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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.’