Reforming emergency care: Primary Care Trust power in action research.

Objectives: A Primary Care Trust (PCT) used its position as lead commissioner in a health economy to search for efficiency gains and to improve the patient journey through accident and emergency (A&E) services in a hard-pressed acute hospital. The project generated an action research approach. As a by-product, we developed a model of the hospital system based on a case study that can be replicated and used to set utilization targets at the micro-level of the hospital organization. This addresses a gap in the literature on hospital utilization that currently focuses on macro-population levels of analysis or simulation models that demand complex data. Primary and secondary care services, in contrast, require a pragmatic model of utilization supported by a few key, readily available data items.

Methods: Mixed quantitative and qualitative methods were adopted in an approach of collaborative enquiry among stakeholders of the health economy. We used the flexible planning tenet of action research that evolved into the subjective meaning tenet by which, to achieve authoritative findings, it was necessary to broaden the line of enquiry to address participants' perceptions.

Results: We have described the current patient flow and a redesigned pathway through A&E services together with targets and action required to reduce admissions, delayed discharges and diagnostic waits in the emergency hospital system. Primary care had a key role in changing the culture, communication and treatment within A&E services.

Conclusion: (i) This study was rapid and sustained a high level of energy and purpose among stakeholders. Action research is an appropriate method to apply to transformational change in the modernization of health-care systems; (ii) Modelling of system dynamics is a critical dimension to the success of whole system change; (iii) Primary care commissioning power is an under-used, but influential, lever for change. At a point when the PCT commissioning structure is under threat, this project exemplifies primary care's ability to engineer change in acute hospital services.