Towards integration of general practitioner posts and accident and emergency departments: a case study of two integrated emergency posts in the Netherlands

In many countries accident and emergency (A&E) departments have a problem with inefficient patient flow because of overcrowding [1–8]. An important factor contributing to this overcrowding is self-referral: increasingly more patients go directly to A&E departments for out-of-hours services without first contacting their general practitioner (GP). At the same time, most of the problems seen in A&E departments are in principal primary care problems and can be regarded as inappropriate use of A&E services. Various studies report that between 15% and 50% of patients make inappropriate use of A&E services [9–18]. Most of these patients can be treated by a GP or nurse and at lower cost [19–26].

In the Netherlands, some GP posts were set up in the vicinity of a hospital or in the hospital itself, in an attempt to reduce self-referrals and inappropriate use of hospital services [27, 28]. More recently, a GP post and a hospital in two regions (Purmerend and Haarlem) took a next step to optimize patient flow at local A&E departments by integrating the care provided by A&E departments and GP posts, forming so-called integrated emergency posts (IEPs). The purpose of these posts is to provide appropriate treatment within one organisation with complex, specialized care being provided by A&E doctors and less complex care being provided by GPs or specially trained nurses, such as nurse practitioners or physician assistants. In this way, it is expected that IEPs will shift the provision of care for certain health problems back from secondary care to primary care while providing patients with appropriate care for their problems.

To date (August 2008), seven IEPs have been established in the Netherlands and in several other regions A&E departments and GP posts are preparing to integrate their services. As similar innovations have not been described in the literature, we investigated whether IEPs meet expectations. To this end, we used data from the IEPs in Purmerend and Haarlem and two control locations to determine (i) whether an IEP changes patient flow by reducing the number of patients seen by A&E staff and by increasing the number of patients seen by the GP or nurse; (ii) whether waiting/consultation times are shorter, thereby speeding up the flow of patients through emergency services; (iii) whether patients treated at an IEP are more satisfied than patients treated at a GP post or A&E department; and (iv) whether doctors, nurses, and other professionals are satisfied with the concept of an IEP.

This study showed that the development of an IEP leads to a shift from secondary care to primary care, a decrease in waiting/consultation times, a decrease in self-referrals, and increased patient satisfaction with telephone contact with care providers. There was no difference in satisfaction between patients who visited an IEP and those who visited a GP post or A&E department. In contrast, employees working at an IEP were less satisfied about their work and working conditions than employees working at GP posts or A&E departments.

However, it should be borne in mind that the integration of GP and hospital cultures and working style will take time, probably longer than the twelve months we allowed. Moreover, we collected data from only two locations, which limits the statistical power of this explorative research. The study had potential methodological limitations: the retrospective case-control design carried a risk of confounding bias, selection bias, and information bias. These risks were minimized by careful selection of the control locations and protocols for uniform data collection. And finally, the response rates to the patient satisfaction surveys were lower than in most patient satisfaction surveys in the Netherlands (40–60%). This restricts generalization for this part of our study.

The shift in patient flow was not caused by a change in patient population because patient characteristics (age, sex, and urgency of the health problem) were similar at T⁰ and T¹. The decrease in the number of patients seen by A&E doctors at the IEP could have been caused by regional developments, such as negative publicity about the hospital and/or its A&E department, changes in cooperation with ambulance services, or management policy decisions. However, no evidence for such problems was found during the interviews or during contact with the different sites.

Primary care costs less than hospital care, so the national introduction of IEPs could reduce national spending on health care. This aspect was not investigated in this study but it would be interesting to analyse the consequences of setting up IEPs on healthcare costs. On one hand, healthcare costs will be diminished by the shift from hospital care to primary care but on the other, the setting up of IEPs will require investment in staff training and numbers, and the provision of joint facilities, such as one check-in counter, one call-centre, and a meeting room. The latter may be necessary to bridge cultural differences between GP post employees and hospital employees.

The decrease in the number of self-referrals to A&E departments after the IEPs were established was expected because a substantial proportion of self-referred patients with minor complaints were sent to the GP after triage and registered in the information system of the GP post.

The decrease in waiting/consultation times at the IEP compared with GP posts or A&E departments is remarkable and could be due to improved triage and patient allocation in the IEPs, so that patients were seen by the most appropriate doctor. Other possible explanations for this decrease, such as changed patient characteristics and staff changes, are not likely since both were relatively stable during the study.

It is surprising that patients were not more satisfied with the IEP provision of care. Theoretically, setting up an IEP creates transparency; patients no longer have to decide whether to visit a GP or an A&E doctor. Moreover, waiting/consultation times were shortened. This lack of satisfaction might be because most patients were seen by nurses rather than by doctors, and the single check-in desk may have comprised patient privacy. Another reason could be that most patients had not recently visited an emergency service and therefore could not compare their experiences with earlier ones in a traditional setting.

Employees at the IEPs were not satisfied about several aspects of their work. This is most likely due to the dramatic changes in work processes as a result of introducing new care professionals and a new triage protocol. Such changes can have considerable consequences. For example, nurses and GP assistants gained more autonomy and responsibility, but this was not always welcomed. Moreover, introduction of IEPs could have financial consequences for employees. In 2007, hospitals and their consultants were paid according to the number of patients seen at the A&E department, yet with the development of IEPs A&E doctors saw fewer patients, which could have had negative financial consequences. In one of the IEPs, the hospital and medical staff had an agreement with the health insurance company that their loss would be compensated. This was not the case in the other IEP.

The introduction of IEPs did not have consequences for the income of GPs or the GP posts.

Crucial to the success of IEPs is that patients are seen by an appropriate professional. This means that triage systems should be effective and preferably uniform. The two IEPs in this study used different triage systems, but a uniform triage system has recently been introduced for Dutch hospitals, GP services, ambulances, and mental health services and is currently being tested in four regions. If this so-called Dutch Uniform Triage System functions as expected, it will help IEPs achieve an efficient workflow and patient-centred care.

IEPs will not resolve all the problems of emergency services and may have some limitations. It will take many years to bridge the cultural gap between primary and secondary care professionals. Moreover, accessible, well-functioning IEPs may even create a demand for emergency services. In lowly populated regions, the provision of acute primary care by GPs might be more efficient than integrated care.

A prospective study with more IEPs and a longer follow-up is needed to determine whether IEPs are a welcome innovation that should be stimulated. That is why we are hoping to stimulate more hospitals and GP posts at home and abroad to establish IEPs. Only with more participants can we gather enough data to enable more definite conclusions to be drawn about this promising innovation.

IEPs could make emergency care more efficient. Patients are more satisfied with some aspects than they are with traditional GP posts and A&E departments. However, professionals are not yet convinced about the advantages. Other GP posts and A&E departments in different countries should be encouraged to set up IEPs.