Programme theories to describe how different general practitioner service models work in different contexts in or alongside emergency departments (GP-ED): realist evaluation

Cooper, Alison ORCID: https://orcid.org/0000-0001-8660-6721, Edwards, Michelle ORCID: https://orcid.org/0000-0001-7432-2828, Davies, Freya ORCID: https://orcid.org/0000-0002-6956-1100, Price, Delyth, Anderson, Pippa, Carson-Stevens, Andrew ORCID: https://orcid.org/0000-0002-7580-7699, Cooke, Matthew, Dale, Jeremy, Donaldson, Liam, Evans, Bridie, Harrington, Barbara, Hepburn, Julie, Hibbert, Peter, Hughes, Thomas, Porter, Alison, Siriwardena, Aloysius, Watkins, Alan, Snooks, Helen and Edwards, Adrian ORCID: https://orcid.org/0000-0002-6228-4446 2024. Programme theories to describe how different general practitioner service models work in different contexts in or alongside emergency departments (GP-ED): realist evaluation. Emergency Medicine Journal 41 (5) , pp. 287-295. 10.1136/emermed-2023-213426

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Abstract

Background: Addressing increasing patient demand and improving emergency department (ED) patient flow is a key ambition for NHS England. Delivering general practitioner (GP) services in or alongside EDs (GP-ED) was advocated in 2017 for this reason, supported by £100million (US$130million) of capital funding. Current evidence shows no overall improvement in addressing demand and reducing waiting times, but considerable variation in how different service models operate, subject to local context. Methods: We conducted mixed-methods analysis using inductive and deductive approaches for qualitative (observations, interviews) and quantitative data (time series analyses of attendances, re-attendances, hospital admissions, length of stay) based on previous research using a purposive sample of 13 GP-ED service models (3 inside-integrated; 4 inside-parallel service; 3 outside-onsite; and 3 with no GPs) in England and Wales. We used realist methodology to understand the relationship between contexts, mechanisms and outcomes to develop programme theories about how and why different GP-ED service models work. Results: GP-ED service models are complex, with variation in scope and scale of the service, influenced by individual, departmental and external factors. Quantitative data were of variable quality: overall no reduction in attendances and waiting times, a mixed picture for hospital admissions and length of hospital stay. Our programme theories describe how the GP-ED service models operate: inside the ED, integrated with patient flow and general ED demand, with a wider GP role than usual primary care; outside the ED, addressing primary care demand with an experienced streaming nurse facilitating the ‘right patients’ are streamed to the GP; or within the ED as a parallel service with most variability in the level of integration and GP role. Conclusion: Our programme theories inform recommendations on how services could be modified in particular contexts to address local demand, or whether alternative healthcare services should be considered.

Item Type:	Article
Date Type:	Published Online
Status:	Published
Schools:	Medicine
Publisher:	BMJ Publishing Group
ISSN:	1472-0205
Funders:	National Institute for Health Research (NIHR) HS&DR
Date of First Compliant Deposit:	5 March 2024
Date of Acceptance:	15 February 2024
Last Modified:	31 Oct 2024 17:10
URI:	https://orca.cardiff.ac.uk/id/eprint/166889

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