The NHS in England will receive an extra £100m in 2017-18 to invest in triage by GPs and other measures to ease the flow of patients into hospital emergency departments. The spending was justified by the Chancellor of the Exchequer with claims that “onsite GP triage in A&E departments can have a significant and positive impact on A&E waiting times”.(1)
Such claims appear at odds with recent systematic reviews that conclude the evidence base for using primary care services in emergency departments is weak and based on poor quality studies.(2-4) Overall attendances may even paradoxically increase due to provider-induced demand.(4) Attendance of sicker patients with more complex conditions may be part of the reason for rising pressure on emergency departments,(5,6) which would not be addressed by this initiative. Recruitment for this additional GP workforce would also be challenging.
Recognising the paucity of evidence on this pertinent issue, last year the NIHR Health Services and Delivery Research programme commissioned research to evaluate different models of care using GPs in (or alongside) emergency departments. As one of two commissioned studies, we are currently in the early phases of an evaluation of the effectiveness, safety, patient experience and system implications of such ‘GP-ED’ models, aiming to address the key policy questions of where or how the greatest value can be delivered.(7) As part of this early work we will send a national survey to all principal (‘type 1’) emergency departments in England and Wales to improve understanding of the GP-ED models already in place, the extent to which they achieve their aims, and to learn about the successes and consequences of different model types. We encourage all emergency departments to participate in this survey, to help improve understanding and to assist us in the selection of exemplars for case study sites to evaluate in more detail in the next phase of the study.
We understand the scale, complexity and urgency of the challenge of improving emergency department care, but it is vital that such critical policy decisions are rooted in evidence of benefits, safety and patient experience, and an understanding of wider system implications. We need to avoid the development of services which are then subsequently difficult to withdraw, but for which there is no good evidence of effectiveness.(8)
1. All emergency departments must have GP led triage by October BMJ 2017;356:j1270
2.Turner J, et al. What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review https://www.ncbi.nlm.nih.gov/books/NBK327599/
3.Khangura JK, et al. Primary care professionals providing non‐urgent care in hospital emergency departments. The Cochrane Library. 2012.
4. Ramlakhan, S, et al. Primary care services located within EDs: a review of effectiveness. Emer Med J 2016;0:1-9
5. Sicker patients the main reason for A&E winter pressures. The King’s Fund, UK. 2017 https://www.kingsfund.org.uk/press/press-releases/sicker-patients-main-r...
6. What’s going on in A&E? The key questions answered. The King’s Fund, UK. 2017 https://www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-e...
7. Edwards et al. Evaluating effectiveness, safety, patient experience and system implications of different models of using GPs in or alongside Emergency Departments. NIHR HS&DR 15/145/04 https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/1514504/#/
8. McDonnell A, Wilson R, Goodacre S. Evaluating and implementing new services BMJ 2006;332(7533):109.
Competing interests: NIHR HS&DR 15/145/04 Commissioned Study: GPs in EDs - Evaluating effectiveness, safety, patient experience and system implications of different models of using GPs in or alongside Emergency Departments.