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GPs in A&E departments fail to curb demand

Co-located services are costly and increase demand, says study

Adrian O'Dowd

Tuesday, 12 April 2016

Primary care services that are located in emergency/urgent care facilities often do not reduce demand on A&E services and are not cost-effective, concludes a study* published today in Emergency Medicine Journal.

Some UK hospitals have tried co-locating primary care doctors and nurses within their emergency department in response to steadily rising numbers of patients seeking emergency/urgent care over the past decade.

The idea has been to try and help patients with problems that could be more appropriately dealt with in primary care.

Although schemes have been implemented at significant cost in many cases, there has been relatively little evaluation of the effectiveness of this approach.

Researchers led by Sheffield Children's NHS Foundation Trust and the University of Sheffield therefore, reviewed the available evidence published between 1980 and 2015 on unscheduled care given by GPs in, or immediately adjacent to, a hospital emergency care facility.

They assessed the impact on demand and throughput, patient satisfaction, and cost effectiveness. 

In all, 20 relevant studies were included in the review, which revealed significant variation in the reported estimates of patients seeking emergency care deemed suitable for primary care instead.

There was little evidence to back locating primary care services in emergency care facilities, as the review found evidence of an increase, rather than a decrease, in demand for urgent/emergency care services.

The researchers said this could be because once healthcare resources became available, they would be overused, irrespective of their quality.

If these co-located services were not available 24/7, patients could simply turn to emergency care instead, particularly those seeking care out of hours, they argued.

The review found some evidence for an improvement in waiting times, but this was not universal, and was likely to be due to the increased number of clinicians available to treat patients.

Overall, the review found little evidence of an improvement in crowding or throughput from streaming primary care patients out of emergency care.

In addition, diverting emergency care patients to primary care services did not save money, because set-up and ongoing indirect costs, dwarfed the marginal savings to be made.

Neither patients nor staff particularly favoured a co-located service, the evidence showed.

The authors said: “An understanding of the demand profile and number of patients with primary care conditions expected to attend an [emergency department] is fundamental to forecasting the resources they require and the associated cost.

“By blurring the line between emergency and primary care by co-locating services, there is a risk of losing the continuity of care that primary care provides, and encouraging ad hoc health seeking behaviour.

“This is likely to lead to confusion, longer pathways and lower degrees of satisfaction with the services being used.”

In an accompanying editorial,** Professor Derek Burke, of Sheffield Children's Hospital NHS Foundation Trust said: “The bottom line is that, before we make major changes to the current systems of unscheduled care in any particular health community, we must be absolutely clear about what we are aiming for – improved access; improved flow; reduced costs and/or improved patient satisfaction.

“Failure to rigorously plan changes in service provision at best will lead to an expensive and disruptive trial-and-error approach to resource allocation.”


Picture credit: kay roxby / Shutterstock.com

* Ramlakhan S, et al. Primary care services located with EDs: a review of effectiveness. Emerg Med J doi:10.1136/emermed-2015-204900
** Burke D. Primary care services located with EDs: a review of effectiveness. Emerg Med J doi:10.1136/emermed-2015-205667

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