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Do general practitioners working in or alongside the emergency department improve clinical outcomes or experience? A mixed-methods study

Scantlebury, Arabella; Adamson, Joy; Salisbury, Chris; Brant, Heather; Anderson, Helen; Baxter, Helen; Bloor, Karen; Cowlishaw, Sean; Doran, Tim; Gaughan, James; Gibson, Andy; Gutacker, Nils; Leggett, Heather; Purdy, Sarah; Voss, Sarah; Benger, Jonathan Richard

Do general practitioners working in or alongside the emergency department improve clinical outcomes or experience? A mixed-methods study Thumbnail


Authors

Arabella Scantlebury

Joy Adamson

Chris Salisbury

Heather Brant

Helen Anderson

Helen Baxter

Karen Bloor

Sean Cowlishaw

Tim Doran

James Gaughan

Andy Gibson Andy.Gibson@uwe.ac.uk
Associate Professor in Patient and Public Involve

Nils Gutacker

Heather Leggett

Sarah Purdy

Sarah Voss Sarah.Voss@uwe.ac.uk
Professor of Emergency and Critical Care

Jonathan Richard Benger



Abstract

OBJECTIVES: To examine the effect of general practitioners (GPs) working in or alongside the emergency department (GPED) on patient outcomes and experience, and the associated impacts of implementation on the workforce. DESIGN: Mixed-methods study: interviews with service leaders and NHS managers; in-depth case studies (n=10) and retrospective observational analysis of routinely collected national data. We used normalisation process theory to map our findings to the theory's four main constructs of coherence, cognitive participation, collective action and reflexive monitoring. SETTING AND PARTICIPANTS: Data were collected from 64 EDs in England. Case site data included: non-participant observation of 142 clinical encounters; 467 semistructured interviews with policy-makers, service leaders, clinical staff, patients and carers. Retrospective observational analysis used routinely collected Hospital Episode Statistics alongside information on GPED service hours from 40 hospitals for which complete data were available. RESULTS: There was disagreement at individual, stakeholder and organisational levels regarding the purpose and potential impact of GPED (coherence). Participants criticised policy development and implementation, and staff engagement was hindered by tensions between ED and GP staff (cognitive participation). Patient 'streaming' processes, staffing and resource constraints influenced whether GPED became embedded in routine practice. Concerns that GPED may increase ED attendance influenced staff views. Our quantitative analysis showed no detectable impact on attendance (collective action). Stakeholders disagreed whether GPED was successful, due to variations in GPED model, site-specific patient mix and governance arrangements. Following statistical adjustment for multiple testing, we found no impact on: ED reattendances within 7 days, patients discharged within 4 hours of arrival, patients leaving the ED without being seen; inpatient admissions; non-urgent ED attendances and 30-day mortality (reflexive monitoring). CONCLUSIONS: We found a high degree of variability between hospital sites, but no overall evidence that GPED increases the efficient operation of EDs or improves clinical outcomes, patient or staff experience. TRIAL REGISTRATION NUMBER: ISCRTN5178022.

Journal Article Type Article
Acceptance Date Aug 31, 2022
Online Publication Date Sep 20, 2022
Publication Date Sep 1, 2022
Deposit Date Sep 30, 2022
Publicly Available Date Sep 30, 2022
Journal BMJ open
Electronic ISSN 2044-6055
Publisher BMJ Publishing Group
Peer Reviewed Peer Reviewed
Volume 12
Issue 9
Pages e063495
DOI https://doi.org/10.1136/bmjopen-2022-063495
Keywords Emergency medicine, 1506, 1691, health policy, accident & emergency medicine, qualitative research, primary care
Public URL https://uwe-repository.worktribe.com/output/10005588
Publisher URL https://bmjopen.bmj.com/content/12/9/e063495
Additional Information Approval was obtained from East Midlands – Leicester South Research Ethics Committee (ref: 17/EM/0312); University of Newcastle Ethics Committee (Ref: 14348/2016) and the Health Research Authority (IRAS: 230848 and 218038). All participants provided informed consent before taking part in the qualitative study.

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