key: cord-0293565-72829ekt authors: Aldus, C. F.; Pope, I.; Brainard, J. S.; Ruston, A.; Hughes, G.; Everden, P. title: Feasibility and evaluation of an emergency department-based GP streaming and treatment service date: 2022-05-16 journal: nan DOI: 10.1101/2022.05.13.22275043 sha: 52f47b68be389b897d605fd3c93ee7ec507b3c19 doc_id: 293565 cord_uid: 72829ekt BACKGROUND: Emergency departments (EDs) are under ever-increasing pressure. The General Practitioner Streaming and Treatment (GPST) service implemented at a large ED in England UK aimed to identify and treat patients who attended an ED but who might effectively be managed in primary care to reduce pressure on ED services. METHODS: Patients attending ED were met by a GP nurse practitioner who streamed them to the GPST service or usual ED care. Routinely collected electronic records, satisfaction questionnaires and interviews were used to evaluate patient outcomes, staff experiences, service outcomes and impacts on usual ED services. RESULTS: Approximately 96% of GPST patients were seen by a clinician within one hour and all within 87 minutes. Routinely collected ED datasets indicate statistically significant reductions in patients streamed to usual ED care who had to wait > 4 hours for disposition (p=<0.005). Of 769 patients with GPST consultation (approximately 10% of all walk-in patients) 421 (55%) needed no further intervention by ED. The speed at which GPST patients were managed exceeded patient expectations and was a major determinant of their satisfaction. No staff expressed dissatisfaction, but some suggested possible improvements in patient eligibility criteria and built environment design features. CONCLUSIONS: Concurrent provision of GPST correlated with shorter waits for ED attenders to receive health care. Patient and staff experiences of GPST were positive. A robust assessment of safety and health economic outcomes would be useful to refine eligibility criteria and cost effectiveness. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 F e a s i b i l i t y a n d e v a l u a t i o n o f a n e m e r g e n c y d e p a r t m e n t -b a s e d G P s t r e a m i n g a n d t r e a t m e n t s e r v i c Introduction E m e r g e n c y D e p a r t m e n t ( E D ) s e r v i c e s a r e u n d e r i n c r e a s i n g p r e s s u r e . I n 2 0 1 8 -1 9 t h e r e w e r e 2 4 . 8 m i l l i o n a t t e n d a n c e s i n E D s i n E n g l a n d . 1 T h i s i s a n i n c r e a s e o f 4 p e r c e n t c o m p a r e d w i t h 2 0 1 7 -1 8 a n d 2 1 p e r c e n t s i n c e 2 0 0 9 -1 0 . T h i s r e p o r t d e s c r i b e s a g e n e r a l p r a c t i t i o n e r S t r e a m i n g a n d T r e a t m e n t S e r v i c e ( G P S T ) f e a s i b i l i t y s t u d y c o n d u c t e d a t t h e N N U H E D i n t h e p e r i o d 1 6 D e c e m b e r 2 0 1 9 t o 2 8 F e b r u a r y 2 0 2 0 . G P S T a i m e d t o i m p r o v e p a t i e n t e x p e r i e n c e ; s u p p o r t a c c e s s t o a p p r o p r i a t e c a r e a n d r e s o u r c e s ; r e d u c e t h e n u m b e r o f w a l k -i n p a t i e n t s ' s e e n i n E D ; i m p r o v e s t a f f w e l l b e i n g ; p r o v i d e a s a f e s e r v i c e a n d c h a n g e u n p l a n n e d c a r e t o p l a n n e d c a r e w h e r e p o s s Design of the GPST service T p r o c e s s i s i l l u s t r a t e d i n F i g u r e 1 . B r i e f l y , t r a i n e d c l i n i c i a n s s c r e e n e d a n d s t r e a m e d p a t i e n t s w h o a r r i v e d a t t h e E D u s i n g n o n -u r g e n t m o d e s o f t r a n s p o r t ( i e . n o t c o n v e y e d v i a a m b u l a n c e ) a s s o o n a s p o s s i b l e a f t e r t h e i r a r r i v a l ( i d e a l l y w i t h i n 1 5 m i n u t e s ) . S t r e a m i n g t y p i c a l l y i n v o l v e d a s s e s s i n g e l i g i b i l i t y v i a a b r i e f h i s t o r y t o d e t e r m i n e w h e t h e r t h e p a t i e n t m e t t h e p r e s c r i b e d i n c l u s i o n o r e x c l u s i o n c r i t e r i a . P a t i e n t s m e e t i n g i n c l u s i o n c r i t e r i a w e r e o f f e r e d t h e o p p o r t u n i t y t o b o o k a s a m e d a y a p p o i n t m e n t a n d f o l l o w c o n c u r r e n t N H S G P I m p r o v e d A c c e s s S e r v i c e P r o t o c o l s 1 3 . . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 16, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 preprint P a t i e n t s w h o w e r e e l i g i b l e c l i n i c a l l y c o u l d c o n t i n u e t o a G P a p p o i n t m e n t i f t h e y c o n s e n t e d t o G P S T a c c e s s i n g t h e i r m e d i c a l r e c o r d s . I f a n e l i g i b l e p a t i e n t d e t e r i o r a t e d , t h e y w o u l d b e m o v e d , v i a a n a g r e e d e s c a l a t i o n r o u t e , t o E D . P a t i e n t s n o t e l i g i b l e f o r i n c l u s i o n i n t h e G P S T f e a s i b i l i t y s t u d y w e r e d i r e c t e d t o u s u a l E D s t r e a m i n g a n d c a r e . T h e s e r v i c e w a s d e s i g n e d t o o p e r a t e b e t w e e n 8 . 3 0 a m a n d 6 p m . E l i g i b i l i t y c r i t e r i a w e r e b a s e d o n p a t i e n t h i s t o r y , p r e s e n t a t i o n a n d w h e t h e r t h e a t t e n d e e w a s r e g i s t e r e d a t e l i g i b l e G P s u r g e r i e s ( s e e F i g u r e 1 f o r d e t a i l s ) . . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. ; a t a w e r e u s e d t o a s s e s s w h e t h e r t h e p r e s e n c e o f G P S T r e d u c e d b u r d e n o n E D b a s e d o n t h e n u m b e r o f w a l k -i n p a t i e n t s s e e n i n N N U H E D p e r d a y , t i m e t o b e i n g s e e n b y a d o c t o r a n d t h e n u m b e r o f b r e a c h e s . D e s c r i p t i v e s t a t i s t i c s a n d S t u d e n t ' s t -t e s t ( i n d e p e n d e n t s a m p l e s , t w o -t a i l e d a s s u m i n g u n e q u a l v a r i a n c e ) a t a 9 5 % l e v e l o f s i g n i f i c a n c e w e r e u s e d t o d e s c r i b e a n d c o m p a r e b r e a c h e s i n t h e 3 m o n t h s p r i o r t o G P S T d e p l o y m e n t a n d d u r s m e a n c h a n g e s i n a t t e n d a n c e a t a n e a r b y ( 4 m i l e s a w a y ) Ability to change care from unplanned to planned GPST safety GPST activity . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. ; . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. ; . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Patient interviews T w e l v e G P S T a d u l t p a t i e n t s a n d o n e a d u l t a c t i n g a s p r o x y f o r a c h i l d a g r e e d t o b e c o n t a c t e d . E i g h t p a t i e n t s s u b s e q u e n t l y c o u l d n o t b e c o n t a c t e d ( n = 3 ) ; d i d n o t r e s p o n d t o a t t e m p t s t o c o n t a c t t h e m ( n = 4 ) ; o r d i d n o t a g r e e t o t a k e p a r t ( n = 1 ) . U p t o f o u r a t t e m p t s w e r e m a d e t o c o n t a c t e a c h p e r s o n . F i v e p a t i e n t s w e r e i n t e r v i e w e d . I n t e r v i e w s w e r e c o n d u c t e d b e t w e e n 2 3 M a r c h 2 0 2 0 a n d 3 0 M a r c h 2 0 2 0 ( a t t h e s t a r t o f C O V I D - 1 9 l o c k d o w n ) . O f t h o s e i n t e r v i e w e d t w o s a i d" I v i s i t e d t h e h o s p i t a l b e c a u s e I h a d b e e n t o t h e G P w h e n I t h o u g h t I h a d p n e u m o n i a a n d w i t h a l l t h e c o u g h i n g m y r i b s w e r e vo d f o r : c o n d i t i o n s w h i c h r a n g e d f r o m s t r a i g h t f o r w a r d t o s e r i o u s . T h i s h a d t h e p o t e n t i a l t o i n f l u e n c e t h e i r p e r s p e c t i v e o f t h e s e r v i c e . F o r e x a m p l e , t h e f o l l o w i n g r e s p o n d e n t h a d h u r t h e r t h u m b w h e n s h e f e l l o v e r . S h e h a d b e e n t o l d b y h e r G P t o g o s t r a i g h t t o A & E : " I t i s a g o o d i d e a , t h i s t r i a g e s e r v i c e a n d g o o d f o r m i n o r c u t s , a b r a s i o n s , m i n o r f a l l s - n o t m a j o r i s s u e s . I t i s g o o d t o s e p a r a t e o u t t h e c u t t h u m b f r o m s o m e t h i n g m o r e s e r i o u s . S o i t g o o d f o r t h a t … " F e m The copyright holder for this preprint this version posted May 16, 2022. e e n t o h o s p i t a l t w o w e e k s b e f o r e w i t h a c h e s t i n f e c t i o n a n d b e c a u s e I h a v e a s t h m a I h a d t o g o b a c k b e c a u s e i t h a d n o t c l e a r e d u p . I s a w a n u r s e a n d s h e s a i d s h e c o u l d n ' t h e a r a n y t h i n g i n m y c h e s t b u t p r e s c r i b e d a n t i b i o t i c Experience of streaming Experience of seeing patients . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. ; . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. ; T s t a f f r e p o r t e d a n y p a t i e n t s a f e t y i s s u e s i n r e l a t i o n t o u s e o f G P S T . H o w e v e r , l a c k o f h a n d w a s h i n g f a c i l i t i e s , p r e s e n t i n g a p o t e n t i a l s a f e t y i s s u e , w e r e r e p o r t e d . N o p a t i e n t s w e r e e s c a l a t e d f r o m G P S T t o E D p a t h w a y s , d u e t o p a t i e n t d e t e r i o r a t i o n , a s p o t e n t i a l l y a n t i c i p a t e d i n t h e p r o t o c o l . . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. ; https://doi.org/10.1101/2022.05.13.22275043 doi: medRxiv preprint F u t u r e e v a l u a t i o n s h o u l d r o b u s t l y e x p l o r e h o w G P S T i m p a c t s t h e c a p a c i t y o f N N U H E D t o m e e t i t s 4 h o u r t a r g e t s t h r o u g h c o m p a r a t i v e e v a l u a t i o n w h i c h i n c l u d e s c o s t -e f f e c t i v e n e s s a n a l y s i s . T h e r e w a s n o e v i d e n c e o f a n y n e g a t i v e i m p a c t o f G P S T o n u s e o f w a l k -i n c e n t r e s . A c c e p t a b i l i t y i s a n i m p o r t a n t a s p e c t o f a n y f e a s i b i l i t y s t u d y . P a t i e n t s i n d i c a t e d t h a t t h e G P S T s e r v i c e w a s a c c e p t a b l e t o t h e m a n d s t a f f a l s o e x p r e s s e d s a t i s f a c t i o n w i t h t h e i r e x p e r i e n c e o f w o r k i n g i n t h e s e r v i c e . T h e r e w a s n . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 preprint N o p a t i e n t s w e r e e s c a l a t e d f r o m G P S T t o E D p a t h w a y s a s a r e s u l t o f d e t e r i o r a t i o n i n h e a l t h ( a s p e r p r o t o c o l ) d u r i n g t h e i r G P S T c o n s u l t a t i o n a p p o i n t m e n t . T h i s m a y s u g g e s t t h a t e l i g i b i l i t y c r i t e r i a a r e e f f e c t i v e w i t h r e s p e c t t o s a f e t y . H o w e v e r , a l o n g w i t h c o m m e n t s f r o m s t a f f , a n d t h e r e l a t i v e l y l o w p r o p o r t i o n o f p a t i e n t s ( 1 8 % ) s t r e a m e d t o G P S T a p p o i n t m e n t s ( c o m p a r e d t o e v i d e n c e f r o m r e s e a r c h s t u d i e s ) t h i s f i n d i n g m a y i n d i c a t e t h a t e l i g i b i l i t y c r i t e r i a a r e o v e r c a u t i o u s . G P S T s t a f f t h o u g h t t h a . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 This protocol outlines proposals for an independent evaluation led by the University of East Anglia (Faculty of Medicine and Health Sciences) of an initiative locating the GP Streaming -Treatment+ service in front of the Emergency Department (ED) at Norfolk and Norwich University Hospital (NNUH). This is in the context of increased waiting times and the perception that some attendances could be better managed by services other than ED. Hospitals across England are increasingly unable to meet the "four hour target", which assesses departments on the proportion of patients arriving and leaving the ED in less than 240 minutes. Streaming patients who could be managed elsewhere, away from or out of highly pressured EDs, to co-located GP led primary care services, may support patients receiving the care they need whilst improving performance against the four-hour standard. The service is commissioned by Norwich CCG, North Norfolk CCG and South Norfolk CCG and was initiated to support improved access to appointments in the community and reduce burden on ED. The service will initially be a 6-8-week pilot, which commenced on 17 th December 2019. The purpose of this evaluation is inform future decisions about investment and service design. Trained clinicians will screen patients at the front door of ED as soon as possible after their arrival (and always within 15 minutes). Streaming will typically involve a brief history and use of inclusion/exclusion criteria to assess if a patient is suitable for a GP appointment. If they are suitable, they will be offered the opportunity to book a same day appointment and follow the GP Improved Access Service Protocols. If the patient deteriorates, they will move to an agreed escalation route to ED. Patients not suitable for the GP STREAMING -TREATMENT+ route will be directed to the ED Streaming Nurse/Reception and continue the ED patient pathway in the normal way. This process is summarised in Figure 1 below. The service operates between 8.30am and 5.30pm. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint Symphony data from NNUH . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) We would like to invite you to take part in our service evaluation. This information sheet will provide you with details about the aims of the evaluation as well as what we will ask of you. Please take your time to read the following information. If you have any questions, or would like more information, please feel free to contact us. The aim of this evaluation is to examine the effect of the GP Front Door/Streaming Treatment and Service on patient care and satisfaction, staff well being and the organisation and delivery of Emergency Department Services. You have been invited as you are either: a) A patient that has used the service. b) A member of staff who has been involved in the delivery of care or the organisation or management of the service. No, your participation is voluntary. You are free to withdraw from the interviews at any point. If you agree to an interview and you withdraw, your data will be destroyed up to the point at which it is anonymised The study will involve either a face-to-face meeting within the Emergency Department or a telephone/face to face interview at a time and place that is convenient for you. The interview would last about thirty minutes. We will record the conversation either on a tape recorder or on paper. Your data will be anonymised and stored securely on university servers. Your consent form will be kept in a locked cabinet in a locked office at UEA in accordance with the university's data protection rules. Yes. Your involvement in the evaluation will remain strictly confidential and all data will be kept on a password protected computer and accessed by the research team only. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 16, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 If you have any further questions about this evaluation or any of the information given above please do not hesitate to contact us on the e-mail addresses below and we will be happy to answer any questions you may have. If you agree to participate in the above evaluation please initial in the box at the end of each sentence and complete the details at the bottom of the form. 1 I confirm that I have read and understood the information sheet for participants, dated 16.12.19 version 1, and have had the opportunity to ask questions. 2 I agree to the interview being audio recorded and/or written notes taken for the purposes of analysis and possible publication. 3 I understand that all data will be anonymised and any identifiable factors will be removed by the evaluation team. 4 I agree to be interviewed to participate in this study. 5 I understand that I can withdraw my consent to participate at any point but that my data may not be removable. Name of person taking consent Signature Date . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 16, 2022. ; Could you describe your role within the delivery/organisation of the service? What do you think the aim/purpose of the service is? Could you describe your experience of streaming patients into the service? Has your experience been what you expected or having you found anything surprising? What are your views on the inclusion and exclusion criteria? Are there any specific conditions the service could see but are currently excluded? If you were running the service what would you do differently? What is your view on whether the service is a good use of resources? Have you enjoyed working in the service -is there anything that could be done to make your experience of working in the service better? If you were asked to advise the organisers of the service on how the service could be improved what three things would you recommend? Anything you would like to add? Thank you very much for taking your time to participate. All data will be processed confidentially and we can send you a copy of the report if you would like to know the outcomes of the project. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 16, 2022. ; Overview of project aims and objectives Could you describe your role within the delivery/organisation of the service? What do you think the aim/purpose of the service is? Could you describe your experience of /seeing treating patients using the service? Has your experience been what you expected or having you found anything surprising? What are your views on the inclusion and exclusion criteria? Are there any specific conditions the service could see but are currently excluded? Could you describe a particularly positive experience that you have had whilst working in the service? Could you describe a particularly negative experience that you have had whilst working in the service? What is your view on whether the service is a good use of resources? How would you describe the quality of clinical care provided by the service? What has your experience of repatriating patients back to their own GP investigations or follow up been like -could you give examples? What has your experience of referring patients on to the ED been like -could you give examples? If you were asked to advise the organisers of the service on how the service could be improved what three things would you recommend? Anything else you would like to add? Thank you very much for taking your time to participate. All data will be processed confidentially. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 16, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 • How do clinicians find the process of seeing ED patients in GP Streaming -Treatment+? How do clinicians find the process of repatriating patients back to their own GP practice? • How do patients perceive being seen in GP Streaming -Treatment+? • What are the barriers to streaming patients to GP Streaming -Treatment+? • Are there more patients who are suitable to be seen in GP Streaming -Treatment+ that are currently being seen? • Do the location and times of operation seem appropriate? Why/why not? • Does the unit address a need that A&E at NNUH is not set up to manage? • Barriers and facilitators to pathways and flow between departments • Clinician perceptions as to which groups of patients can be seen safely in this service and which cannot Evaluation Works. The Evaluation Cycle Evaluating health interventions: Introduction to Evaluation of Health Treatments, Service Policies and Organizational Interventions Evidence-Based Policy: A Realist Perspective A i m s a n d O b j e c t i v e s o f t h i s E v a l u a t i o n Aim: To evaluate the impact of the GP Streaming -Treatment+ on patient care, patient satisfaction, staff wellbeing and NNUH ED. Objectives: 8. To describe the activity undertaken by GP Streaming -Treatment+. 9. To assess whether patients are satisfied with their use of GP Streaming -Treatment+. 10. To assess whether the presence of the GP Streaming -Treatment+ service has an impact on staff wellbeing. 11. To assess whether the presence of GP Streaming -Treatment+ reduces burden on ED. 12. To assess unintended impacts of the service (e.g. increased use of other services, adverse events). 13. To assess the ability of the service to change care from unplanned to planned. 14. To assess whether the service is safe.This protocol was informed by the NHS/NIHR "Evaluation Works" service evaluation toolkit (Evaluation Works 2019) and "Evaluating Interventions" (Ovretveit 1998) . As the period for the pilot evaluation is short (6-8 weeks) we will focus on the collection and analysis of routinely collected data. Where resources allow, we will also collect data to support the evaluation objectives.r k A realist evaluation framework will be used to make sense of quantitative and qualitative data (Pawson & Tilley 1997; Pawson 2006) . Realist frameworks evaluate what works (outcome) for who in what circumstances (context) and how (mechanism). This is known as a 'CMO' (Context, Mechanism, Outcome) framework ( Figure 2 Phone calls to a sample of patients To assess whether the service is safe.To collect data on adverse events we will ask practices to feedback if they come across any in relation to use of GP Streaming -Treatment+ Dec 2019 -March 2020a Qualitative interviews will be conducted with a sample of staff and patients. Informed consent will be obtained prior to the interview. Interviews will be semi-structured and based on a topic guide. We expect the topic guide to include:• Does the process of GP streaming effectively identify suitable patients to be seen in GP Streaming -Treatment+? Are GPs the most suitable clinical workforce for the presenting conditions seen? • Could the process of streaming to GP Streaming -Treatment+ be done more effectively? • What information do GPs gather during the streaming process and does it change management? • Which patients are most suitable for the GP Streaming -Treatment+?Analysis: Interviews and focus groups will be recorded where possible, or extensive notes taken. A thematic analysis will then be undertaken. i m e l i n e s The pilot service went live on 17 th December 2019 and will run for 6-8 weeks. This evaluation will be conducted concurrently, and we aim to provide a short evaluation report at the end of March 2020. Overview of project aims and objectives Could you describe your role within the delivery/organisation of the service?What do you think the aim/purpose of the service is?Could you describe your experience of booking patients into the service?Has your experience been what you expected or having you found anything surprising?Have you faced any particular difficulties in undertaking this role?If you were asked to advise the organisers of the service on how the service could be improved what three things would you recommend Anything else you would like to add? Thank you very much for taking your time to participate. All data will be processed confidentially and we can send you a copy of the report if you would like to know the outcomes of the project. Overview of project aims and objectives What made you decide to choose to use the service today?How was your experience of contact with the people on the front desk offering the service?What was your experience of being seen by one of the clinicians? If you came in again with the same problem would you still choose to use the service, if yes why? If no why?What do you think would have improved the service for you?What do you plan to do next with regards to the problem you came in with today? Anything else you would like to add? Thank you very much for taking your time to participate. All data will be processed confidentially. Version 1; 28.2.20; Overview of project aims and objectives Could you describe your role within the delivery/organisation of the service?What do you think the aim/purpose of the service is?How have you found the GP front door service?Do you think they are seeing appropriate patients?If you were asked to advise the organisers of the service on how the service could be improved what three things would you recommend? Version 1; 28.2.20; Overview of project aims and objectives Could you describe your role within the delivery/organisation of the service?What do you think the aim/purpose of the service is?How do you think it is performing currently?What effect do you feel it is having on ED workload?How will we know if the service is performing well?How do you think it could be improved?If you were asked to advice on how it could be improved what three things would you recommend? Anything else you would like to add? Thank you very much for taking your time to participate. All data will be processed confidentially. Version 1; 28.2.20; Overview of project aims and objectives Could you describe your role within the delivery/organisation of the service?What do you think the aim/purpose of the service is?How do you think it is performing currently?What effect do you feel it is having on ED workload?How will we know if the service is performing well? If you needed follow up investigations or referrals did these happen and how did it work for you?If you came in again with the same problem would you still choose to use the service, if yes why? If no why?Would you recommend the service to others? If yes why if no why?What sort of conditions do you think should be seen by the service?If you were asked to advise the organisers of the service on how the service could be improved what three things would you recommend?What do you think would have improved the service for you?