics were guided by the theories to which the staff member could most helpfully contribute. We met regularly during the day to discuss findings and prioritise further topics to explore. Eleven visits were conducted mid-week (usually Monday–Wednesday) with six including observations into the evening. Two visits were conducted over a weekend. Most GP-ED services were not 24 hours; therefore, night observations were not conducted. Two researchers spent approximately 8 hours per day in the ED. We completed 23 sets of field notes (2 for each GP-ED site and 1 for each control site).

Interviews with staff

We interviewed key staff members at each case site to explore, test and refine theories developed from Phase 1 and those emerging throughout the site visits. We carried out formal realist interviews,34 structured around the theories most relevant to that individual and their role during our case study visits using a tailored interview guides for each staff group (see Project web page). Most staff approached agreed to an interview; however, at some EDs, we experienced difficulties in recruitment because the department was very busy (e.g. Parallel-3).

We used a realist teacher–learner interview technique, sharing our theories with the interviewee for discussion.34 In total, we interviewed 106 members of ED staff (including 26 GPs) across all 13 sites34 (see Tables 21 and 22 in Appendix 2 for a summary of staff interviewed at each site). Interviews lasted 10–60 minutes and were audio-recorded and transcribed. Interview data from CDs collected during Phase 1 were also taken forward into the Phase 2 analysis.

Patient safety incident reports

In total, 14 anonymised reports were provided from 6 sites (either during the visit or in response to 3 follow-up reminders). The reports were uploaded to a remotely accessible secure computer platform (PISA platform) at Cardiff University for analysis. Reports were included if there was evidence of a patient safety incident involving the GP-ED model.

Patient interviews

We aimed to interview up to 12 patients per case site (6 seen by an ED doctor and 6 seen by a GP). The sampling frame included patients who had one of the six marker conditions identified in Phase 1 (see Chapter 3). We used two methods of recruitment:

1. By mail – NHS research nurses screened electronic records to identify patients who had attended the ED in the last 3 months, with a marker condition. Eligible patients were mailed study information and consent forms were returned to the research team to arrange a telephone appointment.
2. At the hospital – During site visits, a member of hospital staff would identify eligible patients while they were in the ED and provide them with participant information and consent form (see Project web page). Patients were asked to return the consent form to the research team and an interview was then arranged. Researchers also took consent from some patients at the ED and arranged a telephone interview.

Overall, we invited 748 patients to take part in a telephone interview. Forty-three patients (6%) provided initial consent, but 19 were subsequently uncontactable. Twenty-four patients (3%) were subsequently interviewed (see Table 23 in Appendix 3 for summary of participant characteristics). We faced several challenges with recruiting patients, which we have reported in a published paper to maximise learning for future studies.18 Eligibility criteria limited the number of patients who could be invited for an interview, and complicated IT systems made identifying eligible patients difficult and time-consuming. At some sites, there was no or little research support available to recruit patients, and a lack of personal interaction between researchers and patients may have limited recruitment.

The interview guide (see Project web page) explored patients’ motivations for attending the ED and their expectations and experiences in terms of seeing an ED clinician or a primary care clinician to develop our theories from Phase 1. We (ME) interviewed 24 patients by telephone from 1 week to 3 months after their ED visit. Nine of the 13 case study sites were represented (including all models). We included data from two patients at an additional site with no GP model which were collected when the site was being considered for inclusion as a case study site (CD interview site 5). Interviews lasted between 9 and 39 minutes (average 16 minutes).

Ethical approval

Ethical approval for Phase 2 data collection was provided by South Wales Research Ethics Committee REC reference 17/WA/0328.

Data analysis

Local patient safety incident ‘Datix’ reports

We (AC) coded reports that described an incident involving the GP service in or alongside the ED using the multiaxial PISA coding framework.139 This identifies the primary incident type closest to the patient, and any contributing incidents using the principles of recursive analysis. The reports received described instances of:

• inadequate patient management (n = 3)
• triage or streaming-related errors (n = 3)
• errors with handwritten prescriptions (n = 3)
• problems with investigation follow-up (n = 2)
• diagnostic error (n = 1)
• referral delay (n = 1).

Findings from the incident report analysis fed into the realist interviews to explore mechanisms that led to the unintended outcomes.

Observation and interview data

Our audio-recorded interviews were transcribed verbatim. We created NVivo 11 project files for each GP-ED model (Integrated, Parallel, Outside and Control) which included all qualitative data available (Phase 1 interviews with CD, Phase 2 field notes and staff and patient interviews) for each site. We then created codes for each theory area (e.g. GP role, patient safety).

Developing and refining theories

We used the coded data to generate ‘if, then, because statements’. These statements were used to begin the theorising process at the level of individual data extracts. They were exported to Microsoft Excel spreadsheets, one page for each model type, and consolidated these using the three questions, based on the questions described by Pearson et al.:141

1. Is this statement novel (and can therefore be imported directly into the CMO)? and/or
2. If the statement was not novel, does this challenge the explanations made in related statements? and/or
3. Does this statement add important refinements to the understanding of contexts, mechanisms or outcomes?

Once we had developed CMOCs for each service model, we created a spreadsheet for each of the main themes to map and analyse CMOCs between service models. For the patient safety theme, the local patient safety incident ‘Datix’ report data were used to support existing CMOCs or generate new ones.

The CMOCs were then synthesised using Pawson’s theory-building processes.23 For example, adjudication principles were used to evaluate the relative strength of the different evidence sources. Based on meta-ethnography principles, we rated data obtained during observations as most trustworthy, followed by participants’ descriptions of their own behaviour, then participants’ accounts of the behaviour of others and finally our own interpretations of the data.23 Reconciliation principles were used to explain contextual differences that may have resulted in contradicting outcomes. Juxtaposition principles were used when reported outcomes could be explained by observation or interview data. Theories that resulted in the same outcome could be consolidated across service models into a multifaceted explanation, rival explanations could be situated depending on which mechanisms were activated in which contexts. Independent researchers took the lead for different themes with findings presented and discussed weekly within the study team. (Please see Appendix 4 for an outline of the steps in the realist analysis.)

Engaging with our co-applicant group

We presented our CMOCs to study co-applicants in regular meetings (five 2-hour meetings between May 2017 and November 2018) and discussed our interpretations. During these meetings, members of the group contributed their expert knowledge to help in refining our theories.

Second stakeholder event

This full-day event was held in Bristol on 3 December 2019 after all case site visits had been completed (see Project web page). There were 70 attendees (13 public contributors, 11 NHS managers, 8 commissioners/policy makers, 8 ED doctors, 6 GPs, 2 nurses, 19 academic staff from this study and the GP-ED study and 3 admin/support staff). Theories refined from qualitative data about GP role and streaming mechanisms were presented. Small group work with 8–10 participants, facilitated by a co-applicant, focused on validation of the patient experience and safety findings with stakeholder feedback on quality improvement ideas and potential measurements of safe care. The facilitators’ notes were collected, and findings fed back in a plenary session. Stakeholder input for these areas was sought, particularly, due to the poor patient recruitment for interviews and the low numbers of patient safety incident reports collected.

Using middle-range theories to interpret findings and create programme theories

Realist studies use knowledge from middle-range theories of social phenomena to develop CMOCs and to help explain causation in a programme theory.23,142 We searched for theories and conceptual frameworks from a wide range of literature relating to medical decision-making, emergency care nursing, patient experience of emergency care, health economics and health service delivery. This was an informal process in which the researchers used their existing knowledge and targeted electronic searches to explain recurring phenomena identified during the data analysis. When we identified potentially suitable theories or frameworks, we discussed them as a research team and with co-applicants with specialist knowledge to evaluate their relevance. Once selected, we used them to help interpret our findings and develop our theories as outlined below.

Results

Overview of case sites

Table 4 provides an overview of the characteristics of the sites visited. Sites were spread across England [North (4), Central (4), South (4) and Wales (1)].

In addition to the variation shown in Table 4, our site visits revealed additional differences in how primary care services operated within each model, as briefly described below.

Inside–integrated sites

One small rural site (Integrated-2) employed GPs who were interested and experienced in emergency medicine to work in the role of middle-grade emergency medicine clinicians due to difficulties in recruiting ED clinicians. Another site (Integrated-1) described an ‘integrated front door’ with nurses streaming to GPs who worked as part of a wider team of clinicians (including specialist nurses, an emergency care practitioner, physiotherapists) providing a 24-hour service. There was an ethos of ‘sorting patients out’ once they attended the ED, due in part to the wide geographical area it served, rather than referring patients back to community primary care. There, GPs were supported to pursue their own interests, using either a traditional GP approach or managing ‘emergency medicine’ type patients. At Integrated-3, the GPs were led by a GP consultant, and saw elderly 999 admissions and some referrals for additional investigations from community primary care in the day and primary care type patients in the evenings.

Inside–parallel sites

Two sites (Parallel-1, Parallel-3) were observed to favour redirecting patients to community primary care when possible. Parallel-3 had a non-clinical staff member in a specific role (‘navigator’) to enable this and Parallel-1 favoured sending patients to the co-located GP OOH service rather than them being seen in the ED by a GP. The GP-ED service at Parallel-1 operated only during the OOH period at the time of the visit and has since ceased. In contrast, at Parallel-2, where an ED consultant worked alongside GPs in a former walk-in centre, there was a preference for addressing patients’ problems in the ED. At Parallel-1, Parallel-3 and Parallel-4, GPs were noted to be seeing low numbers of patients. This related to a limited number of sessions (Parallel-3), and strict streaming criteria limiting the number of eligible patients (Parallel-1 and Parallel-4). GPs at Parallel-4 were also expected to supervise and support prescribing among the ACPs in the primary care service. At Parallel-2, there were concerns that when the GP-ED model, which seemed to generate its own demand, closed in the evening, patients were then seen in the ED which increased their workload.

Outside–onsite sites

Triage and streaming processes varied across these sites. It was possible to ‘walk into’ the GP-ED service at sites Outside-1 and Outside-2, and at Outside-2 patients were then assessed by a primary care nurse. At Outside-1, most patients were not triaged (with the exception of under-16s and people with mental health problems) but could be advised to attend the main ED next door by the receptionist if they were presenting with urgent complaints, for example, chest pain. Patients at Outside-3 went through two streaming processes, first being streamed to attend the GP-ED service from the ED or 111, and then being assessed again by a primary care nurse using a computer algorithm. At Outside-3, there was little distinct primary care identity, with ED doctors and ED ANPs also working in the service. The service was nurse led at Outside-2, supported by a GP locum. At Outside-1, a stronger GP identity was identified, facilitated by clear leadership, induction and appraisal processes and an IT system shared with community primary care.

Control sites

All three control sites had previously used GPs in the department in some capacity (closely linked to the GP OOH service in Control-1, in an ED clinician role in Control-3). Control-2 reported a lack of demand for a specific GP-ED service. Concerns were also raised about the suitability of ED patients for streaming to a GP service from nursing staff (Control-1) and senior ED clinicians (Control-3). At two sites (Control-1 and Control-2), patients were often referred having already seen their own GP in the community. At Control-3, it was reported that ‘exit block’ (transferring patients from ED to hospital wards) was the main challenge in managing flow through the department rather than patients attending with primary care type problems.

Ethos and purpose of the service

As identified in our taxonomy (see Chapter 3), a GP-ED model may aim to provide more of an EM service or more of a primary care service.5 While this often followed the form (e.g. more integrated – more EM; more separate – more primary care), there were also examples of crossover (e.g. an outside–onsite model which had access to ED investigations) where the form of the service did not always align with the proposed functions.

Our taxonomy recognised the importance of local leadership and culture in influencing whether clinicians took on an emergency medicine or primary care type role (see Chapter 3).5 During case site visits, we developed an understanding of local culture and ‘ethos’ of the service, often seemingly driven by the way in which the CD viewed the role of the GP-ED model and varied significantly.

At some sites, there was a clear vision that everything possible should be done when patients attended the ED (Integrated-1, Parallel-2).

We wouldn’t just be a fob off service, so we weren’t just going to see people and say ‘you need to go back and see your GP about that’, no, we were going to sort you out.

At two EDs located in a rural location, redirecting patients back to community service was not feasible because patients would have to travel too far (Integrated-1 and Integrated-2). However, at some sites, a strong gatekeeping ethos was necessary and primary care patients were redirected to community primary care. This occurred where there was less consistent GP cover (Parallel-1), or the hospital was in a densely populated area with a high volume of demand (Parallel-3), or a high level of walk-in urgent care attendances (Outside-1 and Outside-2) or a high rate of 111 referrals (Parallel-2).

We will navigate patients and either suggest they see the GP that’s standing here with us, but that’s only a couple of mornings a week, or we will navigate them back to their own GP.

Additionally, there were examples of sites where the scope of the work of the GP was strictly limited by either the ED (Parallel-1) or the private provider of the GP service (Parallel-4) due to concerns about the perceived risks of the GP-ED model.

Funding the service

Interview data identified complicated funding arrangements for GP-ED models. Concerns were raised that the distance between clinical commissioning groups (CCGs) and the services they funded meant that some CCGs were funding multiple services to perform largely similar functions, while multiple CCGs might fund different services serving the same community.143 Separate funding schemes were seen to disincentivise co-operation across services, particularly at Integrated models where this would increase outgoings. Views were mixed on more integrated funding models. Staff from the control sites cited a lack of dedicated funds as a barrier to implementing GP-ED models, integrated funding models were seen as favourable at the Parallel sites, while the Outside models reported successfully developing single health economies in which Hospital Trusts jointly funded and governed community and urgent care.

Managers at the control sites suggested that employing Advanced Practitioners and Physician Associates might be more cost-effective than recruiting GPs. However, managers at the sites with GP-ED models recognised that the increased workload for ED doctors associated with supervising these staff groups was a potential concern.

Staffing the service

There were GPs with a range of experience across all models of service. Those working in parallel and outside models mostly also had community GP roles in addition to working in the ED, while integrated models had mostly experienced GPs with a special interest in emergency medicine who only worked in the ED (see Appendix 3).

Recruiting local GPs was seen as desirable because they understood the local community and had a ‘vested interest’ in providing high-quality care at the ED. However, some services struggled to recruit because multiple services were trying to access the same pool of local staff.

Many sites had experiences of using private providers of GP services. However, there were problems with recruitment and staffing, which meant that ED staff had to cover their work. Another challenge with using private providers was a lack of accountability due to convoluted commissioning procedures.

We have kind of a strange arrangement whereby the CCG pay an external company … [to] run the in hours service. But then they sublet the out-of-hours service to yet another external provider … they probably ran the whole year at about two thirds of our slots being filled … there seems very little that the CCG could kind of hold [company name] to account.

Drivers of demand

Rising demand at EDs was seen as inevitable, relating to multiple factors including the aging population with associated increased complexity of patients presenting at ED. The proportion of demand related to patients with primary care type problems was seen to vary in relation to several factors including the characteristics of the local population (e.g. transient populations unable to access community primary care) and the capacity and performance of local community primary care.

At some sites, there was a perception that people were generally good judges of when they required ED level care, with staff noting that the probability of serious illness among people attending the ED is greater than that among patients attending primary care. One CD attributed this to the local largely well-educated middle-class population selecting services appropriately (Integrated-1). However, at other sites, staff reported patients choosing to attend the ED for convenience, reporting an increased societal expectation of being able to address any health problem immediately.

It sort of reflects current society, that we need everything done now, so you get somebody coming in at 10 am because they couldn’t get a GP appointment until 4 pm for their chronic problem.

In some areas, overstretched local primary care services referred patients to the ED, while staff at other sites believed that the capacity available in community primary care was responsible for attendances by people with primary care type problems. The 111 service also referred people directly to EDs, with some staff reporting concerns that ED attendance was not always necessary. A lack of access to community primary care or a culture of attending hospitals rather than GP services among some groups was also noted to drive demand.

There’s a huge student population who don’t tend to use their GPs, 15,000 patients apparently don’t have an allocated GP, there’s a big problem with the homeless, and a big problem with different ethnic groups … if your culture is that when your child is ill you bring them to a hospital, not take them to a GP, then it’s hard to overcome that cultural difference.

I observed a patient come into ED triage with a headache and concerns because she had previously was investigated for stroke-like symptoms. She told the nurse that she had come to the ED because it was hard to get an appointment with her GP. After checking her obs (which were normal), she was streamed to be seen for minor illness in the walk-in-centre.

Service developments driving demand

There was concern at several case sites that publicising a new GP-ED model would drive demand. At one site (Parallel-2), staff believed increased attendances were related to the significant publicity around a new building opening.

Our attendance rate went up by 30%. The trust wanted to go big bang into the press … We started to see whole populations coming to us which never came before.

Two other sites intentionally limited the visibility of their GP-ED model to avoid generating additional demand (Integrated-1 and Parallel-4).

Improvements in the 111 service in one area (Parallel-2) enabled operators to review waiting times in urgent care services across the region and refer patients to services with shorter waiting times. This created additional demand from patients who might have otherwise attended a service elsewhere and this was a source of frustration for the ED staff.

Theory development and refinement across four themes

We now present data under four key themes:

• streaming and flow
• the role of the GP and how it influences clinical decision-making
• communication between GP-ED models and the ED
• patient experience.

Patient safety was recognised to be a key outcome in the first three themes and so data relating to safety are reported in these sections, rather than in a separate theme. For each theme, we explain the findings from Phase 1 to be explored, and present the data gathered to help develop and refine these theories during Phase 2. For each theme, we present CMOCs outlining our refined theories based on the qualitative data analysis.

Theme 1: streaming and flow

Our initial theory developed in Phase 1 described how staff involved in streaming interpret available guidance based on their own experience to influence which patients are streamed to GP-ED models.

We observed three main pathways where patients are streamed to ED clinicians or primary care clinicians: front door streaming (patients streamed by a nurse at the front door of the ED – before being booked in at reception); streaming inside the ED during a more complex assessment (including triage and streaming – after being booked in at reception); no primary care streaming (usual triage, with GPs self-selecting patients).144 These pathways were influenced by whether the primary care service was ‘inside’ or ‘outside’ the ED and were often adapted based on local circumstances such as the department layout, patient demand levels, skill mix and interests of primary care staff and the accessibility of community primary care services. Varied approaches to streaming were also implemented for specific patient groups (e.g. older people, children). Pathways were also in place to redirect patients with non-urgent primary care problems to community-based services. Adaptations to protocols were employed, based on staffing, patient demand and links to community primary care (see Project web page).

In this section, we discuss our theories relating to the quality of streaming decisions, the efficiency of moving patients through the ED and the ways in which oversight of the streaming process can improve the service.

Data sources

The new and refined theories presented in this chapter were developed from interviews with the ED staff and GPs and observations of primary care streaming.

Applying formal theory

We used a middle-range theory that has previously been applied to triage decision-making to aid interpretation of our findings (the Revised Cognitive Continuum Theory).145 This helped explain how experienced and senior nurses stream patients from the ED front door using their intuitive and reflective judgement to make quick decisions. In EDs where nurses carry out more complex assessments inside the ED, they mostly make use of decision tools and computerised triage systems using system-aided judgement (requiring less intuition).

Findings

Experience of the staff member involved in streaming

During the RRR, we developed two candidate theories outlining possible advantages and disadvantages of GPs performing streaming at the ED front door. During our site visits, there was no evidence of GPs routinely acting in a streaming role. However, at Integrated-3, the lead GP sometimes saw patients during a triage assessment when the department was very busy. He reported that he was able to improve patient flow by ‘seeing and treating’ patients during their initial assessment. However, it was not felt to be sustainable nor a desirable role for other GPs due to the intensity of the decision-making and a higher patient safety risk.

it really helps just clear the triage stream for a bit, but what we’ve found with that is it’s very labour intensive, it’s hard work, difficult … it is high pressure, it’s high turnover, and it’s quite high risk, because you are making very quick decisions.

All outside models and one parallel model (Parallel-3) in a large hospital with high attendances used senior nurses and nurse practitioners in front door streaming. Clinicians at these sites recognised the importance experienced streaming nurses at the front door.

We have to have experience up front because it’s an extremely important job getting them in the right place.

Where streaming was inside the ED (most parallel models and Integrated-1), there was often a mix of senior nurses, nurse practitioners and less experienced nurses making streaming decisions during a complex triage assessment.

Highly experienced nurses were reported to make quicker and better-quality streaming decisions, allowing patients to move through the ED more quickly. They appeared to use both intuitive and reflective judgement in their decision-making and to have more confidence in their decision-making, leading to more effective streaming (patients streamed to the service/clinician most appropriate for their needs). Other ED clinicians reported that senior nursing staff were also more confident about redirecting patients with non-urgent problems elsewhere and communicating their reasoning with patients, helping improvements in patient flow.

they’ll be used to making those decisions about discharging patients, so they’ll often feel comfortable to say, ‘that’s such a minor injury, you don’t need to wait and be seen’, or ‘that’s very much (a community) primary care condition, we’re not going to be able to help you with that …’

Less experienced nurses took longer to carry out assessments and were more cautious in making streaming decisions. They were sometimes reported to order unnecessary investigations, so some patients waited longer to be seen. They also experienced delays in obtaining support with their decisions because they were less confident in communicating with senior ED staff and GPs to influence their decisions about which patients might be appropriate for them to see. Thus, there were fewer opportunities for peer-aided judgment leading to poorer patient flow.

… they will go in too deep to why people have come, which then takes time … they have less influence … some of them don’t know how to approach sort of people … and talk to them in a medical way that speeds this transition along.

They appeared to rely more on system-aided judgement (e.g. guidelines and algorithms) to inform their decisions. Where streaming guidance was not well developed, less experienced nurses were thought to be more at risk of making errors in their streaming decisions. Some GPs reported that less experienced nurses lacked knowledge of the types of patients that GPs manage and their scope of practice in terms of access to investigations and making referrals.

Sometimes, the right decisions aren’t necessarily being made … there just isn’t that experience and that intuitive knowledge … .

At some sites, non-clinical staff became involved in the triage and streaming process. At Parallel-4, understaffing meant that the streaming nurse also had to administer treatments. Consequently, receptionists with no clinical training had a list of patients’ presenting complaints about which to call the triage nurse to attempt to avoid delays.

Streaming guidelines and training

Emergency department doctors, nurses and GPs reported that some streaming nurses had difficulty identifying patients with appropriate conditions for the GP service (Parallel-1, Parallel-2, Parallel-3 and Outside-1). GPs also reported that sometimes the nurse did not appear to be aware which presenting conditions were appropriate for the service.

It’s a bit hit and miss, it depends on what the help of the triage nurse is, there’s no set system … sometimes patients you’re seeing are inappropriate … but there’s lots of things that I could be seeing which I don’t end up seeing, because they’re deemed to be an A&E case.

Locally adapted guidance, protocols and training supported nurses making streaming decisions (promoting system-aided judgement), aiming to ensure patients were streamed to the most appropriate clinician or service.

We have our streaming assessment workbook … they undergo numerous assessments and then they have a final assessment and then when we’re happy that they are competent they are signed off and they can do it themselves.

Guidance relevant to the local primary care service was felt important but an experienced streaming nurse using clinical judgement was felt to be essential (Parallel-3, Parallel-4, Outside-1). Relying too heavily on guidance could be problematic: for example, junior nurses sometimes were not experienced enough to ask intuitive questions, leading to patients being inappropriately streamed.

It’s criteria led, but I think experience comes into it a lot … when a junior member of staff sees a patient in the streaming cubicle, they normally only hear the duration and the problem, the actual history of why they’ve come today gets missed.

With no clear guidance available to support their judgement and decision-making, less experienced nurses were reported to have sometimes missed ‘red flags’, and inappropriately streamed patients needing emergency care to a primary care service, causing risk of healthcare-associated harm. Thus, when junior nurses made streaming decisions based solely on their limited clinical experience (intuitive and reflective judgements), there was considered more scope for error with potential for delays in assessment and appropriate treatment when patients needed to be redirected back to the ED.

A patient presented at a triage assessment with a rash on his leg and was streamed to the out-of-hours GP. The GP sent him back to wait to be seen in the emergency department for further investigations with suspected deep-vein thrombosis.

Where there was no clear streaming guidance established, some of the ED staff perceived GPs to be selective and seeing fewer patients than expected. Conversely, where guidance was too strict and GPs did not have flexibility about which patients they could see, the GP-ED model was also perceived to have less impact on overall patient flow within the department.

Material in this section has been reproduced from Edwards et al.146 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.

Teamworking and communication

When the ED and primary care staff had positive teamworking relationships, there was good communication between the ED and primary care team. This enabled ED nurses to develop better knowledge of the skillset in the primary care team and which patients they could stream to them, so patients were more appropriately streamed.

it’s developing an understanding between ourselves and the urgent care team about what can and can’t be seen

Our RRR identified that GPs were just one part of the wider ED and hospital team and recognised that where ED staffing was inadequate or transferring patients to wards was delayed, a GP-ED model was unlikely to influence flow through the department. This theory was supported by data from a control site where a GP-ED model had previously been ineffective.

So we’re throwing extra resource at the front door when actually it’s the back end of the hospital where the biggest problem is, and ironically if community care was better which is part of the GP remit, then we might not have such a big problem at the front door.

We developed two new theories based on these data. The first describes the interaction between the experience of the streamer, their understanding of the GP-ED service and the availability of relevant streaming guidelines. The second describes further inefficiencies in streaming systems that we identified.

Refined theory – quality of streaming decisions

Staff performing streaming to primary care integrate their clinical experience, knowledge of the local GP-ED service and local guidelines to make streaming decisions. When staff are highly experienced (C), they are competent and confident in evaluating how to use this information (M) resulting in high-quality streaming decisions that ensure patients are appropriately directed to optimise patient flow through the department (O). If staff have the skills (C) to identify appropriate investigations for patients during the streaming process (M) and can arrange these, this may improve efficiency (O).

When staff have less clinical experience, less understanding of the GP-ED model or less clear guidance with which to work (C), they may take longer to assess patients, or miss important information (M), resulting in poorer-quality streaming decisions, and delays in patient care (O). If inexperienced staff (C) request unnecessary investigations during streaming (M), this can decrease efficiency (O).

Refined theory – efficiency in moving patients through the department

If there is no clear guidance about which patients primary care staff see or the guidance is too strict (C), then primary care staff may not see all patients that could potentially be seen by a primary care clinician (M), and streaming may not be effective in improving waiting times and patient flow in the ED (O). Additionally, when EDs are short staffed or experience ‘exit block’ (C), then GP-ED models (M) may not improve overall flow (O). If patients are inappropriately assessed and streamed to one service and then need to be (re-) streamed back to another service (C), they spend more time waiting to be seen (O) and may experience delays in receiving appropriate care and treatment (O).

Oversight of the streaming process

Day to day

Good communication between services allowed streaming nurses to understand the capacity of the different streams which influenced streaming decisions (Outside-1).

In EDs where streaming was inside the ED, a senior staff member (e.g. ED consultant) screened the notes of patients already streamed to the ED to identify patients that could be changed to the primary care stream to improve flow (Integrated-1, Parallel-1, Parallel-4). At Outside-3, where streaming was from the front door, a (non-clinical) operational manager made decisions about suspending streaming to urgent care and redeploying ANPs from the front door to the Urgent Care Centre to see patients when the demand for primary care was high and capacity in the service was limited. This was to prevent primary care patients from waiting for extended periods of time and to enhance overall flow.

I’ll oversee exactly how many patients are in there, how many patients are going down there per hour and whether the GP is struggling or not.

On Wednesday at 1.40 streaming to the UCC has been put on pause because the GP has 10 patients waiting. The operations manager has authorised this pause. All patients are now to be seen in the ED.

Service improvements

Many case sites were happy to share learning about how and why the streaming process worked well in their experience and how it had been developed and modified to ensure appropriate patients were streamed to the GPs.

Strategies such as training and mentoring for nurses, local-level evaluation, developing local guidance and streaming pathways and creating physical spaces from which nurses can stream and to which patients can be streamed aimed to help improve flow.

We run rapid improvement workshops … we spot bits of the processing that aren’t right and think about how we could make it better …

One site described how they felt the streaming guidance for young children was inadequate and after a ‘near miss’, the process was modified to include paediatric-specific early warning scores and healthcare assistant support, to ensure basic measurements could be taken (Integrated-1).

New theory: service improvements

On a day-to-day basis, if staff performing streaming or those with oversight of the streaming system have a good understanding of the current capacity and skillset available in the GP-ED model (C) and can adapt to these by changing which patients are streamed or by redeploying staff (M), then delays in patient care may be reduced (O).

In the longer term, when departments have systems in place (C) to learn from problems identified in the streaming process and to make changes to the process (M), appropriate patients can be safely streamed to the GP-ED service, and flow through the department may improve (O).

Theme summary

We have described the contextual factors and mechanisms that are perceived to affect whether patients are efficiently and safely streamed to primary care or emergency care clinicians when attending an ED. Figure 4 shows the connections between contexts, mechanisms and outcomes and illustrates how certain outcomes (e.g. streaming to the most appropriate service and improvement in patient flow) also influence patient safety. Strategic and operational management also influenced other contextual factors such as the experiences of nurses, the implementation of guidance, teamwork and communication.146 We discuss how these findings can inform service design in our toolkit (see Project web page).

FIGURE 4 Summary of theories relating to streaming and flow.146 (Figure not reproduced here; see the original article.)

Theme 2: general practitioner role and influence on clinical decision-making

Our RRR identified that GPs could take on a range of different roles in GP-ED models, including acting more like ‘traditional’ GPs or more like emergency medicine clinicians.15 Similarly, our taxonomy identified multiple different influences on whether the GP-ED model operated more like an emergency medicine or a primary care service.5

This section now describes how our case site data helped to refine our initial theory about the role of the GP in GP-ED models.

Data sources

The theories in this section were largely developed from the first-hand accounts of GPs working in GP-ED models, supported by accounts from other primary care clinicians and our own observations at sites. One formal theory, Croskerry’s dual process model of clinical reasoning,31 was used to aid the interpretation of the results around diagnostic decision-making.

Findings

Contextual factors influencing general practitioner role

Our initial theory suggested that it was individual clinician factors that influenced the role GPs took on. However, our qualitative case study data also described the influence of wider system and department-level factors.

Hospitals where the GPs were employed by the NHS Trust, rather than a primary care provider, often functioned more like an emergency medicine service (Integrated-1, Integrated-2, Integrated-3). At one site, this related to a shortage of emergency medicine clinicians (Integrated-2). At one site where GPs had the autonomy to select their own patients, the CD described how GPs were perceived to improve flow within the department because they required no supervision.

[GPs] are senior decision makers, they’re autonomous … they’re not coming back to ask how to manage patients … they can just crack on and knock through the patients, so the amount of time the A&E consultant is spending down doing queue busting has massively dropped, and we can focus on the resus majors patients.

General practitioners were also observed to adopt an ED clinician role at one model (Outside-3) where geographical distance was overcome by GPs sending patients back to the ED for acute investigations including blood tests, X-rays and ultrasound scans. This service was also staffed by ED ANPs who were able to deal with minor injuries and therefore the unit was more integrated with the ED than other ‘outside’ services.

There were some sites where GPs were employed by the NHS Trust but delivered more traditional GP services (Parallel-4, Outside-2). At these sites, department-level organisational factors appeared to be the main drivers of the GP role. For example, services that were physically distanced from the ED, with no access to acute investigations, functioned more as traditional GP services (Parallel-4, Outside-1, Outside-2). Strict streaming protocols and different computer systems meant the GPs at some sites were only able to see patients who had been assessed as appropriate for GP management, supporting a traditional GP role (Parallel-4, Outside-1, Outside-2); this was facilitated by strong GP clinical leadership (Parallel-2, Outside-1). At another site, the ED CD’s leadership allowed flexibility of the role of the GPs, depending on the skillset and interest of the individual GPs (Integrated-1). Where governance responsibilities lay and whether GPs should follow ED protocols or treat the patient as they would in a community primary care setting was unclear at one inside–parallel service (Parallel-1).

I’m an autonomous practitioner, but then I’m working in A&E under another consultant effectively, so there are those problems there as well … It’s just who’s in charge isn’t it, and how you work, whether you follow A&E protocol or you follow your GP hat.

As highlighted in our original theory, individual GPs’ interests and expectations were also described to influence their roles and the function of services. At some integrated sites, GPs described how they had chosen to work there because of their interest in emergency medicine. At another integrated site (Integrated-3), GPs were encouraged to maintain a traditional GP approach in the evening when the department experienced more walk-in patients. Individual GPs’ experience was perceived to facilitate a traditional GP role in this context, with this site (Integrated-3) reporting that they actively recruited experienced GPs.

How clinicians decide their role

We used our case site interviews with GPs to explore how they felt that working in ED settings influenced (or not) their clinical decision-making.

Using a general practitioner approach

Some GPs who worked in a service where they had no access to acute investigations and often a strict streaming process, reported that the patient cohort they managed was very similar to usual primary care.

If they’ve self-selected to come to hospital because they perceive that they’re really ill and in need of something urgent, I suppose they are at high risk but quite a lot are redirected here by NHS 111, or the practice receptionist is most common now.

They reported that sick patients may also present to community primary care and the GPs could therefore manage the patients with their usual GP approach (Parallel-1, Parallel-2, Parallel-3, Outside-1, Outside-2). Skills that they reported to rely on included having confidence in clinical skills, being comfortable with uncertainty, having a threshold to admit patients for further investigation if necessary and using recognised ‘safety netting’ techniques, so that patients were aware when they should seek medical help again.147

Clear guidance and expectation of the role of the GP were reported to facilitate this approach, supported by strong GP and emergency clinician leadership.

The general theme we say to our GPs is we shouldn’t work any differently here than we would do if we sat in our practices, just because we’re in a hospital, we don’t do anything differently … we’re not trying to be a mini A&E here.

More cautious general practitioner approach

Other GPs, some at the same hospitals as above, perceived that they saw a different cohort of higher-risk patients than in usual primary care and incorporated this into their clinical decision-making (Integrated-1, Integrated-3, Parallel-1, Parallel-2, Parallel-3)

Working in an urgent care A&E environment, you’re going to see potentially a lot sicker patients, you’re going to see the sub-arachnoid bleeds, potentially the subdurals after head injuries … so again, in my experience the sort of characters that tend to do GP work in an A&E department are quite au fait with these conditions.

They described using additional clinical skills to manage these patients including longer consultations to take a more thorough clinical history to establish chronology of symptoms and events; being aware of their role and limitations; and having a different threshold for admitting patients for further investigation.

An expectation to adopt an emergency medicine approach

Some GPs, however, described internal conflict about when it was appropriate or not to use acute investigations. Sometimes the decision had been taken away because the patient had already had investigations requested at triage which needed to be interpreted. Some clinicians described not being aware that tests had already been requested (Integrated-1, Parallel-1).

It’s very frustrating because then you’ve only found out because the patient’s told you, literally as they’re going out the door ‘oh, did my blood tests come back?’

Expectation of the department, loss of confidence in clinical skills and medicolegal concerns were all described to influence the GPs’ use of investigations when they felt they would not have done so in usual primary care.

Thinking about defence, if you don’t do tests when they’re right next to you, and something were to happen … you would have to be able to stand up to that and defend yourself and say why you didn’t do those tests, so it’s tricky.

The choice to use a GP or emergency medicine approach

Some GPs working in integrated services described how even if they did have access to acute investigations, then many patients could still be managed by a traditional GP approach using the clinical skills described above. Ability to select the right patients and experience of the GP were felt to facilitate this approach.

If you select the right patients to see, as a GP in the department, you should be able to deal with them in a similar way to you do in primary care, but always just having that slight radar on to think okay, is there something else going on, do we need to do that little bit more?

Categorising patients into those that needed investigations and those that did not was also described, with investigations being used as a decision-making tool when patients could not be confidently categorised as either ‘safe to see and treat’ or ‘definitely needing admission’.

There’s the group in the middle where you’re uncertain whether this patient needs urgent admission or not, and you use the investigations as a tool to help in that decision-making.

General practitioners described being able to use acute investigations for patients when clinically indicated, because they were confident in interpreting results; were aware of protocols for high-risk conditions; they wanted to prevent unnecessary hospital admissions; and had the support of ED staff to provide this level of service. X-ray reporting systems were described as a useful backup to advise patients that a radiologist would also be reviewing the films while dealing with minor fractures.

These data were used to develop the following two theories about the roles taken on by GPs.

Refined theory: maintaining a general practitioner approach

If GPs who are experienced (C) and confident in their clinical skills (C) work in GP-ED models where a primary care role is clearly defined by departmental systems and structures, they are able (M) to use their usual ‘GP approach’ to care in the ED setting (O). However, if GPs work in EDs with access to investigations (C) where investigations are requested during triage, there is an expectation to follow ED protocols (C) or governance responsibility is unclear (C), GPs may feel that they are required to use these investigations (M), become less confident in their clinical skills (M) or have medicolegal concerns (M), resulting in more investigations being requested for patients in GP-ED models than in usual primary care (O).15

Refined theory: flexibility in approach

If GP-ED models involve GPs seeing a cohort of patients they perceive to be higher risk (C), GPs may manage this risk by adapting their usual approach, for example, longer consultations (M) or a different threshold for admission or using investigations (M), to safely manage patient care (O). If GPs with additional emergency medicine skills and experience (C) work in EDs seeing a wider range of patients (C) with access to acute investigations (C), they can assess (M) which patients can be safely managed by a usual GP approach and which patients require an emergency medicine approach including acute investigations (O).

Potential risks associated with a ‘general practitioner’ approach in the emergency department

One theory developed in Phase 1 (see Chapter 3) described the potential risks associated with GPs seeing patients outside their usual remit which they had inadequate skills to manage.

Clinical directors from 9 of the 10 hospitals with a GP service had no patient safety concerns related to the GP service. The CD of an inside–parallel service had concerns about the skillset of primary care practitioners working in the ED and which organisation held governance responsibilities, following two local patient safety incidents (missed cervical spine fracture and a wound managed inappropriately) (Parallel-1).

The CD from one control site that no longer had GPs working in the department (Control-3) discussed a historical case of diagnostic error involving a child seen by a GP and expressed concerns that GPs treat patients differently to ED clinicians.

Well, we got it wrong, we streamed the wrong patients to them, and they got treated as GP patients and they weren’t. We had one … a litigation case … an under 1, unwell, horrible obs, went to the GP. The GP didn’t look at the obs, looked at the child and went “they look okay,” went away, came back in and was really septic and almost died.

Three ‘Datix’ reports referred to inadequate management, two of which related to a lack of knowledge about specific ED protocols.

ED protocol not followed, child with suspected non-accidental injury not admitted to paediatrics and sent home for outpatient follow-up.

Mitigating the risks of being a general practitioner in emergency department

There were examples of how strong clinical leadership could promote patient safety, with good practices including clear induction and appraisal processes, and periodically auditing a sample of GPs’ medical records for evidence of appropriate clinical decision-making and safety netting (Outside-1).

We used Croskerry’s framework highlighting the risks of cognitive errors at different stages of the diagnostic process (hypothesis generation; hypothesis evaluation; and hypothesis verification) to structure and explain our findings about how GPs described strategies to mitigate such errors.148,149 In line with Croskerry’s model,148 the GPs interviewed described how they began generating hypotheses before the clinical encounter began, based on the written triage and streaming notes. Even at this early stage, some GPs reported referring patients back to the ED if they felt the patient was not suitable for a GP consultation.

Croskerry’s model describes factors that are thought to be important in hypothesis generation as: acuity (severity) of the patient’s condition; disease prevalence and heuristics.148 Croskerry suggests that the acuity of the patient’s condition is most relevant when ED doctors generate hypotheses.148 GPs working in ED settings reported categorising patients into those that required immediate medical attention or investigation and those that did not, rather than focusing on a specific diagnosis. As described above, GPs’ perception of the prevalence of serious disease and whether the cohort of patients was similar to usual primary care or a higher risk was described to impact their clinical decision-making. GPs who perceived the cohort of patients to be at higher risk, described a different level of concern and managing risk in the ED than in usual primary care.

I think that the group of patients I see in A&E is very different to the patients that I see in general practice … I’m quicker to be concerned with an A&E patient … statistically the chances of it being something more significant are much higher in A&E.

General practitioner experience and their associated confidence in clinical skills was a common theme across the case sites for why services were successful and patient care was safe.

Initial information gathering from the patient, to understand why they had presented to the ED that day and the background of the presenting complaint, was described by some experienced GPs as key to diagnostic decision-making.

Hypothesis evaluation

As described above, while some GPs felt confident in using their clinical skills to eliminate the potential for serious disease, others felt that the ED setting necessitated a more cautious approach. The level of caution GPs displayed did not clearly relate to the type of service model within which they worked, with some more cautious clinicians identified across all models.

Some GPs who did have access to acute investigations described how they used their clinical skills to manage risk and choose which patients to manage with a GP approach and which to investigate. Croskerry discusses that the threshold for managing risk and when to request further investigation is influenced not only by experience but also by personal traits of the individual. Contextual factors were also noted to influence this behaviour, including investigation availability and departmental expectation. Some GPs working in more integrated models expressed that time could be used as a risk management tool in the ED, which was not possible in the usual primary care consultation.

Sometimes we just give them a bit of time, I call it the ‘cup of tea test’. Often, they look better after a cup of tea which helps the decision.

Hypothesis verification

General practitioners reported that often their priority was to exclude serious disease rather than making an actual diagnosis. There was also an acceptance of the limitations of the service and that the diagnostic process may be incomplete.

I don’t have access to all of your notes … I can’t organise blood tests, I can’t organise scans … I’ll have to send you back to your GP.

General practitioners described the strategy of ‘safety netting’ as good practice to help manage diagnostic uncertainty.147 These findings contributed to the following new theory.

New theory: actions to maintain safe patient care

General practitioners who work in EDs with clear governance processes, who are aware of their intended role and expectation depending on their experience, skillset and patient demand (C), use communication skills to effectively gather patient information (M), actively consider prevalence of more serious diseases that may present to the ED setting (M), use clinical skills to rule out serious diagnoses (M), refer to guidance when acute investigation/referral may be necessary to exclude serious disease (M) and use safety netting to help manage diagnostic uncertainty (M) to deliver safer patient care (O).

Material in this section has been reproduced from Cooper et al.32 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.

Theme summary

Multiple local contextual factors at the wider system, department and individual clinician level can influence GPs to maintain a traditional GP role or adopt an emergency medicine role when working in GP-ED models. GPs described how this influenced their clinical decision-making: no change to their usual GP approach; a more cautious GP approach; the choice to treat patients with a GP approach or to adopt an emergency medicine approach; or an expectation to adopt an emergency medicine approach. Structuring findings with formal cognitive theory highlighted areas with risk of cognitive biases and how GPs perceived these were mitigated to deliver safer patient care.

Theme 3: communication within and between services

As identified in Phase 1, inadequate referral pathways and poor communication between services were implicated in a number of patient safety incidents (see Chapter 3). This section explores communication both within the ED and between the ED (according to type of GP-ED model) and community primary care.

Data sources

To develop this theory further, we used data from local ‘Datix’ reports, observations at case study sites and interviews with ED staff and patients.

Findings

Communication between the general practitioner–emergency department model and the emergency department

Some case study sites were observed or reported to have limited communication between the GP-ED service and the ED. Incompatible computer systems between services were linked directly to patient safety incidents in three local incident reports where patient assessment and treatment had been delayed, and one patient had become ‘lost’ in the system (Integrated-1, Parallel-2, Outside-2). Receptionists at one site described how they had three different computer systems to operate (for the ED, the GP-ED service and the GP OOHs service) which led to duplicate patient entries on different systems and again increased the likelihood of patients becoming lost in or between the different systems (Parallel-4).

Physical distance between services limited face-to-face communication and was felt to contribute to a lack of communication between services at one site.

We’re not very integrated with the ED and we don’t, we don’t feel very integrated, it still feels a bit us and them.

Another site, however, with a separate GP service, reported good communication through the senior nursing team reviewing on-the-day capacity and skillset and moving staff between services to meet patient demand (Outside-3). At sites where local GPs worked regularly within the ED, there was a perception that this also facilitated better communication (e.g. Parallel-4).

An ‘us and them’ culture was observed at another parallel site where there was good opportunity for face-to-face communication. At this site, juniors were not encouraged to ask the GPs for advice (Parallel-1). The personality of an individual GP as preferring lone working was felt to be significant at another site (Parallel-2). Poor communication between the private providers running GP services and the ED at Parallel and Outside models was perceived to create an inhospitable working environment for the GPs, which acted as a disincentive to working for the service.

The integrated sites reported good communication, which was perceived to promote interprofessional learning. Two CDs reported that since GPs had been working in the department, overall patient safety had improved because more experienced, permanent GPs could also give advice to other staff members (Integrated-1 and Integrated-2).

a positive I suppose is the fact that we’ve got someone with experience that is staffing and supporting our rota, which makes it a more safe department to work in.

At the integrated sites, the GPs were permanent staff members and there was good opportunity for face-to-face communication. GPs were described not only to give clinical advice but also to provide advice on primary care referral pathways which several ED staff reported as helpful. We observed a sense of multidisciplinary respect and teamwork with clear ED clinical leadership (Integrated-1, Integrated-2, Integrated-3)

One of the biggest things we didn’t expect is the effect of education, that there’s a GP sitting in the department, so they’re seeing a frail elderly patient, the F2 is sitting next to them seeing a similar patient, and the F2 is going ‘why are you sending your patient home and I’m admitting mine?’, and the amount of cross-fertilisation knowledge and support … we’ve really benefited from.

Strong GP leadership was also seen at several case sites which was reported to improve communication between the services and perceived to improve patient safety (Integrated-1, Integrated-3, Outside-1).

These findings contributed to the following new theory:

New theory: Having service models with strong clinical leadership, employing experienced, regular GPs with opportunity for face-to-face communication between services and compatible computer systems (C) with a culture that encourages formal and informal inter-professional communication and learning (M) and clinical leadership that promotes mutual respect (M), encourages communication between services and teamwork to facilitate safer patient care (O).

Communication with community primary care

There was limited evidence to explore patient safety outcomes from inadequate referral and communication pathways to and from local primary care (which had been highlighted as a potential issue in Phase 1). Collecting data from community primary care was outside the scope of the current project. The lead GP at one site (Outside-1) described good virtual communication with local primary care where both services used the same computer system and were able to access consultation notes. Additionally, she felt this assisted both services to unite antibiotic stewardship messages – if patients chose to present to a different service seeking antibiotics for a viral illness that the local GP had advised were not appropriate, this was clearly documented on computer system and could be taken into consideration. Inadequate discharge summary communication with community primary care was described in one local incident report (Outside-1, Table 25 in Appendix 5).

Theme summary

Communication between the ED and the GP-ED model was important for safer patient care. This appeared to be achieved most consistently in the most integrated models. Barriers to communication at a system level (e.g. IT and department geography) were identified. Senior staff managing the process could overcome some of these problems. Even in services with an apparently favourable setting, the preferences of individuals (e.g. for lone working or about involving GPs in ED care) could hamper communication.

Theme 4: patient experience

In our RRR, we described how patients’ expectations of the care they receive at the ED shaped their satisfaction with the experience of a GP-ED model.

Data sources

Semi-structured interviews with 24 patients/carers of patients who visited the ED with one of six marker conditions (see Chapter 3). We also reflected on feedback from 56 attendees at our second stakeholder event (see Chapter 3) to support our analysis.

Applying formal theory: Sonis et al. developed a conceptual model of patient experience in EDs which is intended as a framework for improving patient experience in EDs, by linking existing problems, potential interventions, resulting outcomes and mechanisms for incorporating feedback.150

We used Sonis’ conceptual model as a framework to help us understand how patient experiences could be improved. This is explored in detail in our published paper (see Project web page).20

Findings

Patients who were seen by a GP, regardless of the GP-ED model or their condition, generally reported being pleased with the quality of care received from staff members. Patients reported that staff were professional, helpful and caring, and emphasis was placed on the importance of this in an ED setting:

… they were particularly brilliant and professional and very caring with my mental state … so I would say that’s paramount really, to a really good service.

While many patients were unaware that they had seen a GP, when asked how they felt about GPs working in EDs, patients generally responded positively. Patients appreciated the experience and knowledge that GPs have, and how this can contribute to better patient care in ED.

I think it’s useful, if they have the time and resources, funding or whatever, I think it’s a great idea, because I think they can work together with their experiences.

Clinicians reported that when patients are not aware that there is a primary care service at the ED, but an explanation is given about why they are being streamed to a GP, as an appropriate clinician with skills and expertise to see them, they seem to find being streamed to a GP acceptable.

Meeting expectations about timeliness and level of care

Timely care

Some patients (8/24), regardless of the GP-ED model or their condition, reported that they perceived their condition as an emergency, which required immediate ED care. Some followed advice to attend the ED from the 111 service or their GP (11/24), others attended after difficulty in accessing, or receiving timely and satisfactory care from community primary care services and expected to attend the ED to receive assessment, diagnosis and treatment on the same day (7/24).

I just needed somebody to give me sort of help … where it come from it didn’t really matter … Getting to the hospital, you’ve obviously come to the right place … and I wasn’t getting any advice at all off my local GP.

Some patients suggested that if there was better access to community primary care services, there would be a reduced need for GPs in EDs, as patients would feel able to access timely appointments in their local community primary care service.

Some of the patients interviewed expected a long wait in the ED and appreciated that by seeing a GP in the ED rather than an ED clinician, they were seen more quickly, and therefore felt positive about GP-ED models. Our stakeholders suggested that timely access, and seeing a clinician on the same day, may be more important to patients than the level of investigations received. Our public contributors placed particular emphasis on the importance of the amount of time spent in ED, and how this is more important than the type of clinician they are seen by. They agreed that if seeing a GP in ED reduces waiting time and allows patients to see a clinician on the same day, then streaming to a primary care clinician in the ED is likely to be acceptable to patients. Patients who attended the ED because they believed they perceived their complaint as an emergency, and were streamed to a primary care clinician, generally found this acceptable if their complaint was dealt with in a timely manner and led to appropriate treatment.

I think it is good because otherwise we would’ve had to wait however long to see a general doctor but … the GP seemed a little bit more knowledgeable.

However, if patients who were streamed to a primary care clinician in the ED did not receive treatment which resolved their issue, and had to seek further treatment elsewhere, this could make the process of primary care streaming less acceptable to patients.

The right level of care

Our initial theory about investigations related to patients being dissatisfied if they did not receive the level of investigations they expected in the ED. We did not find any evidence of patients reporting dissatisfaction relating to investigations. Some patients expressed satisfaction when they felt they had received appropriate investigations and had results explained to them during their visit, by a GP.

… we were happy … to be seen by a GP, and I think for me, as well, knowing that he’d been seen … he’d had his levels checked, and then sort of recovered himself and she was happy for him to go with … the instructions for further medication if things do deteriorate.

Patients reported that previous experiences of attending the ED had given them an expectation of the kinds of tests and investigations that they would receive, and reported therefore feeling satisfied when they had received these same tests and investigations by a GP in the ED.

I had learned from my previous experience with my son that … they would do the standard observations, tests, like checking temperature, monitoring the heart rate and so on, and that was all handled.

Using these data, we refined our initial theory describing how a GP-ED model that meets expectations results in patient satisfaction.

New theory: meeting expectations

Patients attend the ED with expectations around timeliness of care and level of care (e.g. investigations) they require but without specific expectations about who would provide this care, sometimes in the context of having failed to access care they feel they need elsewhere (C). When they are seen in a GP-ED model which meets or exceeds their expectations of being assessed and treated in a timely fashion (M), they are satisfied with experience (O).

Redirection

At some outside–onsite models, patients were streamed to a primary care service to be triaged, before then being redirected to a community primary care service. This meant they had to wait and be assessed twice. One streaming nurse suggested that the streaming system would be more efficient and less frustrating for patients if patients could be discharged and redirected to the community primary care service directly from the ED, as this would reduce waiting time for patients (Outside-3).

At another outside–onsite model, a GP described frustration with the system:

If it’s not for them they [ED] send it here, as their default even if it’s something completely that we’re not going to help them with, … they wait three hours and then they get told we can’t help you which is not great.

Our stakeholders suggested that being sent away may lead to patients feeling dismissed or that they should not have attended ED in the first place but acknowledged that good communication and reassurance are important in these scenarios. In EDs where primary care patients were redirected to booked appointments in community services, patients avoided a potentially long wait in ED to be seen by a GP and can go home and be seen that same day by their own GP. Staff at these sites perceived that patients were likely to feel like they are being helped, rather than sent away to seek care elsewhere themselves, particularly as community services may be closer to their home than the ED. Stakeholder feedback emphasised the importance to patients of seeing a clinician quickly, even if they are sent away from the ED for an appointment in the community.

We developed a second theory specific to the acceptability of redirection.

New theory: redirection

If a patient attends the ED with a problem that could be dealt with in primary care (C), and the ED facilitates access to an appointment in the community which avoids a long wait in ED (M), this is likely to be seen as acceptable (O). However, if the patient is referred to a GP-ED model and this process involves duplicated assessments and long waiting times but does not result in definitive care for their problem (M), then the patient may be frustrated (O).

Theme summary

We found that patients generally find it acceptable to be streamed to a primary care clinician in the ED if they have no expectations of which clinician they should be seen by, trust in the initial assessment process and believe that they will receive good advice at the hospital. Patients reported a positive experience when they felt their complaint had been dealt with in a timely manner, and when they received the level investigations and treatments which they expected.

Summary of Phase 2 qualitative results

The qualitative data collected in Phase 2 have allowed us to generate and refine our theories on: how streaming processes were influenced by nurse experience, guidance and overall operational and strategic management; how GPs found working in EDs influenced their clinical decision-making to maintain a usual GP approach or adopt an ED clinician approach, mitigating safety risks; factors that facilitate teamwork and communication between GP-ED services and the ED; and patients’ expectations and experiences of using services.