Primary care units in A & E departments in North Thames in the 1990s: initial experience and future implications

Background. In 1992, the Tomlinson Report recommended a shift from secondar y to primary care, including specific primary care provision in accident an d emergency (A&E) departments. Availability of short-term so-called Tomlins on moneys allowed a number of experimental services. A study of the experie nce of A&E-based staff is reported to assist general practitioners (GPs) an d purchasers and identify areas for further research. Aims. To find the number and scope of primary care facilities in A&E servic es in North Thames; to find factors encouraging or inhibiting the setting-u p of a successful service; to examine the views of a range of A&E staff inc luding GPs, consultants, and nurses; and to suggest directions for more spe cific research. Method. A postal questionnaire was sent to all North Thames A&E departments , and an interview study of staff in one unit was arranged, leading to a qu estionnaire study of all GPs employed in North Thames primary care services in ABE. This was followed by interviews of staff members in five contrasti ng primary care units in A&E. Results. By mid-1995, at least 16 of the 33 North Thames A&E departments ra n a primary care service. Seven mainly employed GPs, the others employed nu rse practitioners (NPs). Problems for GPs included unclear role definition and their non-availability at times of highest patient demand. GPs' reasons for working in A&E sometimes differed from the aims of primary care in an A&E service. Staff interviews revealed differing views about their role and about use of triage protocols. Ethnicity data were being collected, but no r yet being used, to improve service to patients. Conclusions. A number of benefits follow the introduction of primary care p ractitioners into A&E. Different models have evolved, with a variety of GP and NP staffing arrangements according to local ideas and priorities. There is some confusion over whether these services aim to improve A&E-based car e or to divert it to general practice. Cost information is inadequate so fa r, though the use of GPs has shown the possibility of economy. Appropriate location of services requires clearer identification of costs. This may be possible for the proposed primary care groups.