Evaluation of the emergency care practitioner role in London : a study of the processes and outcomes of clinical decision making

This study of Emergency Care Practitioners (ECPs) in London investigates the processes and outcomes of clinical decision making by ECPs working in two settings - emergency ambulance and GP out-of-hours services. The development of the Emergency Care Practitioner role in the UK is described and placed in the context of urgent care and workforce development policy, and of the literature on extended roles in emergency medical services. The thesis is a mixed methods study and this theoretical approach is described. The thesis then contains five 'results' chapters, each addressing a primary research question: Do ECPs reduce the rate of conveyance to the Emergency Department? A quantitative analysis is presented, using multivariable multi-level logistic regression of a retrospective cohort of patient cases. Is the clinical decision making of ECPs appropriate and how does this compare to that of Ambulance Practitioners and General Practitioners? A quantitative analysis of a prospective cohort study of processes and outcomes of care involving a patient survey and a clinical case review is described. How is decision making experienced in practice by patients? Qualitative analyses of semi structured interviews with patients are presented. How are any differences in decision making experienced by ECPs themselves? A qualitative thematic analysis of semi structured interviews with experienced ECPs is presented. How is decision making experienced in practice by a researcher? Qualitative analyses of two data sets are set out: a documentary analysis of clinical records and an observation of clinical practice. The thesis asserts that the ECP role can have an impact in the London health care economy but requires both statistical rigour and qualitative methods (particularly direct observation) in analysis of its impact, as well as an understanding that small scale innovations such as the ECP role in London can have limited impact without surrounding health system change and time to embed and grow to a level required for system-level impact. This environment supports the use of mixed methods of research to allow for the different actors in the complex phenomenon and its setting under study to have a voice, and to move on from looking for a single unified answer to the overall research question in a shifting innovation.