Award Title: Evaluating effectiveness, safety, patient experience and system implications of different models of using GPs in or alongside Emergency Departments.
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Hospital emergency departments (EDs) are under increasing, sometimes extreme, pressure. Patients are experiencing long hours of waiting to be seen. We have seen media reports of emergency services in crisis. This situation has arisen partly because people attend EDs with problems that GPs could deal with. Finding better ways to assess and treat patients coming to EDs could have a major impact on the experience and care of the millions of people attending EDs and on all NHS services by providing evidence of how best to manage resources. _x000D_
Many EDs now work closely with GPs in three main ways:  _x000D_
•	Assessing patients and sending them back to their GP; _x000D_
•	Assessing patients and sending them to a GP clinic next door to the ED; _x000D_
•	Placing GPs in the ED as extra staff to provide treatment._x000D_
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It is not known how well these arrangements provide care or if they make a difference to how quickly patients receive treatment and referrals for tests and other services. Our study will look at what works, for whom and in what circumstances._x000D_
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In this study we will look at:_x000D_
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1. What are the different ways of working, how are they are organised and how common are they? _x000D_
2. How do they work in practice? Do they do what they were meant to do? _x000D_
3. Hospital admissions, re-attendance, waiting times, patient safety and staff and patient satisfaction _x000D_
4. What are the key factors that lead to a better service? _x000D_
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We will survey all 200 EDs in England and Wales to find out how they work with GPs.  We will call together an expert group of health care professionals, policy makers, patients and public who will examine the findings and _x000D_
1. Decide how best to group together the different ways of working_x000D_
2. Choose a number of problems that people often go to GPs and EDs for, such as back pain or fever in children_x000D_
This will help us in the next part of the study when we will choose 12 EDs to look at more closely, three for each of the main ways of working with GPs and three EDs without GPs. We will collect information from patient case notes and hospital clinical records. We will interview patients, doctors and hospital staff. We will look at any differences in how the chosen common problems are managed by GPs and ED doctors, including treatment costs and how patients felt about their experience. _x000D_
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Overall, our results will show which are the best ways of working and why. The findings will be presented to a second meeting of health care professionals, policy makers, patients and public members who will help us decide, using the evidence we have gathered, which way of working delivers the best care for patients and makes best use of NHS resources. They will help us create a toolkit to guide emergency services commissioners to plan and put into practice the best arrangements for using GPs in EDs in their particular circumstances. _x000D_
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We will report our results to health professionals through publications, presentations, training events and meetings. We will use national, local and social media and patient networks to inform patients and the public._x000D_
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Our study team brings together professionals with a wide range experience in primary and emergency care and includes two active members of the public who have experience of using EDs.  The public contributors will work with the researchers at all stages to plan and undertake this study and publicise the results. Members of the public will also be supported to play an active part in our expert group meetings.

Lay Abstract: Background: The emergency care system is in crisis and evidence is needed urgently to understand how to manage workload and demand to safely achieve the highest standards of clinical and operational care,(1) and whether the recommended addition of co-located GPs,(2) adds value. The evidence base to support service models of General Practitioners (GPs) working within EDs is weak,(3-5) with three main GP-ED models in use: GPs working geographically adjacent to EDs; GPs serving in a triage and screening capacity; and GPs fully integrated into ED service provision.(6) The effectiveness of each model on service provision and quality and safety of care delivery is unclear._x000D_
We therefore propose a realist evaluation to understand how the contextual differences between the three main GP-ED models (patient, staff and organisational factors) influence how the services function in different settings (mechanisms) to generate variations in intended and unintended outcomes (effectiveness and safety of care provided; patient and staff experience; resource consequences and economic impact),(7) based on an effective practice framework.(8)_x000D_
Method: Phase 0: Preliminary work involving analysis of National Reporting and Learning System ED patient safety incident reports for the most frequent and harmful incidents related to GPs and ED clinicians.(9)_x000D_
Phase 1: A national Survey will be undertaken to characterise which GP-ED models are in use in England and Wales and the aims of the services they provide. Also, a rapid realist (literature) review of the context and mechanisms by which different models achieve their outcomes, (10) to generate initial working theories and iterate the GP-ED models taxonomy.(6) This will be explored and clarified in a Stakeholder conference and a set of ‘marker conditions’ (presenting conditions thought to be managed differently by GPs and ED clinicians i.e. investigation & admission rates) will be confirmed for subsequent in-depth analysis in Phase 2._x000D_
Phase 2: Using a mixed methods design, 12 study sites will be purposively sampled for quantitative data collection (Interrupted Time Series analysis of NHSE/NWIS (Wales) and Emergency Care Dataset analysis, plus description of case mix and outcomes, and for economic/resource use evaluation). This will be integrated with qualitative data collection (‘marker conditions’, field observations, key informant interviews, incident report analysis) using techniques such as pattern matching for a mixed methods synthesis. Three sites will be selected for each of the three main model types and three that do not use co-located GPs. _x000D_
Phase 3: Segmented regression analysis of quantitative interrupted time series data, economic modelling of resource and outcome data, combined with field observation and interview data will inform the realist evaluation to compare how the different contexts and mechanisms lead to the outcomes across the GP-ED models and identify what works for whom and in what circumstances. Findings will be provided to Survey participants and a second Stakeholder conference for feedback on credibility, transferability and discussion. _x000D_
Outcomes: to produce a transferable evidence base for commissioning and delivery concerning effective use of GP skills in different ED settings in terms of: cost-effectiveness; resource use; safety of care; patient and staff experience; capacity considerations and training; and sustainability and resilience, in the context of local systems.

Research Activity Codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health Categories: GENERIC HEALTH RELEVANCE