Scant evidence to back locating primary care services in emergency / urgent care

There is little evidence to back locating primary care services in emergency/urgent care facilities in a bid to curb patient demand and improve throughput, finds a review of the available evidence, published online in Emergency Medicine Journal.

Furthermore, the set-up costs dwarf the marginal savings to be made, the findings suggest.

In response to steadily rising numbers of patients seeking emergency/urgent care over the past decade, UK hospitals have hit on the idea of co-locating primary care doctors and nurses within the emergency department, prompted by the theory that many patients have problems that could be more appropriately dealt with in primary care.

Although often implemented "at significant cost in many cases," there has been relatively little evaluation of the effectiveness of this approach, say the researchers.

They therefore reviewed the available evidence published between 1980 and 2015 on unscheduled care given by family doctors (GPs) in, or immediately adjacent to, a hospital emergency care facility.

They assessed the impact on demand and throughput (process outcomes), 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.

"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," the researchers point out.

The review found evidence of an increase, rather than a decrease, in demand for urgent/emergency care services. This is probably because once healthcare resources become available, they will be overused no matter what the quality is like—'if you build it, they will come'—say the researchers.

And if these co-located services are not available 24/7, patients may simply turn to emergency care instead, particularly those seeking care out of hours, they say.

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

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

Nor did it find that diverting emergency care patients to primary care services saved money, because set-up and ongoing indirect costs, which are often not taken into consideration, dwarf the marginal savings to be made.

Neither patients nor staff particularly favoured a co-located service, the evidence showed. If anything, these services risked increasing staff dissatisfaction

And the researchers suggest: "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."

They continue: "This is likely to lead to confusion, longer pathways and lower degrees of satisfaction with the services being used," adding that patients are generally quite good at deciding where to access care, with inappropriate choices largely the result of socioeconomic factors and shortcomings in the unscheduled care system.

In a linked editorial, emergency care consultant and medical director, Professor Derek Burke, of Sheffield Children's Hospital NHS Foundation Trust, outlines serial unsuccessful attempts to manage demand better while improving access to emergency care, dating back to the time of Napoleon.

The phenomenon of ever increasing demand for emergency care services is not unique to the UK, he points out.

But he emphasises that before any further major change is contemplated, "we must be absolutely clear about what we are aiming for," and carry out detailed analyses of current patient flows, including between the various access points, and then monitor and rigorously evaluate the impact.

"Finally, we must come to accept that unscheduled care is now a consumer item and seen by users as being no different from the availability of 24 h shopping. In this age of consumer based healthcare provision, not considering the consumer's view is a recipe for disaster," he concludes.