Table 4.

Reported challenges in implementing and delivering primary care services and emergency medicine services

Type of service	Challenges	Quotes
Separate primary care service	Low and inconsistent primary care demand	“Do we have enough patients to keep the GPs busy, probably we don’t, so we’re seeing just over 2 patients per hour, on average, and it also depends on if it’s a busy shift where there’s lots of appropriate patients”. (hospital 4)
	Difficulty in recruiting GPs and covering the rota	“So we started to employ, or rather the CCG employed, GPs to do an early and a late shift Monday to Friday in the department. They were never successful at fully recruiting to cover all those slots”. (Hospital 8)
	Inability to provide a consistent service	“Some days it doesn’t open at all because someone’s off sick and they can’t cover it last minute”. (Hospital 18)
Integrated emergency medicine service	Low primary care demand	“The CCG has terminated that because they felt that they wanted them to be seeing 3 to 4 an hour, and we just couldn’t give them the patients, we just didn’t have the right kind of patients for them to see”. (Hospital 19)
	Not labelling the primary care area in an integrated model	“We’ve not changed the label outside the hospital, it doesn’t say Urgent Care Centre, it doesn’t say anything else because we didn’t want to have a honey-pot effect of attracting more people in” (Hospital3)
	Avoiding publicity to manage provider induced demand	“We kind of opened it surreptitiously, we’ve never opened with a big bang, so I think any increase in demand has been via 111 rather than walk-un patients” (Hospital 7)
No primary care provision	Lack of space in the ED for GPs	“I think if we had, from a pragmatic point of view, a GP in the department, it would increase pressures because by definition of taking up a room, to deliver that service, that would be one less room to flow patients through from an ED perspective”. (Hospital 16)
	Insufficient funding and inability to recruit	“That’s always been our difficulty I think, in recruitment, is we can’t pay anything like GPs would have been paid to work through OOH”. (Hospital 1)
	Concern that GPs ‘go native’ i.e. start behaving like ED clinicians and ordering lots of tests.	“My worry is that once in the ED footprint, and working that closely with the ED teams, is how soon before they sort of fall back into a non-primary care role”. (Hospital 16)