Primary care clinicians working in or near hospital emergency departments in the UK: A mixed methods systematic review

ObjectivesTo synthesise evidence about primary care clinicians treating patients in or adjacent to hospital emergency departments in the UK. Study designMixed methods narrative systematic review. MethodsEligible studies were in English and described primary care services (general practitioners, GPs, or nurse practitioners) that treat patients within or adjacent to hospital Emergency Departments (ED). Searches were conducted on Medline, EMBASE, Cochrane Library and CINAHL databases. The search included extraction from an international review updated from 2020 to October 2022, and grey literature from inception to October 2022. The methods were informed by consultation with members of the public. ResultsFrom 4189 studies screened, 20 met inclusion criteria. Four studies assessed typology and streaming of services. Seven studies reported patient and public involvement. Ten studies reported differences in clinical outcomes between primary care and emergency services, but not definitive benefit for either. Likewise, results were equivocal for economic evaluations. Diverse delivery formats complicate evaluation and may explain why clinicians had mixed opinions about the utility of such services. Patients were generally satisfied with the service they received, in either primary care or emergency services. ConclusionDiversity of implementation complicate conclusions that can be drawn. Existing evaluations provide little evidence that primary care services in or near emergency departments offers any system advantages for clinical outcomes, or cost savings. Process evaluation in future evaluations is essential to understand what aspects of primary care at emergency departments are likely to improve system and patient care. Implications for the profession and/or patient careThe systematic review assessed outcomes arising due to primary care clinicians providing treatment in or near Emergency Departments (ED) in the UK. There were no consistent benefits for having primary care clinicians in or near EDs. This research highlights the need for healthcare leaders and policy makers to provide more clarity in developing primary care services in or near EDs. It will have impact for leaders in healthcare to consider whether primary care clinicians in or near EDs are providing best value healthcare, or whether other models could provide patients appropriate NHS resources according to their health need. Patient and public involvementThree focus groups (with 13 public advisors) were conducted to understand patients priorities and perspectives for attending EDs with relatively minor health conditions. This helped to guide study design, data extraction and analysis of this review.