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A&E visits rise where access to general practice is worst, claim researchers

Patients who are able to see their GP within two days make fewer visits to accident and emergency departments than those who have less access, researchers have claimed.

In an analysis likely to add more fuel to the debate on the current crisis in A&E, researchers from Imperial College London found that the rate of self-referred A&E visits for patients of the top 20% of the most accessible practices was 10.2% lower than the 20% with the worst access.

But they also found that the two variables with the largest effect on attendances were whether the practice was in an urban or rural area and the socioeconomic status of its practice population - but these were dismissed as policy options to reduce attendances as they were fixed variables.

The analysis - said by the researchers to be the largest of its kind - comes just as the Government-commissioned report by NHS England medical director Sir Bruce Keogh is set to publish its terms of reference.

The GPC has said the study was ‘unwise’ to focus on one element of a multi-factorial problem as there were multiple factors to blame for the pressure on A&E departments.

The Imperial College study analysed A&E department attendances for patients registered to 7,856 general practices in England. Access to primary care was measured using data from the GP Patient Survey, which asked whether the patient was able to book a GP appointment within two days the last time they tried.

The researchers estimated that if the bottom fifth of practices in terms of accessibility provided similar access as the top fifth then 1,111,739 fewer patients would have visited A&E this year, reducing costs by £6,033,906.

Practices located in rural areas had a 15% lower rate of emergency department visits than those in urban areas, and practices with the most deprived populations had a 41.7% greater rate of emergency department visits when compared with practices with the least deprived populations.

It also found that a one unit increase in the percentage of the registered population aged 65 years or over predicted a 1.1% decrease in the rate of emergency department visits.

The prevalence of obesity in the practice’s population increased the rates of emergency department visits, although the prevalence of asthma and hypertension did not, it added.

The report, published in the journal PLOS ONE, concluded: ‘The percentage of the registered population that was able to see a GP within two weekdays, a measure of timely access to primary care, was negatively associated with the rate of self-referred discharged ED visits.

‘Our findings support the hypothesis that some patients who are unable to see a GP within two weekdays self-refer to an ED and are subsequently discharged.’

Lead author Thomas Cowling, from the School of Public Health at Imperial College London, said the study provided the first national evidence of an association between access to general practice and rates of A&E attendances in England and called on politicians to take note.

‘Policymakers should consider this relationship when designing plans to reduce the use of A&E departments.’ he said.

He added: ‘We’ve highlighted this to policy makers because they are unable to change the urban/rural location of a practice and less able to change the socioeconomic status of patients. Access to general practice is something the policymakers can influence.’

But GPC chair Dr Laurence Buckman said that isolating one factor was not helpful. He said: ‘Any research that looks at the complex reasons for the current pressure on emergency services is useful, but it is unwise to focus on one element of the problem.

‘GPs strive to provide the best possible access they can and will always see patients that need to be seen urgently.’

Dr Buckman added that the report showed other variables had a greater effect on rates of emergency department visits, so the focus on access to general practice was distracting.

He said: ‘The text of the report - rather than the press release which focuses on access to general practice - backs up what the BMA has been saying, that there are many factors to this problem.

‘It’s not surprising that the two variables with the largest effect on A&E visits are whether it’s an urban or a rural practice and whether it has more affluent or deprived patients - that’s what you’d expect.’

A DH spokesperson said the Government has plans to tackle access to primary care by making GPs responsible for out-of-hours care for patients.

He said: ‘We know A&E departments are under increasing pressure - that’s why we are working with the NHS to address the problems facing them now and in the future. Access to primary care is an important part of this which is why we have set out plans to ensure that GPs are ultimately responsible for the out-of-hours care given to their patients.’ 

Readers' comments (15)

  • MOst of the variance is explained by deprivation (major factor), then distance from AE then urban area, then age and finally ability to get an appointment with GP within 48 hours

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  • Yes, but the investigators clearly make the point that the only one of these you can easily change is access to the GP. Most of us stick with the same age and sex, and doctors can't fix socioeconomic deprivation (neither can politicians, but that's a story for another day) .

    If they could even get through to make an appointment it would help. Why can't practices be forced to pay a receptionist to answer the phone in working hours. At £6:20 an hour, it wouldn't break the bank. Where I work, almost all practices switch to answer phone at 11:30am, and guess where the punters go instead...

    No-one wants to see GPs work excessively, but improving access in line with what can be achieved by the best practices would clearly help.

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  • It's unclear from this article if each of the factors are standardized for age, distance, deprivation etc.

    If it is, fair enough. If not, it's not worth the paper it's written on and it's just a lazy meaningless research.

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  • None of the practices I work at switch their phones over to answer phones at 1130, I think because it is part of the local PMS agreement. I suspect that may change following the current review.

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  • This study demonstrates that investing in General Practice is likely to save costs in the medium (and ?long) term.

    As there has been a squeeze on General Practice income, there has been a crisis of A+E attendances. Look for this to continue as the department of health follow their own agenda regardless.

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  • Bryan, you should read the stats on AED attendance released by kings fund recently. It doesn't support your (or this research) theory. AED attendances has uniformally and steadily risen for over 10 years. It is the underfunding of the healthcare as a whole to match the changing population which is fueling the current crisis.

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  • Rubbish biased research and findings.
    Just proves all policies that policy makers have implemented has failed so far as gps were being paid for access via Qof according to national patient survey.

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  • >AED attendances has uniformally and steadily risen for over 10 years.

    When WICs and other T2 and T3 units etc are removed from the count A&E attendance has only increased by around 1.7% per year, which is less than the population increase. There hasn't been a REAL increase in A&E attendance at all...

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  • Ashley Liston

    Some practices are finding win-win solutions such as rapid response telephone consulting where ALL requests for GP consultations are called back by a GP within 1hour. 60% problems dealt with on the phone, same day appts the norm, revolution in increased access and massive increase in patient satisfaction. And wait for it---20% reduction in A+E attendance!
    This is not a political stance. It is GPs acting as gatekeepers to their own services and navigators for their patients--core role of a GP

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  • Azeem Majeed

    Factors such as deprivation and urban location were most strongly associated with A & E visits. GP access was also associated. This should be used as evidence to argue for more resources for primary care. Sadly, NHS commissioners are taking a different view and where I practise in Lambeth, many practices have seen cuts of 20% or more in their budgets.

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