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

Background Addressing increasing patient demand and improving 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 £100 million (US$130 million) 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, reattendances, 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 GP-ED services are complex . 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.

A taxonomy of the form and function of GP-ED models or alongside emergency departments: concepts paper.EMJ. 2019;36:625-30 service, to usual primary careas a basis for future evaluation of service models.

BMJ (2020)
Evidence for the effectiveness of streaming ED patients to primary care services Cooper A, Carson-Stevens A, Hughes T, Edwards A. Is streaming patients in emergency departments to primary care services effective and safe ? BMJ 2020;368:8-11 There is limited, outdated evidence to show whether streaming patients to primary care services improves patient flow and reduces cost, and evidence for patient safety outcomes is lacking Health Policy (2021) How GP-ED funding mechanisms influence wider system outcomes.The majority of EDs in England have adopted a GP service.The popularity of different models is dependent on the availability of capital funding to finance structural changes.3. Rationale for evaluation.Explain the purpose of the evaluation and the implications for its focus and design.4. Programme theory.Describe the initial programme theory (or theories) that underpin the programme, policy or initiative. 5. Evaluation questions, objectives and focus.State the evaluation question(s) and specify the objectives for the evaluation.Describe whether and how the programme theory was used to define the scope and focus of the evaluation.6. Ethical approval.State whether the realist evaluation required and has gained ethical approval from the relevant authorities, providing details as appropriate.If ethical approval was deemed unnecessary, explain why.

Learning from diagnostic errors to improve patient safety when GPs work in or alongside EDs
5 6 6 8 METHODS 7. Rationale for using realist evaluation.Explain why a realist evaluation approach was chosen and (if relevant) adapted 8. Environment surrounding the evaluation.Describe the environment in which the evaluation took place 9. Describe the programme policy, initiative or product evaluated.Provide relevant details on the programme, policy or initiative evaluated 10.Describe and justify the evaluation design.A description and justification of the evaluation design (i.e. the account of what was planned, done and why) should be included, at least in summary form or as an appendix, in the document which presents the main findings.If this is not done, the omission should be justified and a reference or link to the evaluation design given.It may also be useful to publish or make freely available (e.g.online on a website) any original evaluation design document or protocol, where they exist 11.Data collection methods Describe and justify the data collection methodswhich ones were used, why and how they fed into developing, supporting, refuting or refining programme theory.Provide details of the steps taken to enhance the trustworthiness of data collection and documentation.Summarise the main findings with attention to the evaluation questions, purpose of the evaluation, programme theory and intended audience 17.Strengths, limitations and future directions.Discuss both the strengths of the evaluation and its limitations.These should include (but need not be limited to): (1) consideration of all the steps in the evaluation processes; and (2) comment on the adequacy, trustworthiness and value of the explanatory insights which emerged.In many evaluations, there will be an expectation to provide guidance on future directions for the programme, policy or initiative, its implementation and/or design.The particular implications arising from the realist nature of the findings should be reflected in these discussions 18.Comparison with existing literature.Where appropriate, compare and contrast the evaluation's findings with the existing literature on similar programmes, policies or initiatives 19.Conclusion and recommendations.List the main conclusions that are justified by the analyses of the data.If appropriate, offer recommendations consistent with a realist approach 20.Funding and conflict of interest.State the funding source (if any) for the evaluation, the role played by the funder (if any) and any conflicts of interests of the evaluators.

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Choudhry M, Edwards M, Cooper, A et al.Senior clinical and business manages' perspectives on the influence of different funding mechanisms, and barriers and enablers, to implementing models of employing General Practitioners in or alongside emergency departments: Qualitative study Health Policy 2021;125(4)482-488 Leaders caution against the use of private providers.Cooper A, Davies F et al.Emergency department clinical leads' experiences of implementing primary care services where GPs work in or alongside emergency departments in the UK: qualitative study BMC Emerg Med 20, 62(2020) Different models of service are necessary based on local contextual circumstances.
Cooper A, Carson-Stevens A, Cooke M, Hibbert P, Hughes T, Hussain F, Siriwardena N, Snooks H, Donaldson L EA. Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis."BMC emergency medicine 2021;21(1): 1-13 Potential priority areas for improvement are a standardisation of initial assessment; clinical decision support for high-risk conditions; and standardised Edwards M, Davies F, Cooper A, McFadzean J, Carson-Stevens A, et al.Patients' experiences of attending emergency departments where primary care services are located: qualitative findings from patient and clinician interviews from a realist evaluation.BMC Emerg Med.2022;22(1):12 Patients generally find being streamed to a primary care service acceptable if they receive suitable treatment in a timely manner, with clear communication from staff Cooper A, Hughes T, Davies F, Price D, Anderson P, et al.The effectiveness of primary care streaming in emergency departments on decision-making and patient flow and safety -A realist evaluation.Int Emerg Nurs.2022;62 Services should: be designed in line with local circumstances and staff skill; use trained streaming nurses; monitor business to help BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Edwards M, Davies F, Cooper A, Price D, Carson-Stevens A, et al.Realist analysis of whether emergency departments with primary care services generate 'providerinduced demand.'BMCEmerg Med 22, 155 (2022)EDs with distinct primary care services were perceived to attract demand for primary care because services were visible, known or enabled direct access to health care services.Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Recruitment process and sampling strategy.Describe how respondents to the evaluation were recruited or engaged and how the sample contributed to the development, support, refutation or refinement of programme theory 13.Data analysis.Describe in detail how data were analysed.This section should include information on the constructs that were identified, the process of analysis, how the programme theory was further developed, supported, refuted and refined, and (where relevant) how analysis changed as the evaluation unfolded Details of participants.Report (if applicable) who took part in the evaluation, the details of the data they provided and how the data was used to develop, support, refute or refine programme theory.15.Main findings.Present the key findings, linking them to contexts, mechanisms and outcome configurations.Show how they were used to further develop, test or refine the programme theory

Case study site characteristics at the time of study
taken from survey data unless stated otherwise *https://www.cqc.org.uk/sites,**for urgent and emergency care services, ***http://www.wales.nhs.uk/sitesplus/866/page/40419(GPED01 omitted, pilot site; GPED05 omitted, streaming service staffed by emergency department staff not GPs BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Data