Limited evidence to support co-locating GPs in A&E, study suggests

Evidence to suggest that co-locating GPs in A&E departments can reduce demand or improve patient satisfaction is limited, UK research suggests.

UK researchers found little evidence overall to support the use of GPs in A&E, and warned that the findings suggested that their presence may in fact increase demand for urgent or emergency care.

The costs of setting up a GP service inside the front door of A&E departments also outweighed small reported marginal cost savings, the researchers warned in the Emergency Medicine Journal.

Researchers from Sheffield and Bradford said that rising emergency department attendances in the UK and in other countries had prompted health systems to investigate ways to reduce demand.

Primary care patients

They wrote: 'One theory explaining this increased demand suggests that this is attributable mainly to patients with problems more suited to primary care and that diverting such patients away from the emergency department may improve access and care across the system.

'To this end, several models of hospital-based unscheduled care services have been developed that primarily use a workforce consisting of GPs or other primary care clinicians. These have been implemented at significant cost in many cases, but with little evaluation of effectiveness in the context of local health services. In many instances, the introduction of alternative and untested forms of urgent care has failed to reduce emergency department attendances.'

To evaluate the effectiveness of co-locating primary care-led urgent care centres (UCCs) in A&E, the researchers looked at studies of systems in the UK, Netherlands, Australia, Spain, New Zealand, Sweden and Ireland.

Despite successes reported in some areas, the researchers concluded that 'the expected benefits of the introduction of such a service are not a given, with variable outcomes reported'.

GP cost savings

The researchers warned that 'the potential savings from a diversion of non-urgent visits to primary care are...likely to be much less than is widely believed'. Although some studies suggested there were cost savings from co-locating GPs in A&E, the researchers highlighted 'variable or ill-defined' information within these and pointed to other studies that suggested the true cost of treating non-urgent cases in emergency departments was relatively low.

Patient satisfaction did not improve with co-located GP services in A&E, the researchers found - and in one case significantly reduced staff satisfaction.

They wrote: '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 healthseeking behaviour. This is likely to lead to confusion, longer pathways and lower degrees of satisfaction with the services being used.'

The researchers also highlighted findings that numbers of low-complexity patients were associated with a negligible increase in length of stay or waiting times in emergency departments, and suggested that improvements shown in some studies where GPs had been placed in emergency departments reflected simply the increase in doctors available overall.

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

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