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24 Urgences KCE reports vol. 19B
General practitioners working in the emergency departments
Gibney et al. investigated if care provided by general practitioners (GPs) to nonemergency
patients, in a suburban ED using an informal triage system, differs significantly
from care provided by usual ED staff 105 . One thousand eight hundred and seventy-eight
patients participated. By comparison with usual ED staff, GPs prescribed significantly
more often (percentage relative difference [% RD] = 12 [95% confidence interval = 1-
23]) and referred more patients to hospital (% RD = 21 [95% CI = 9-33]). This is the
first study to report that sessional GPs working in an ED utilize similar or more
resources than usual ED staff. It emphasizes the need for the continued audit of
initiatives that have been introduced into new settings.
Walk-in centres
Different forms of walk-in centres do exist in different countries. In the UK walk-in
centres are walk in access organisations (no appointment needed) led by nurses
supported by software assessment, aiming at reducing the workload in GP and accident
and emergency departments 106, 107 . The review of the literature, showed important
distinctions in the concept of a walk-in centre in different countries. In some countries
walk-in centres are lead by doctors rather than nurses, in some countries walk-in
centres stand in competition to the family doctor, some walk-in centres (Northern
America and Australia) exclusively serve as an out-of-hours service. Users of walk-in
centres in other countries tend to be a relatively affluent population of working age, and
a different population from those using conventional general practice services. Walk-in
centres are used particularly when other health services are closed. The problems
presented are mainly minor illnesses and minor injuries. People choose this form of care
mainly for reasons of convenience, and satisfaction with the service is generally high.
The very limited evidence available suggests that walk-in centres provide care of
reasonable quality, but there is insufficient evidence to draw firm conclusions about the
impact of walk-in centres on other healthcare services or the costs of such care. A
potential danger of walk-in centres is that patients with serious illness present
themselves to a walk-in centre instead of going to an emergency department.
Chalder et al. 108 investigated the impact of NHS walk-in centres on the workload of
local accident and emergency departments, general practices, and out of hours services
using time series analysis. A reduction in consultations at emergency departments (-175
(95% confidence interval -387 to 36) consultations per department per month) and
general practices (-19.8 (-53.3 to 13.8) consultations per 1000 patients per month) close
to walk-in centres became apparent, but these reductions were not statistically
significant. Walk-in centres did not have any impact on consultations on out-of-hours
services. The authors concluded that it will be necessary to assess the impact of walk-in
centres in a larger number of sites and over a prolonged period, to determine whether
they reduce the demand on other local NHS providers.
Out-of hours care
Leibowitz et al. 109 carried out a systematic review of the international literature to
determine what evidence exists about the effect of different models of out-of-hours
primary medical care services of general practitioner on outcome. Six main models of
after-hours primary care services (not mutually exclusive) were identified: practicebased
services, deputizing services, emergency departments, co-operatives, primary care
centres, and telephone triage and advice services.
Deputizing service is a commercial organisation which arranges for or
facilitates the provision of medical services to patients of general practitioners
(practice principals) by other medical practitioners (deputizing doctors)
during the absence of, and at the request of, the practice principals.
General practice cooperatives: GPs from different practices forming a nonprofit
making organization to provide care for their own patients after hours
GP surgery consultation is a face-to-face consultation between GP and a
patient on practice list in the practice building resulting in patient note entry.