General practice out-of-hours co-operatives in Ireland — emergency service or not?

Alternatives to direct emergency department conveyance of ambulance patients: a scoping review of the evidence

Background

The role of ambulance services is shifting, due in part to more intermediate, non-urgent patients who do not require direct emergency department conveyance, yet who cannot be safely left at home alone. Evidence surrounding the safety, effectiveness and efficiency of alternate care routes is not well known.

Methods

This scoping review sought to identify all studies that examined alternate routes of care for the non-urgent “intermediate” patient, as triaged on scene. Search terms for the sample (ambulances, paramedics, etc.) and intervention (e.g. referrals, alternate care route, non-conveyance) were combined. Articles were systematically searched using four databases and grey literature sources (February 2020). Independent researchers screened title-abstract and full text stages.

Results

Of 16,037 records, 41 examined alternate routes of care after triage by the on-scene paramedic. Eighteen articles considered quantitative patient data, 12 studies provided qualitative perspectives while 11 were consensus or opinion-based articles. The benefits of alternative schemes are well-recognised by patients, paramedics and stakeholders and there is supporting evidence for a positive impact on patient-centered care and operational efficiency. Challenges to successful use of schemes included: patient safety resulting from incorrect triage decisions, inadequate training, lack of formal partnerships between ambulance and supporting services, and insufficient evidence to support safe implementation or continued use. Studies often inaccurately defined success using proxies for patient safety (e.g. decision comparisons, rates of secondary contact). Finally, patients expressed willingness for such schemes but their preference must be better understood.

Conclusions

This broad summary offers initial support for alternate routes of care for intermediate, non-urgent patients. Even so, most studies lacked methodologically rigorous evidence and failed to evaluate safe patient outcomes. Some remedies appear to be available such as formal triage pathways, targeted training and organisational support, however there is an urgent need for more research and dissemination in this area.

EMTs and GPs: what do we think of each other?

BACKGROUND

Ireland's health services are undergoing dramatic reorganisation. The establishment of general practitioner (GP) out of hours cooperatives and the integration of current ambulance services into a national ambulance service are among the issues that will impact on prehospital care of emergencies. The study aimed to explore the perceptions of GPs and emergency medical technicians (EMTs) of their own and each other's roles in the context of such reforms.

METHODS

A census of all GPs (511) and EMTs (301) in three of Ireland's eight health board regions was undertaken. A questionnaire containing 31 statements asked respondents to indicate their agreement (or lack of it) in areas such as general relationships, care, and training, roles in emergencies and future developments.

RESULTS

Of the personnel contacted, 72% of GPs and 75% of EMTs responded. They report excellent working relationships, agree that the ambulance service is of high quality, and that GPs are willing to provide care in emergencies. However, working links are less satisfactory for EMTs, who report a far higher perception of GP use of emergency ambulances than reported by GPs. Both groups are interested in innovative future links.

DISCUSSION

Convergence between the professional groups in different geographic areas and between the disciplines across the areas is striking. They include areas of satisfaction and dissatisfaction. The need for improved liaison between the disciplines is clear.

Out-of-hours co-operatives: general practitioner satisfaction with governance and working arrangements

OBJECTIVE

General practice co-operatives have led to significant improvements in quality of life for general practitioners. Little is known about general practitioners' own experiences with the working arrangements and governance of co-operatives. This study investigates GP satisfaction, the working environment, governance and future developments in co-operatives.

METHODS

A questionnaire was sent to GPs in two co-operatives in the Republic of Ireland, covering mixed urban and rural areas.

RESULTS

Of 221 GPs in the co-operatives, 82% responded and confirmed the co-operatives' positive effects on their lives. However, 57% still received requests for out-of-hours care while off duty, most commonly from patients who preferred to see their own doctor. Half felt overburdened by out-of-hours work, especially those over 40 y of age. Twenty-five per cent were dissatisfied with the GP complaints mechanism. The majority (63%) would prefer a GP/health board partnership for the organization of out of hours, while 23% wanted sole responsibility. GPs indicated a strong need for better ancillary services such as nursing, mental health, dentistry, pharmacy and social work. Access to records is an important issue in terminal care and mental illness.

CONCLUSION

While GP co-operatives are a success story for general practice, they will work better for general practitioners and their patients if nursing, mental health, dentistry, pharmacy and social services are improved. Support and training is needed in mental health, palliative and emergency care to increase competence and reduce stress. GPs are willing to work with health authorities in further co-operative development. More attention needs to be paid to the complaints and suggestions of GPs in the running and governance of their co-operatives.