Staff perceptions on patient motives for attending GP-led urgent care centres in London: a qualitative study

Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed-methods realist evaluation

Background

Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner-emergency department service models.

Objectives

To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner-emergency department models.

Design

Mixed-methods realist evaluation.

Methods

Phase 1 (2017-8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018-21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost-consequences analysis of routine data; and case site data for 'marker condition' analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021-2), to conduct mixed-methods analysis for programme theory and toolkit development.

Results

General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner-emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner-emergency department models.

Limitations

The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with 'marker conditions'). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as 'telephone first' and their relevance to our findings remains unexplored.

Conclusion

Findings suggest that general practitioner-emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner-emergency department services.

Future work

The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner-emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy.

Study registration

This study is registered as PROSPERO CRD42017069741.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.

Does an emergency access button increase the patients' satisfaction and feeling of safety with the out-of-hours health services? A randomised controlled trial in Denmark

OBJECTIVE

To investigate if the option to bypass the telephone queue can increase satisfaction and feeling of safety in callers.

DESIGN

Randomised controlled parallel superiority trial. Data from questionnaire survey.

SETTING

Two out-of-hours (OOH) services in Denmark.

PARTICIPANTS

217 510 citizens who called the OOH services between 4 September 2017 and 30 November 2017.

RANDOMISATION

Two-faze study period: First half with randomisation of participants based on their date of birth; even date randomised to intervention, uneven date randomised to control group. Second half with all participants included in intervention group.

INTERVENTION

Providing randomised callers (intervention group n=146 355) with the option to bypass the telephone waiting line through an emergency access button (EAB), while the rest got the normal service (control group n=71 155). All EAB users were invited to a questionnaire survey as well as random participants who did not use the EAB (of whom approximately 50% did not have the EAB option).

MAIN OUTCOME MEASURES

Satisfaction and feeling of safety in callers.

RESULTS

2208 of 6704 (32.9%) invited callers answered the questionnaire (intervention group n=1415 (users n=621, non-users n=794); control group n=793). The OR for answering in the two categories with highest satisfaction when provided with the EAB option was 1.34 (95% CI 1.07 to 1.68) for satisfaction with the waiting time, 1.21 (95% CI 0.91 to 1.60) for overall satisfaction and 1.46 (95% CI 1.12 to 1.89) for feeling of safety. Approximately 72% (441/621) of EAB users reported that the EAB option increased their feeling of safety with the OOH services 'to a high degree' compared with 25% (197/794) of callers who had the EAB option without using it.

CONCLUSIONS

The EAB can provide fast access to OOH telephone advice in case of severe illness. It favours citizens perceived in most need of urgent healthcare and significantly increases both feeling of safety and patient satisfaction.

TRIAL REGISTRATION DETAILS

NCT02572115 (5 October 2015).

Tendency to contact general practice instead of self-care: a population vignette study

Background

Demand for general practice in the UK is higher than supply. Some patients seek appointments with GPs for minor illnesses rather than self-care.

Aim

To identify the characteristics of people with a tendency to contact GPs rather than self-care.

Design & setting

A national survey of the British adult population was undertaken in 2018, which included vignettes.

Method

Two vignettes focused on illness in adults: half of responders completed a vignette about cough and sore throat for 3 days, and the other half completed a vignette about diarrhoea and vomiting for 2 days. Logistic regression was undertaken to identify characteristics associated with contacting GPs compared with dealing with the problem themselves, calling NHS 111, or contacting another service, including a pharmacist.

Results

The response rate was 42%, with 2906 responders. Responders were twice as likely to select ‘contact GP’ for the diarrhoea and vomiting vignette than for the cough and sore throat vignette (44.7% versus 21.8%). Factors associated with tendency for GP contact included being aged >75 years (odds ratio [OR] 2.0, 95% confidence interval [CI] = 1.2 to 3.2); from black, Asian and minority ethnic (BAME) communities (OR 2.1, 95% CI = 1.5 to 3.0); feeling overwhelmed by unexpected health problems (OR 1.4, 95% CI = 0.99 to 2.1); lower health literacy (OR 1.2, 95% CI = 1.0 to 1.4); and believing that general practice is not overused (OR 1.3, 95% CI = 1.1 to 1.7).

Conclusion

Type of symptom, personal characteristics, and population beliefs about general practice utilisation explain the tendency to contact GPs for minor illness amenable to self-care.

Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study

Background

There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use.

Objectives

To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives.

Design

This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking.

Results

From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice.

Limitations

Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service.

Conclusions

Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered.

Future work

There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions.

Study registration

This study is registered as PROSPERO CRD42017056273.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

Profile and Motivation of Patients Consulting in Emergency Departments While not Requiring Such a Level of Care

Consultations that do not require an emergency department (ED) level of care have increased. We explored attitudes of non-urgent patients in two academic hospitals in France with a similar fast track organization. One of them is a Parisian hospital with 90,000 patients/year who are admitted to the ED, while the other admits 40,000 patients/year in a smaller city. During one month in 2018, the triage nurse handed out a survey to patients coming for non-urgent consultations. It was given back to the fast track physician at the end of the visit; 598 patients agreed to answer. They were mostly young males with adequate social coverage, consulting for osteo-articular pathologies, without any significant difference between the two sites (p = 0.32). They were equally satisfied with the care they received (p = 0.38). Satisfaction was inversely correlated to waiting time (p < 0.0001). Convenience, accessibility of emergency facilities, and geographic proximity were motivation factors. These results suggest that primary care providers who can access testing facilities in accordance with patient needs might be a solution to help reduce overcrowding in EDs.

'Clinically unnecessary' use of emergency and urgent care: A realist review of patients' decision making

Background

Demand is labelled ‘clinically unnecessary’ when patients do not need the levels of clinical care or urgency provided by the service they contact.

Objective

To identify programme theories which seek to explain why patients make use of emergency and urgent care that is subsequently judged as clinically unnecessary.

Design

Realist review.

Methods

Papers from four recent systematic reviews of demand for emergency and urgent care, and an updated search to January 2017. Programme theories developed using Context‐Mechanism‐Outcome chains identified from 32 qualitative studies and tested by exploring their relationship with existing health behaviour theories and 29 quantitative studies.

Results

Six mechanisms, based on ten interrelated programme theories, explained why patients made clinically unnecessary use of emergency and urgent care: (a) need for risk minimization, for example heightened anxiety due to previous experiences of traumatic events; (b) need for speed, for example caused by need to function normally to attend to responsibilities; (c) need for low treatment‐seeking burden, caused by inability to cope due to complex or stressful lives; (d) compliance, because family or health services had advised such action; (e) consumer satisfaction, because emergency departments were perceived to offer the desired tests and expertise when contrasted with primary care; and (f) frustration, where patients had attempted and failed to obtain a general practitioner appointment in the desired timeframe. Multiple mechanisms could operate for an individual.

Conclusions

Rather than only focusing on individuals' behaviour, interventions could include changes to health service configuration and accessibility, and societal changes to increase coping ability.

Sense-making strategies and help-seeking behaviours associated with urgent care services: a mixed-methods study

Background

Policy has been focused on reducing unnecessary emergency department attendances by providing more responsive urgent care services and guiding patients to ‘the right place’. The variety of services has created a complex urgent care landscape for people to access and navigate.

Objectives

To describe how the public, providers and policy-makers define and make sense of urgent care; to explain how sense-making influences patients’ strategies and choices; to analyse patient ‘work’ in understanding, navigating and choosing urgent care; to explain urgent care utilisation; and to identify potentially modifiable factors in decision-making.

Design

Mixed-methods sequential design.

Setting

Four counties in southern England coterminous with a NHS 111 provider area.

Methods

A literature review of policy and research combined with citizens’ panels and serial qualitative interviews. Four citizens’ panels were conducted with the public, health-care professionals, commissioners and managers (n = 41). Three populations were sampled for interview: people aged ≥ 75 years, people aged 18–26 years and East European people. In total, 134 interviews were conducted. Analyses were integrated to develop a conceptual model of urgent care help-seeking.

Findings

The literature review identified some consensus between policy and provider perspectives regarding the physiological factors that feature in conceptualisations of urgent care. However, the terms ‘urgent’ and ‘emergency’ lack specificity or consistency in meaning. Boundaries between urgent and emergency care are ill-defined. We constructed a typology that distinguishes three types of work that take place at both the individual and social network levels in relation to urgent care sense-making and help-seeking.Illness workinvolves interpretation and decision-making about the meaning, severity and management of physical symptoms and psychological states, and the assessment and management of possible risks. Help-seeking was guided bymoral work: the legitimation and sanctioning done by service users.Navigation workconcerned choosing and accessing services and relied on prior knowledge of what was available, accessible and acceptable. From these empirical data, we developed a model of urgent care sense-making and help-seeking behaviour that emphasises that work informs the interaction between what we think and feel about illness and the need to seek care (sense-making) and action – the decisions we take and how we use urgent care (help-seeking).

Limitations

The sample population of our three groups may not have adequately reflected a diverse range of views and experiences. The study enabled us to capture people’s views and self-reported service use rather than their actual behaviour.

Conclusions

Much of the policy surrounding urgent and emergency care is predicated on the notion that ‘urgent’ sits neatly between emergency and routine; however, service users in particular struggle to distinguish urgent from emergency or routine care. Rather than focusing on individual sense-making, future work should attend to social and temporal contexts that have an impact on help-seeking (e.g. why people find it more difficult to manage pain at night), and how different social networks shape service use.

Future work

A whole-systems approach considering integration across a wider network of partners is key to understanding the complex relationships between demand for and access to urgent care.

Study registration

This study is registered as UKCRN 32207.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The impact of general practitioners working in or alongside emergency departments: a rapid realist review

OBJECTIVES

Worldwide, emergency healthcare systems are under intense pressure from ever-increasing demand and evidence is urgently needed to understand how this can be safely managed. An estimated 10%-43% of emergency department patients could be treated by primary care services. In England, this has led to a policy proposal and £100 million of funding (US$130 million), for emergency departments to stream appropriate patients to a co-located primary care facility so they are 'free to care for the sickest patients'. However, the research evidence to support this initiative is weak.

DESIGN

Rapid realist literature review.

SETTING

Emergency departments.

INCLUSION CRITERIA

Articles describing general practitioners working in or alongside emergency departments.

AIM

To develop context-specific theories that explain how and why general practitioners working in or alongside emergency departments affect: patient flow; patient experience; patient safety and the wider healthcare system.

RESULTS

Ninety-six articles contributed data to theory development sourced from earlier systematic reviews, updated database searches (Medline, Embase, CINAHL, Cochrane DSR & CRCT, DARE, HTA Database, BSC, PsycINFO and SCOPUS) and citation tracking. We developed theories to explain: how staff interpret the streaming system; different roles general practitioners adopt in the emergency department setting (traditional, extended, gatekeeper or emergency clinician) and how these factors influence patient (experience and safety) and organisational (demand and cost-effectiveness) outcomes.

CONCLUSIONS

Multiple factors influence the effectiveness of emergency department streaming to general practitioners; caution is needed in embedding the policy until further research and evaluation are available. Service models that encourage the traditional general practitioner approach may have shorter process times for non-urgent patients; however, there is little evidence that this frees up emergency department staff to care for the sickest patients. Distinct primary care services offering increased patient choice may result in provider-induced demand. Economic evaluation and safety requires further research.

PROSPERO REGISTRATION NUMBER

CRD42017069741.

The decision-making process for unplanned admission to hospital unveiled in hospitalised older adults: a qualitative study

BACKGROUND

The hazards of hospitalisation, and the growing demand for goal-oriented care and shared decision making, increasingly question whether hospitalisation always aligns with the preferences and needs of older adults. Although decision models are described comprehensively in the literature, little is understood about how the decision for hospitalisation is made in real life situations, especially under acute conditions. The aim of this qualitative study was to gain insight into how the decision to hospitalise was made from the perspective of the older patient who was unplanned admitted to hospital.

METHODS

Open interviews were conducted with 21 older hospitalised patients and/or their next of kin about the decision-making process leading to hospitalisation. Data were analysed according to the Constructivist Grounded Theory approach.

RESULTS

Although a period of complaints preceded the decision to unplanned hospitalisation, ranging from hours to years, the decision to hospitalise was always taken acutely. In all cases, there was an acute moment in which the home as a care environment was no longer considered adequate. This conclusion was based on a combination of factors including factors related to complaints, general practitioner and home environment. Three parties were involved in this assessment: the patient, his next of kin and the general practitioner. At the same time, a very positive value was attributed towards the hospital. Depending on the assessment of the home as care environment by the various parties, there were four routes to hospitalisation: referral, shared, demanding and bypassing.

CONCLUSIONS

For all participants, the decision to hospitalisation was taken acutely, even if the problems evoking admission were not acute, but present for a longer period. Participants saw admission as inevitable, due to the negative perceptions of the care environment at home at that moment, combined with the positive expectations of hospital care. Advance care planning, nor shared decision making were rarely seen in these interviews. An ethical dilemma occurred when the next of kin consented to hospitalisation against the wishes of the patient. More attention for participation of older adults in decision making and their goals is recommended.

Describing team development within a novel GP-led urgent care centre model: a qualitative study

OBJECTIVE

Urgent care centres (UCCs) co-located within an emergency department were developed to reduce the numbers of inappropriate emergency department admissions. Since then various UCC models have developed, including a novel general practitioner (GP)-led UCC that incorporates both GPs and emergency nurse practitioners (ENPs). Traditionally these two groups do not work alongside each other within an emergency setting. Although good teamwork is crucial to better patient outcomes, there is little within the literature about the development of a team consisting of different healthcare professionals in a novel healthcare setting. Our aim was therefore to describe staff members' perspectives of team development within the GP-led UCC model.

DESIGN

Open-ended semistructured interviews, analysed using thematic content analysis.

SETTING

GP-led urgent care centres in two academic teaching hospitals in London.

PARTICIPANTS

15 UCC staff members including six GPs, four ENPs, two receptionists and three managers.

RESULTS

Overall participants were positive about the interprofessional team that had developed and recognised that this process had taken time. Hierarchy within the UCC setting has diminished with time, although some residual hierarchical beliefs do appear to remain. Staff appreciated interdisciplinary collaboration was likely to improve patient care. Eight key facilitating factors for the team were identified: appointment of leaders, perception of fair workload, education on roles/skill sets and development of these, shared professional understanding, interdisciplinary working, ED collaboration, clinical guidelines and social interactions.

CONCLUSIONS

A strong interprofessional team has evolved within the GP-led UCCs over time, breaking down traditional professional divides. Future implementation of UCC models should pro-actively incorporate the eight facilitating factors identified from the outset, to enable effective teams to develop more quickly.

Statewide retrospective study of low acuity emergency presentations in New South Wales, Australia: who, what, where and why?

OBJECTIVE

The present study aims to use a statewide population-based registry to assess the prevalence of low acuity emergency department (ED) presentations, describe the trend in presentation rates and to determine whether they were associated with various presentation characteristics such as the type of hospital as well as clinical and demographic variables.

DESIGN AND SETTING

This was a retrospective analysis of a population-based registry of ED presentations in New South Wales (NSW). Generalised estimating equations with log links were used to determine factors associated with low acuity presentations to account for repeat presentations and the possibility of clustering of outcomes.

PARTICIPANTS

Patients were included in this analysis if they presented to an ED between January 2010 and December 2014. The outcomes of interest were low acuity presentation, defined as those who self-presented (were not transported by ambulance), were assigned a triage category of 4 or 5 (semiurgent or non-urgent) and discharged back to usual residence from ED.

RESULTS

There were 10.7 million ED presentations analysed. Of these, 45% were classified as a low acuity presentation. There was no discernible increase in the rate of low acuity presentations across NSW between 2010 and 2014. The strongest predictors of low acuity ED presentation were age <40 years of age (OR 1.77); injury or musculoskeletal administrative and non-urgent procedures (OR 2.96); ear, nose and throat, eye or oral (OR 5.53); skin or allergy-type presenting problems (OR 2.84).

CONCLUSIONS

Low acuity ED presentations comprise almost half of all ED presentations. Alternative emergency models of care may help meet the needs of these patients.