Article Text
Abstract
Objectives To describe how processes of primary care access influence decisions to seek help at the emergency department (ED).
Design Ethnographic case study combining non-participant observation, informal and formal interviewing.
Setting Six general practitioner (GP) practices located in three commissioning organisations in England.
Participants and methods Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29).
Results Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like ‘urgent’ and ‘emergency’ was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use.
Conclusions This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around ‘inappropriate’ patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups.
- ACCIDENT & EMERGENCY MEDICINE
- Organisation of health services
- HEALTH SERVICES ADMINISTRATION & MANAGEMENT
- PRIMARY CARE
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Footnotes
Contributors FM was lead researcher on the study and contributed to design, fieldwork and analysis/interpretation, as well as drafting the manuscript and revisions. EB was a researcher on the study and conducted fieldwork and analysis/interpretation, and made a significant contribution to manuscript revisions. LW and KC contributed to study conceptualisation, design and interpretation of data, and made a significant contribution to manuscript revisions. DL contributed to study conceptualisation and interpretation of findings, and made a significant contribution to manuscript revisions. AH, PT, CS and RM contributed to interpretation of the data and provided feedback on the manuscript. SP was the principal investigator for the study; she led the design, supervised the project and its staff, and made a significant contribution revising the manuscript. All authors approved the final version of this manuscript.
Funding This work was supported by the National Institute for Health Research School for Primary Care Research, grant number FR6/168. DL is funded by the NIHR Oxford Biomedical Research Centre.
Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
Competing interests None declared.
Ethics approval NRES Committee West Midlands – Coventry & Warwickshire.
Provenance and peer review Not commissioned; externally peer reviewed.
Correction notice The article has been corrected since it first published. The Funding and Disclaimer statements have been added in.