GP access has become a focus of governmental response to rising A&E attendance. Outlining a ‘new deal for general practice’ on 19th June Jeremy Hunt cited safeguarding hospital capacity as a key driver for seven-day primary care access.
The logic is that a significant proportion of A&E visits are for problems that could be managed in primary care and lack of available GP appointments drives people to A&E.
Can greater GP access reduce A&E use? The answer seems to be probably, some of the time and in certain contexts. A recent systematic review by our team found an association between better primary care access and reduced A&E attendance in US and Canadian studies, but no clear association in European studies.
Using patient-reported data from the GP Patient Survey, Tom Cowling and colleagues found that a significant number of A&E or walk-in-centre visits were preceded by an unsuccessful attempt to see a GP.
Manchester CLAHRC’s evaluation of six demonstrator sites found that additional weekend and evening access was associated with a 3% overall reduction in A&E activity. The full report, shows that the statistic refers to decreased A&E use in two of the six sites and take up of weekend appointments was low unless a partner GP was working, which raised questions about sustainability.
Our data, from detailed ethnographic study of six GP practices in three CCG areas, helps illuminate some of the story behind the numbers. When we spoke to patients who had recently used A&E they described GP access as convoluted, with 111/out-of-hours contact adding to ambiguity. It was common for demand for same-day access to primary care and A&E use to be attributed to ‘consumer culture’, but patient use of A&E tended to be the result of rational assessment of risk and appropriate options — A&E, described as reliable and straightforward, was seen as the judicious response.
When we observed reception and waiting areas and interviewed staff we witnessed a system under pressure to meet demand and areas of realised or potential access inequity. Appointment systems, which evolved incrementally, were layered and intricate. Reception staff were generally responsible for establishing level of patient need so access was often dependent on their skill and experience.
Telephone access was privileged as a way to improve access, with phone lines opening before practice doors and telephone triage or call-back widely used. However, this created disadvantages for some patients — those with no access to a telephone/limited phone credit, and those patients with hearing loss or whose main language was not English.
Our findings suggest that transparency, simplicity and fairness of access are likely to influence patients’ feeling about primary care as a source of timely care. While the political drive for enhanced access is unlikely to diminish, action can be taken at the practice level make access more equitable. Simply put, quality of access rather than quantity may have greatest impact on A&E attendance.