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Editor's blog Friday 5th March 2010: Primary care and emergency departments report

Hello. Today sees the release of a new report from the Primary Care Foundation. (COI declaration - I've previously written up a couple of conferences for one of the Foundation's directors.)

Primary care and emergency departments is a title sure to grab plenty of attention, given the rising tide of A&E attendances and its financial impact on PCTs.

The Primary Care Foundation are probably best known for their benchmark for out-of-hours providers, lessons from the first two iterations of which can be found here.

This new report looks at the growing co-location of primary care services alongside and within acute care A&E settings. It states that "Primary care practitioners can enhance emergency departments by bringing vital skills and expertise to a multi-disciplinary team. To achieve this, managers and clinicians need to develop strong working relationships.

"Building mutual respect takes time, but it is vital if initiatives of this kind are to lead to a more integrated service. As one GP put it “if everyone is involved it becomes seen as a joint baby, not a primary care service in their midst”.

"Successful schemes are the product of sustained attempts to test out new ideas, learn from each other and improve patient care, based on clear recognition of the skills of each group of clinicians and mutual respect. However, in practice there can be a clash of cultures, with staff divided by different training, approaches to managing risk, governance systems, language and their experience of different case mixes".

Cost pressures
It correctly reports that despite rhetoric about the motivation for providing a primary care service in A&E, the motivation is financial, creating potentialy challenging situation for an acute trust's financial viability. The importance of meeting the 4-hour 'P45' waiting time target in A&E is also significant.

The report suggests that "services that are integrating urgent care and developing local tariffs, that incentivise all partners to work in the patients’ best interests, appear
to be heading in a more promising direction. In time, an overall cost reduction may be achieved from this approach".

The fab four
It is based on four principles, against which the authors assessed examples of primary care clinicians working with emergency departments:
1. Patient safety comes first. The system must be safe for the patient.
2. Capacity must be matched to demand.
3. Patients should be seen by the skill group best able to meet their
needs, but flexibility should be built in to the system.
4. Clinical and operational governance processes should apply to all
patients and all pathways across primary and emergency care,
supporting the development of safe care and making good use of

Less primary care in A&E than you might think, and no need for queues
The report challenges the common preconception that much of the additional demand in A&E comes from unmet primary care needs.

The authors found that in those who applied to participate in the study (evidently, self-selecting trusts which consider their practice to be good), "when we used a consistent definition and a consistent denominator of all emergency department cases we found that the proportion that could be classified as primary care cases (types that are regularly seen in general practice) was between 10% and 30%".

The authors note the crucial importance of good-quality first contact with the patient at reception. They also challenge the idea - which they report to be common - that queueing is "inevitable", writing, "we observed that the main reasons queues build up are poor scheduling of staff or inadequate premises that make it difficult to deploy staff effectively. This is a feature of overall management and governance.

"In fact, long queues can be avoided if capacity is sufficient to meet the demands of patients as they arrive, especially if a true ‘see and treat’ model is implemented".

Governance gaps and cost-effectiveness lacunae
Somewhat alarmingly, they found that "in many services there is a lack of clarity over responsibility for important aspects of the scheme. There appeared to be little, if any, joint clinical or operational governance. Some organisations have started to address the problem of split accountability and the increased risks this involves, by developing closer
collaboration across organisational boundaries".

On funding, they suggest that they have seen local innovation to unbundle and split tariffs which mitigates risk to the parts of the health economy. Depressingly yet unsurprisingly, they add that "we found it very difficult to access information from commissioners or providers about the cost effectiveness of these services, despite initial requests for information of this kind and further reminders.

"It may be that this information is difficult to access or that it is not routinely collected.
More work needs to be done to develop a consistent format for collecting this information to support wider comparisons across services".

More broadly, their narrative review of the data and an academic review of published literature found that the evidence base for current practice in this field is lacking, in cost-benefit terms and as regards effective behavioural change among patients.

Take-home messages
The report draws a series of useful conclusions for commissioners and providers.

It enphasises the importance of clinical engagement and participation from the outset; the need to address all aspects of the service and to recognise that there are no quick fixes; improving and linking IT systems (ahem); and putting work in this specific area within the context of a whole urgent and emergency care pathway.