EMJ ‘Bite Size’ by Dr Nick Marriage


Can a Partnership between General Practitioners and Ambulance Services Reduce Conveyance to Emergency Care. Villarreal et al.


To evaluate a new model of Emergency ambulance response in which paramedic crews from the ambulance service were supported by GPs to provide alternatives to transfer to hospital.

Design: Retrospective review looking at the implementation of a new service.

Setting: Worcester, UK – a mixed urban & rural county with 67 Medical Practices and 2 Emergency Departments. The study was conducted from Oct 2012 – Nov 2013.

Population: Patients, of any age, who contacted 999 directly or via community based services such as care homes who contacted 999 at times when a GP was available from midday till 8PM weekdays and 8 till 8PM at weekends.

Inclusion criteria: Those deemed appropriate by WMAS call handlers or ambulance crew (paramedics OR technicians).

Methods: After receiving a 999 phone call a standard dispatch protocol and initial triage was conducted. This resulted in a GP (via own transport), ambulance crew or both seeing the patient. In instances where an ambulance was the primary dispatch there was provision for telephone advice from the GP or a face to face visit. The GPs underwent a day of prehospital training. Ambulance staff were briefed via email and printed weekly briefings.

 What did they find?

A total of 23,395 999 calls were made which resulted in 1,903 GP supported assessments of which about 10% were referrals from community services. 64.1% of these referrals were assessed face to face by a GP, the rest received telephone advice. Following any GP input 21.2% were transported to an ED compared to the overall average of 61% by West Midlands ambulance service. Subgroup analysis revealed that women and patients over the age of 75 were least likely to be conveyed to hospital after the intervention.

 What else would we like to know?

The service has continued to run from October 2012 – oct 2016. It would be interesting to see how cost effective this service is.

The authors comment on the lack of follow up. We don’t know if this service prevented presentations to the emergency department or merely delayed them. Unfortunately, this data was not collected.

Almost 95% of cases initiated by community based care services did not result in an emergency presentation. It would be interesting to see why these services were calling 999 in the first instance. Perhaps they lack robust clinical support.


It would seem that patients appreciate this service and that it does a good job at decreasing immediate presentations to the ED. Community based pathways that avoid unnecessary presentations and admission to hospital are an important part of emergency patient care. They also need to be cost effective. Empowering GPs to facilitate paramedics and ambulance technicians to make sound clinical decisions about patient care seems like a service that should be explored nationwide.


From Emergency Medicine Journal – July2017 Volume 34 Issue 7