Recruitment was difficult, contacting the lead GPs in 25 practices by letter led to no initial responses. Following contact with practice managers, four practices provisionally agreed. One subsequently was unable to offer a date for the interview, despite repeated contacts. Many other practices promised a response but few were received. Of the nine refusals received, most related to lack of time or participation in other research projects.
Three practice-based interviews were conducted with a total of 14 primary health care professionals. The first practice interview involved two GPs, a GP (in training), a nurse practitioner and two nurses. The second interview involved five GPs and the third practice interview involved three GPs. Of the 14 participants four used the RAOU regularly, six used it less frequently. None of the nursing professionals were aware of the RAOU. We were able to describe four themes, which are summarised in Table 2.
Theme 1: RAOU Benefits
Most of the participants felt the RAOU was a useful additional service and saw it as a good "halfway house". The ability to offer specialist opinion locally, with facilities to observe children and access rapid diagnostic tests was highly valued.
There was excellent feedback regarding the ease of telephone access to the unit. Practitioners valued the quick access and the call handling by nurses, particularly as this avoided the wait to be connected to the on call doctor via switchboard. A number of the participants commented on how helpful the staff were in comparison to referrals to other hospital departments.
They're always really friendly... They'll see the child straight away so it's easy, there are never any sort of hard questions, they just want to know the basics ... So yes the ease of access is good.
GP (in training) in Practice 1
Practitioners valued the unit's ability to observe children, which often allowed safe discharge home once assessment had taken place. This meant that children who previously may have been admitted for a short stay could be observed and discharged. They saw this period of observation as very useful for a range of conditions including gastroenteritis, bronchiolitis, asthma and upper respiratory tract infections.
Kids vary. They may be bad in the morning, good in the afternoon: give them Calpol and they may be well an hour later, so I think its nice just having somewhere to send them in to be observed. You know ... if mum says he really hasn't taken any fluids, you don't always believe her, but it's nice just to know they can be watched for a few hours.
GP (in training) in Practice 1
The ability of the unit to provide a second opinion by a senior specialist was also valued, Several practitioners commented that this was reassuring not just for parents but also for themselves.
I've found it really useful for the 'rule of threes' consultations. A patient comes back for the third consultation for the same illness and it either means that your diagnosis is wrong, they've lost confidence in you or they're very anxious parents. In any of those three scenarios then it's really useful to have another opinion.
GP 1 in Practice 2
Practitioners valued the fact that the unit could quickly access diagnostic tests, such as urine testing. They commented that often if these diagnostic tests were negative, an admission could be prevented.
Sometimes ...you're sending him up purely for an chest x-ray, if that prevents a hospital admission then its all for the good.
GP 1 in Practice 2
Practitioners commented that location was important for the patients. This was particularly so for families with poorer access to transport.
Because it is a long way to go to the Heath from here... I mean our practice is mainly social class V/VI ...A lot of the young mothers don't have a lot of money, they don't have access to regular transport and so having a paediatric assessment unit that is closer ... is handy actually.
GP 3 in Practice 3
Theme 2: Referral difficulties
The most striking theme was uncertainty regarding the referral of patients, particularly the interface between the two local paediatric units. There was confusion about where to send children and the exact referral criteria for the RAOU. Some practitioners had experiences of being 'bounced' between centres when trying to refer a child. The practitioners also described experiences of differences of opinion as to whether a child should be referred to the inpatient unit or be seen in the RAOU when speaking to the RAOU staff. This created delays and unwelcome stress, and some practitioners worried it may sway their original decision about the safest and most appropriate place for the child to be reviewed [w1].
That was my worry... where you sort of made your decision but you thought they probably ought to go to the Heath and then you speak to somebody at the Heath they say "oh you know we're really busy here, have you thought of sending them to Llandough"
GP 2 in Practice 2
What I thought would have been a good admission for the Heath but I was told it was better for Llandough and Llandough disagreed and I was caught in that horrible position... "I don't know where to send you".
GP 2 in Practice 3
There was concern about the restrictions caused by limited opening hours. The majority of practitioners felt that the final referral time of four o'clock was too early, as one hour for observing the unwell child may be inadequate to formulate an appropriate management plan [w1].
The dehydrated ones... if it comes to about four o'clock then it's too late ... You need those children to be there quite early, for there to be enough time... [for assessment]
GP 3 in Practice 2
You quite often get mums coming in from work and seeing a sick child and coming in at half past five quarter to six, so it would be nice if they were open longer.
Nurse Practitioner Practice 1
Theme 3: Lack of Information
There was considerable concern regarding the lack of information about the RAOU. Although referral criteria had been sent to surgeries when the unit opened, not all referring practitioners had received them and many were vague about the unit's details..
I've got it somewhere, in my rainforest worth of protocols and guidelines in my room.
GP 1 in Practice 3
Practitioners all wanted more information regarding the unit and its facilities. Common queries were regarding the number of available beds, the staffing arrangements, and the availability of investigations..
Do they do investigations with bloods and things like that there?
GP 2 in Practice 1
For some practitioners the lack of information prevented them using the service, particularly as they were much more aware of the facilities available at the inpatient unit.
It's easy to just ring the Heath and say "please see this child, yes I think they need admission", because I don't know, but I know the Heath has got all resources.
GP 1 in Practice 1
Theme 4: Infrastructure and safety
There were some worries regarding the safety of the unit, due to it not being an inpatient centre with all the associated facilities. There was concern that children could deteriorate quickly between being triaged by the GP as fit for the RAOU and arrival on the unit, which it was feared would be less able to provide emergency treatment of very unwell children. These fears were compounded by a lack of knowledge of the facilities available. However, others thought these concerns were counter-balanced by the benefits of the service and the understanding that an ill child at the RAOU would be managed and then transferred.
I think another difficult thing is knowing that the unit at Llandough has been shrunk down so much and all the acute stuff is now at the Heath. Sending acutely ill children to Llandough feels a bit uncertain, in case they then have to be transferred to the Heath
GP 1 in Practice 1
There was discussion surrounding the sustainability of the service. Practitioners were wary of the risk of closure of the unit due to other acute services being moved to the teaching hospital.