In this study, we explored the position of physicians and patients on the co-location of a GPC and an emergency service for unplanned care. The majority of patients calling for unplanned care were in favour of a co-location. More than two thirds of all patients believed the benefit of co-location lies in decreases of waiting times. Although for particular problems patients preferred to visit an ED, the majority also had confidence in the competences of a GP. Co-location is particularly preferred by younger patients, patients who had confidence in a telephone operator and patients who were satisfied with a telephone advice.
The majority of ED-physicians and three quarter of the GP’s were in favour of a co-location for unplanned care. Physicians believed that the adequacy of referral was the major advantage of this system. They also expected a decrease in workload and waiting time and an increase of care quality. Only one third of the GP’s believed that they were sufficiently skilled to work in a co-location. In particular ED physicians feared an increase of prescription of technical examinations by GP’s. Only half of the ED physicians and a handful of GP’s were in favour of a 24/7 opening of the co-location.
When patients use unplanned care services they are mainly concerned about waiting times, adequacy of referral and competences of the attending physician (and medical staff) (6, 8, 15). Waiting times for unplanned care are a major concern in most health care systems (16). Self-referring patients, understaffing and infrastructural restrictions are the main cause of this problem (5, 8, 16). Patients in our study were prepared to accept a referral for unplanned care if a trained telephone operator performed the triage. In addition, patients do not always expect a physical encounter with the attending physician and in some cases a telephone advice suffices. From earlier research, we know that referrals by this operator happen safe and adequate to all levels of care (9, 17–20). Increasing the adequacy of referring will undoubtedly decrease the patient inflow for unplanned care, workload and waiting lists. In a co-location service, patients expect a reduction of transfers for further examination or follow up (7, 11, 12, 21–23). Therefore, a particular point of attention in the organisation of unplanned care is the accessibility of the services. Local government can play a role in housing and supporting the ease of access to these services but also in public campaigns to promote the correct use (10, 24). Second point of attention is the patient who expects to be directly in contact with a physician when seeking unplanned care. These patients are less likely to follow the advice of an operator and will probably present to their preferred level of care, which in reality will mean that they will sign in to the ED (5, 6, 23). This action will slow down the time to intervention for the index patient but also for correctly referred patients by interfering with the regular workflow. A third group that needs particular attention are the older patients being less prepared to accept a referral to a co-location service. This might not surprise as they are used to the current system (6, 25, 26).
Although patients considered visiting the ED for particular problems, they declared to have enough confidence in the skills and competences of the GP. The link between these type of problems (wounds, musculoskeletal problems) and emergency care is rather the result of an image problem than of a rational believe that GP’s are unable to deal with minor traumas (5, 22, 26–28). Younger patients, patients who adhered less to the common principle of self-referring or patients who relied upon the advice of an operator were more likely to be in favour of a co-location. It seems evident that the more knowledge and confidence patients have in the current healthcare systems, the more they will accept new systems (10, 29). Repeated and comprehensible public campaigns play a major supporting role in the acceptance of a new system (10).
A higher number of ED physicians were in favour of a co-location as compared to the GP’s. GP’s are reluctant to be involved in hospital care fearing that their input and expertise will be overruled or even dispensable (8, 11, 30) Therefore, in a co-location care system a strict flowchart and role definition is very important (17, 23, 31). Both groups confirmed indeed that a co-location might improve the adequacy of referral, lower the workload and decrease waiting times. These indicators have a high impact on health care outcome and satisfaction of patient and care provider (6, 28). The GPs’ concern to play only a minor role in a co-location can be altered by adjusting the infrastructure and working conditions to the needs of primary care. Above, most GP’s did not feel competent enough to work in a highly equipped environment with access to technical examinations. Together with adjusted infrastructure, GP’s will also need an introduction to use the available devices and to (co-) interpret results of technical examinations. Since particularly ED physicians feared an increase of technical examinations, an on the spot initiation and introduction of GP’s will meet this concern and probably reduce the number of unnecessary or inadequate technical examinations (11). This intervention will also meet the expectation of both groups that a co-location will be cost effective. Another important issue was the claim by both groups to remain an independent ‘organisation’. To align this structural independency with collaboration in patient care, a robust corporation agreement will be indispensable (7, 29). The observation that GP’s and ED physicians disagreed on opening hours of the co-location might be a first subject of discussion. GP’s were reluctant to opt for a 24/7 service. Other than the ED-physicians, GP’s operate independently in their own practice during the regular hours. Day shifts in a 24/7 service imply a reorganisation of their practice schedule. Second, ED-physicians already work in a 24/7 schedule meaning implying that a full day and night service will not affect their working conditions. Physicians who rejected the idea of a co-location were more likely to prefer a 24/7 system. This apparent contradiction can be explained by the assumption that in a 24/7 service, scheduling of duty will be executed under better circumstances and conditions. For GP’s it is reassuring that patient follow up is guaranteed when they are on duty.
The major strength of this study lies in the population reached. A representative part of the target population participated during the test period. This is also the first study giving insights in the bottom up construction of collaboration between ED and primary care for unplanned care. The questionnaires were constructed with the aid of the task force of unplanned care in Belgium. This group of experts was at the base of the restructuring of unplanned care and therefore well placed to support this research.
A participation bias cannot be ruled out since most questionnaire were completed by patients visiting the GP. The population frequently visiting the ED might be absent in this study. Although, most patients in Belgium have a GP and visit the GP at least once a year. Second, no distinction was made between patients who completed the questionnaire for themselves or third parties accompanying a patient. However, in case of a third party, this person will also decide on the level of care needed. Finally, this study did not focus on objective outcomes as cost effectiveness, care quality and patient and physician satisfaction. The study only relied on the assumptions, expectations and insights of the participants.