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.
In this study, 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.
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 service model and the date of any service change. Through interviews with key informants we will also examine the hypotheses that underpin GPED and its anticipated benefits.
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 (ITS) 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 traditional ED staff), and we will also assess 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 particularly on the wider local urgent care system, and combine this with a parallel qualitative study to ascertain the views and experiences of GPED from the staff working across the case study sites and from patients and carers using survey and interview techniques.
Finally, we will calculate costs and consequences of the different GPED models on the basis of their estimated effects alongside estimated resource use, with the objective of identifying genuine changes in resource utilisation. Work Package B will generate a number of propositions that we will then explore in more detail using a prospective methodology in Work Package 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 Work Package 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 and resource use within the wider healthcare system.
Data collection will build on the methods developed in Work Package B, and will include:
• ED data, combined with local data sources relating to the wider urgent care system
• A longitudinal qualitative interview study collecting data from a wide range of staff in the case-study sites at two time points, before and after GPED implementation
• Staff surveys before and after GPED implementation
• Non-participant observation of clinical practice
• Patient and carer interviews.
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, safety and experience in the UK and internationally.