Title: General Practitioners and Emergency Departments (GPED): Efficient Models of Care
Funder: Department of Health and Social Care

Abstract: Background Pressure is growing on UK Emergency Departments (EDs), with declining performance and adverse effects on patient outcome and experience. One proposed solution is to locate GPs in or alongside the ED, with a number of models introduced. Currently, 40% of EDs report primary care co-location, however evidence of effectiveness is weak, and there is no consensus regarding the most efficient model of care. Research question What is the impact of GPs working in or alongside the ED (GPED) on patient care, the primary care and acute hospital team and the wider urgent care system? What is the differential impact of different service models of GPED? Methods Mixed-methods study, comprising three Work Packages (WPs). Work Package A We will map, describe and classify current models of GPED in all EDs in England, building on previous work. This will include details of the model and the date of any service change. Through interviews with key informants we will also examine the hypotheses and anticipated benefits that underpin GPED. Work Package B We will measure the impact of the leading models of GPED identified in WP A, compared to a no-GPED model, using a retrospective analysis of routinely available Hospital Episode Statistics (HES) data. We will adopt a quasi-experimental approach using a repeated interrupted time series design and estimate difference-in-difference regression models with closely matched non-GPED sites as controls. Our primary outcome measure is the number of ED attendances (i.e. those managed by usual ED staff) with a wide range of secondary outcomes. This will be complemented by a detailed mixed-methods analysis in six case study sites that have implemented GPED. We will triangulate ED and HES data with local data sources and observable characteristics, focusing on the local urgent care system, and combine this with a parallel qualitative study to ascertain the views and experiences of GPED from staff, patients and carers using survey and interview techniques. We will calculate costs and consequences of the different GPED models on the basis of their estimated effects and resource use, with the objective of identifying genuine changes in resource utilisation. WP B will generate a number of propositions that we will then explore using a prospective methodology in WP C. Work Package C We will complete prospective mixed-methods case studies in four sites as they implement service changes that reflect the most promising GPED models, examining the propositions generated in WP B and with a two-way relationship between quantitative and qualitative data collection and analysis. We will examine the effect of implementing GPED on staff, patients, flow, resource use and the wider healthcare system. Data collection will build on the methods developed in WP B, and will include: • ED data, combined with wider local system (e.g. primary care) data; • A longitudinal interview study, collecting data from staff in the case-study sites before and after GPED implementation; • Detailed staff surveys before and after GPED implementation; • Non-participant observation of clinical practice; • Patient and carer interviews. Benefits We will disseminate a comprehensive assessment of GPED from multiple perspectives to identify the most efficient model of care, maximise clinical and cost effectiveness, reduce staff pressure and improve patient outcome and experience in the UK and internationally

Lay abstract: Emergency departments (EDs) in the UK are under severe pressure because so many people are using them. This means that staff become stressed and patients may not always get the treatment they need in a timely way. One way of reducing the demand on EDs may be to have General Practitioners (GPs) working in or next to the ED. We know that some patients come to an ED with a problem that can be dealt with by a GP. Some EDs already have GPs working in or next to them, but we don’t know the best way to organise this sort of service, or the effect it has on patients, GPs and other NHS staff. GPs are also relatively expensive and in short supply, so they must be used efficiently. We plan to research the different ways that GPs can work in or next to an ED. Our team includes very experienced researchers in Bristol, York and Newcastle, so we will be able to examine a large area of the country. We have clinical experts, including GPs and ED consultants, and other team members with a lot of experience of collecting and making sense of hospital data, analysing the costs of healthcare and understanding staff issues. We have established a patient and public group that will work with us to make sure our research includes the things that matter to patients. We have carefully calculated the staff that are needed to complete this project and identified the other expenses that we will encounter, so the research provides good value for money. In the first phase of our work we will look at all the EDs in the UK that already have GPs in or next to them. We will divide the approaches used in different hospitals into groups, and interview key leaders to find out what they think the benefits are. In phase 2 we will do a full comparison of these EDs using patient, staff and hospital information. We will work closely with the Health Research Authority and make sure that all information is treated as strictly confidential. We will look at how many patients were seen, what their waiting times were, how long they stayed in hospital and other areas of interest that might be influenced by having a GP in or next to the ED. We will compare a period of time before GPs were introduced with a period of time afterwards, and also EDs that don’t have GPs working in this way. We will then pick six places where GPs are already working in or next to the ED and study them in detail, collecting local information on the way that patients use health services in that area, and interviewing and surveying patients and staff who have experience of GPs working in or next to the ED. We will then be in a good position to predict what is likely to happen when GPs are introduced to the ED, and will explore these ideas further in phase three. We will work with four hospitals that are about to start using GPs and will study what happens before and after the change by collecting a wide range of local data, surveying and interviewing staff before and after, observing what happens in the ED on a day-to-day basis and interviewing patients and carers who have used the service. We will consider the things that are important to patients, staff, the hospital and the NHS as a whole, and examine the costs compared to the benefits that can be achieved. Our recommendations about the best ways for GPs to work with EDs will reduce pressure on staff, get the best value from NHS funding, improve patient satisfaction and help to ensure that EDs provide the best possible care in the future.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE