RT Journal Article
SR Electronic
T1 Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice
JF BMJ Open
JO BMJ Open
FD British Medical Journal Publishing Group
SP e013816
DO 10.1136/bmjopen-2016-013816
VO 7
IS 4
A1 MacKichan, Fiona
A1 Brangan, Emer
A1 Wye, Lesley
A1 Checkland, Kath
A1 Lasserson, Daniel
A1 Huntley, Alyson
A1 Morris, Richard
A1 Tammes, Peter
A1 Salisbury, Chris
A1 Purdy, Sarah
YR 2017
UL http://bmjopen.bmj.com/content/7/4/e013816.abstract
AB 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.