GP roles in emergency ambulance services in the United Kingdom: a qualitative realist study

Background Demand on emergency healthcare services is increasing. Utilising GPs in emergency ambulance services (EAS) may be effective in reducing avoidable conveyances to emergency departments and releasing emergency ambulances for higher-acuity cases. There is limited evidence on models of GP EAS roles in the UK. Aims To describe current provision of GP EAS roles and to develop a provisional explanatory programme theory. Design & Setting Qualitative realist interview study with professionals with detailed knowledge and experience of GPs working in EAS. Method Interviews were conducted with 27 participants to explore the mechanisms by which GP EAS roles produce their intended outcomes in different contexts. Results The GP role is predominantly to undertake enhanced remote patient assessment following an initial algorithmic triage, aiming to provide the most appropriate level of care. Whilst optimising the clinical response to individual callers, this also serves a system-level function by protecting ambulance resources to support timely responses to high-acuity patients. The mechanism behind GP-triage was explored through existing middle-range theories around risk individualisation, the process of translating organisational risk appetite to individual patient contacts. This helps the ambulance service make 'braver' decisions; those involving non-conveyance, alternatives to conveyance, or lower-acuity responses. GPs do this effectively due to their seniority, broad clinical knowledge and experience, approach to risk and uncertainty, ability to practice outside guidelines, consultation and communication skills, and system awareness. Conclusion GPs in EAS serve both individual patients and the system by individualising organisational approaches to risk and resource management.