Still looking in the wrong place: Literature-based evidence of why patients really attend an emergency department

Presenting complaints at an Emergency Department (ED) that could (and should) have been seen in primary care is discussed in the literature as 'inappropriate use' of hospital-based emergency services. These medically inappropriate requests are perceived as a threat to service quality, implying more costs than necessary. Using Systems Thinking/Dynamics, this paper introduces an evidence-based framework to explain why people increasingly attend an ED instead of a primary-care-based emergency facility, with patient demographics (age and deprivation), signposting sources and patients' perceptions (reflecting latent needs) identified as the main determinates of ED use. The framework makes explicit the endogenous dynamics of referral, service choice and service reputation (where expectations and confirming experiences are iteratively shaped over time). The work can be employed at the strategic level as a framework to inform attendance management when evaluating or altering the healthcare system. This is achieved by presenting how the healthcare system responds to patient encounters and how patient behaviour adapts in response. At the operational level, the proposed framework enables modellers and healthcare planners to develop hospital-based and primary-care-based emergency care interventions with empathy and compassion for patients. We highlight opportunities for future work as the healthcare system is complex and requires more in-depth exploration/modelling to complete the picture.