Intended for healthcare professionals

Practice Uncertainties

Is streaming patients in emergency departments to primary care services effective and safe?

BMJ 2020; 368 doi: (Published 25 February 2020) Cite this as: BMJ 2020;368:m462
  1. Alison Cooper, clinical research fellow1,
  2. Andrew Carson-Stevens, clinical reader in patient safety and quality improvement1,
  3. Thomas Hughes, emergency medicine consultant2,
  4. Adrian Edwards, professor of general practice1
  1. 1Division of Population Medicine, School of Medicine, Cardiff University, UK
  2. 2John Radcliffe Hospital, Oxford, UK
  1. Correspondence to A Cooper CooperA8{at}

What you need to know

  • Co-located primary care services have been introduced in emergency departments in the UK to reduce crowding and improve patient care and safety

  • There is limited, outdated evidence to show whether streaming emergency department patients to primary care services improves patient flow and reduces costs; and evidence is lacking for patient safety outcomes

  • Commissioners and service providers should consider whether governance systems are clear and reflect whether general practitioners in emergency departments are encouraged to function more as primary care or emergency medicine clinicians to suit the local patient demographic profile, demand patterns, and staff recruitment needs

Between 10% and 43% of patients presenting to emergency departments can be managed in primary care, according to estimates from observational studies.1234 Increasing demands on emergency healthcare systems have led to the development of different healthcare models, including “streaming” patients presenting with non-urgent conditions to primary care services.5 These strategies are intended to improve patient flow and reduce crowding in the emergency department. In 2017 NHS England made substantial investments for all emergency departments to have co-located primary care facilities so they are “free to care for the sickest patients.”67

However, the evidence for this initiative is weak.89101112 Different service models are described in different contexts using ambiguous terminology. A “co-located” primary care service may deliver patient care in a separate unit to the emergency department, without access to acute diagnostics, thus similar to normal general practice settings. Alternatively, general practitioners may work …

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