PPI and Scoping Review about GP services offered at Front door of A&E: Q&A with Dr. Paul Everden, North Norfolk Primary Care

GP at Door of Accident & Emergency (GDAE) services are now routinely deployed in our acute hospitals across Norfolk and Waveney. They aim to assess patients when they first arrive at A&E and signpost those who do not need urgent care towards other more appropriate care services to help reduce pressure on A&E.

Dr. Paul Everden takes the time to speak with us about the PPIScoRev project and how the positive effects of GPFD (GP Front Door) has had on the Emergency Department and the plans for the future of the project.

What is the background to this project?

Health services are struggling to meet patient demand, especially emergency health care like Accident and Emergency departments. One way to alleviate the demand on UK A&E departments could be well-run drop-in appointment primary care services running next to the A&E, what we call GP at door of A&E (GPFD) services.

The core idea is to meet patients when they walk through the door at A&E, but before they are booked in, do a quick assessment whether they might be suitable for a primary-care style service. If they meet the criteria, which is to say if they arrive under their own steam and present with a seemingly minor non-urgent problem, they can be directed to the GPFD where usually they will get seen faster than if they went into the A&E care stream.

We can always take them straight back to A&E if their condition deteriorates. In the Norfolk GPFD services, there are typically two clinicians available: a nurse practitioner and a qualified GP. 

We wanted to evaluate the potential benefits of GPFD in several ways. First, we analysed the service activity, how many patients, what times of day do they present, how does their age, sex or deprivation description compare to people using regular A&E services, what happens when they finish at GPFD which might be an onward referral or discharge with no further treatment, and can we find any benefits for the adjacent A&E? These studies have a service evaluation format.

Our second strand of research was to look for published literature about other GPFD or very similar programmes, where primary care was offered at other UK A&Es, to see what benefits they might have delivered.

And finally, we ran workshops with different groups in our catchment area to prepare some ideas about how to interview patients themselves about their healthcare seeking experience, in a series of public involvement and engagement exercises. 

What did you find out from the service evaluations of local GPFD initiatives?

In a pilot study for about 8 weeks in 2019-20, GPFD seemed to coincide with improvement in the 4-hour target at the same site (NNUH).

In longer term implementation, over 1 year of service data, GPFD seemed to help improve 4-hour waits at the James Paget hospital but didn’t have any benefits when implemented at the Queen Elizabeth hospital at Kings Lynn.

Patients at all these sites were overwhelmingly positive about their experiences and staff found the service acceptable too. We couldn’t identify that any harms came from the GPFD services.

We could see that relatively more referrals to secondary care were generated at the QEH than at the NNUH or Paget: we suspect that there are somewhat different decision-making criteria happening at the QEH, and that could affect what benefits the GPFD services could achieve there. 

What did you find out from the literature review?

The overall impression of previous literature was neutral about benefits that GPFD services might provide – to anyone. GPFD programmes don’t seem to particularly have saved money or improved key performance targets (like the 4-hour target) at A&Es.

Patients are largely oblivious to whether they are in a routine A&E care stream or at GPFD: patients just want to be seen quickly and receive reassurance and appropriate treatment. What we can also say is that there are a lot of different formats that could be broadly described as GPFD.

We didn’t find any other programmes that were very similar to the GPFD design that has been used in Norfolk and Waveney. We think that GPFD in Norfolk has an advantage because it’s separate and independent from A&E.

A primary care clinician is able to rapidly assess patients walking into the door and identify them as suitable for a general practice approach to their assessment and management. We have full access to all their GP notes electronically. We can write immediately into these notes keeping their practice informed and up to date without waiting for discharge letters.

In fact, we would appear like a branch surgery for the patient’s registered practice. This gives us the unique opportunity to manage the patient just like they had stepped into their own practice. We can avoid unnecessary investigation, start primary care management and arrange follow up within their own GP surgery.

Risk is measured differently in primary care compared to hospital. The key is the selection of the correct patients through triage. We see this as a ‘pull’ model where we select and ‘pull’ into GP front door, as opposed to the ‘push‘ model where emergency department (ED) staff triage and ‘push’ patients into GPFD, which we know happens elsewhere.

What did you find out from the PPI exercise?

The NHS lacks capacity to deal with a large, sustained surge in demand, which is exactly what has happened in the post-pandemic period. There were always some people who might go to A&E with a relatively minor health problem, and this seem especially likely to happen recently when it’s widely documented that many people are struggling to get appointments with their GP.

We can’t assume that we know what the decision-making process is for people who go to A&E with a relatively minor problem, though, instead it makes sense to simply ask them about what their health care seeking experience was before they presented. 

We ran 3 PPI sessions: one in Norwich, one in a small town (North Walsham) and one in a sparsely populated area (near Pulham Market). Our advisors ranged in age from 18 to mid-70s. So, we hope that we got a broad range of perspectives.

Everyone agreed that the big appeal of going to A&E with a minor health problem was the full range of reassurance that people hoped to get, and a ‘one-stop’ feel that they could get a lot of their health care needs met at once.

The advisors gave many suggestions in how we could go about asking people about their previous experiences trying to get health care without implying stigma.

We were super aware that a lot of people are afraid of being judged, that maybe they did the wrong thing by going to A&E with their health problem. We want people to be honest with us about whether they just went to A&E as first choice or if they tried to see any other health care provider.

We couldn’t expect that honesty if we implied in any way that we were judging them or saying they shouldn’t be in A&E. So, the advisors were important to help us find neutral ways of asking people what happened, did they try to get advice or treatment and how, before they made decisions to go to A&E with their health problem. 

How will you use the information gathered in the PPI exercise, literature review and service evaluation going forward?

Having done the groundwork to know how to interview people sensitively, we are still hoping to secure some funding in future that would enable us to actually undertake those interviews. 

The literature review is being considered by a peer-review journal and hope to get it published in 2024. 

The service evaluations may be periodically refreshed, as the services get refined and developed, partly changing because of the evaluation done so far. 

Are you still excited about the potential of GPFD? Why?

Very excited. We are now running GPFD at all three hospital ED’s in Norfolk and Waveney. Two of these ED models are ‘pull’ where we triage and select the patients to be seen in GPFD. The other ED is a ‘push’ model where senior ED staff select the patients to be seen by us. We have just done a pilot to look at the 2 models and this confirms our thoughts that ‘pull’ is superior to ‘push’.

There was a 38% increase in the numbers being seen in GPFD with the pull model, all being adequately managed.

The result of this scheme being done correctly has demonstrated the ability to divert an average 35% away from ED leaving the clinicians in ED more time and space to see the patients that needed that level of care.

The satisfaction of both patients being seen in GPFD and the clinician’s seeing them remains high. At the same time our evaluation does not suggest that this satisfaction is causing people to only go to A&E with minor problems rather than attend their own GP practice. 

It is very exciting to see patients being managed effectively in a more timely manner and reducing the very long wait times in ED minors. The positive knock-on benefit is that people with more serious conditions get seen sooner in the ED department. No clinician wants to see an ill patient suffering for longer than needed and I see GPFD as an enabler in this respect.

We are also starting to ask a question that has yet to be answered well in the literature – why does a patient choose to go to ED rather than their GP? From the PPI we have found reasons why it is hard to ask this question. Maybe there is a distinct group of patients that would tend to choose hospital over GP services. If we could understand why, could we offer something similar in the community away from the hospital. Further research is needed.

In the meantime, there are many opportunities to look at how we can enhance the GPFD service. If we accept this as an ongoing need, we can increase the capability and start to convert unplanned care into planned with improved integration of patients back into primary care.

It would be great if we could apply similar models to patients being seen by urgent ambulances in the community and thus reduce conveyances to hospital ED's.

There are huge knock-on problems from ambulances sitting in ED off-loading bays, unable to take their patients into hospital and then return to the road where emergencies still need their response. Also, inappropriate conveyance can lead to unnecessary admission with all the unfortunate adverse outcomes in the frail and elderly such as hospital-associated deconditioning (HADS).

You could call this GPFD in the community - intercepting before conveyance to ED front door. It would be a chance to work across many health care providers including social care to keep patients appropriately within the community.