NIHR DC Discover

NIHR Signal Continuity in primary care may be linked to reduced unscheduled hospital care

Published on 27 May 2014

doi: 10.3310/signal-000089

One positive finding from this review of a broad range of observational studies was that being able to see the same doctor in primary care was associated with fewer emergency department visits and emergency hospital admissions. Other factors associated with less unscheduled secondary care were younger age, higher socioeconomic status, not having a chronic disease or multiple health conditions, shorter distance to primary care compared with secondary care, and easier access to primary care. Because studies were from a number of countries with differing health systems, some of the findings are less directly relevant to the UK.

Share your views on the research.

Why was this study needed?

Unscheduled use of secondary care rose 8.5% between 2010 and 2011 in the UK. Some think people accessing secondary care in an unscheduled way could be seen more cost-effectively in primary care, saving up to £238 million per year, according to the Kings Fund. There is also wide variation in unscheduled use of secondary care between different general practices. This review wanted to find out some of the reasons for this.

What did this study do?

The systematic review used Cochrane review methodology to identify individual observational studies from the UK, US, Canada, South America and Europe. Most were-cross sectional designs, with some longitudinal, case control, and one before-and-after study. The main outcome of interest was unscheduled use of secondary care, measured by emergency department attendance and emergency hospital admissions.

The studies were combined by narrative description. The studies were from differing national healthcare systems and described very different types of patient populations, for example, all GP patients, specific groups such as people with diabetes, or paediatric patients. This makes it difficult to generalise findings, given differences in study populations and systems of care.

What did it find?

The researchers identified 48 relevant papers describing 44 unique studies.

  • More unscheduled use of secondary care was associated with factors associated with low socioeconomic status and a greater prevalence of acute illness, such as increasing age and chronic disease.
  • Less unscheduled use of secondary care was associated with more convenient primary care locations for patients and greater continuity of care, such as being able to see the same healthcare professional.
  • Overall, the findings for each factor varied by context, particularly by country and healthcare system.

What does current guidance say on this issue?

The 2012 NICE guideline on patient experience in adult NHS services suggests that continuity is vital to patients receiving effective, appropriate care. It recommends the assessment of each patient's requirement for continuity of care and how that requirement will be met. The Keogh Urgent and Emergency Care interim review reported the vision for planning services at the end of 2013. This is being delivered through local urgent and emergency care networks, a priority new model of care under the NHS Five Year Forward View strategy.

What are the implications?

There is the potential to reduce costly unscheduled use of secondary care by understanding factors associated with its use, but the relationships between factors are complex. The review did not cover patients’ views on barriers and facilitators to accessing and using healthcare, part of the picture. However, the results did suggest that NHS England’s policy guidance is a step in the right direction. This emphasises treating people as close to home as possible and suggests a return to named GPs for the vulnerable elderly.

Commissioners can use resources like the NHS Right Care programme’s atlas of variation to compare local emergency department attendance and unplanned admission rates with others and consider strategies for reducing avoidable admissions.

Citation

Huntley A, Lasserson D, Wye L, et al. Which features of primary care affect unscheduled secondary care use? A systematic review. BMJ open 2014 4;5:e004746. This project was funded by the National Institute for Health Research School for Primary Care Research.

Bibliography

Huntley A, Wye L, England H, Salisbury C, Purdy S, Lasserson D, Morris R, Checkland K. Primary care factors and unscheduled secondary care: a series of systematic reviews. 2014. Centre of Academic Primary Care, University of Bristol

NICE Guideline CG138 Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. CG138. London: National Institute for Health and Care Excellence; 2012

NHS Right care programme. London: NHS England and Public Health England; 2014/15

NHS England. Commissioning for Value – comprehensive data packs to support CCGs and NHS England in the regions. London: NHS England; 2015

NHS England. Transforming urgent and emergency care services in England. Urgent and Emergency Care Review. End of Phase 1 Report. London: NHS England; 2013

NHS England. Five Year Forward View: Chapter 3, New Models of Care. London: NHS England; 2014

O'Cathain A, Knowles E, Maheswaran R, et al. A system-wide approach to explaining variation in potentially avoidable emergency admissions: national ecological study. BMJ Qual Saf. 2014 Jan;23(1):47-55

Tian, Y. Data briefing: emergency hospital admissions for ambulatory care-sensitive conditions. Kings Fund report. 3 April 2012

Why was this study needed?

Unscheduled use of secondary care rose 8.5% between 2010 and 2011 in the UK. Some think people accessing secondary care in an unscheduled way could be seen more cost-effectively in primary care, saving up to £238 million per year, according to the Kings Fund. There is also wide variation in unscheduled use of secondary care between different general practices. This review wanted to find out some of the reasons for this.

What did this study do?

The systematic review used Cochrane review methodology to identify individual observational studies from the UK, US, Canada, South America and Europe. Most were-cross sectional designs, with some longitudinal, case control, and one before-and-after study. The main outcome of interest was unscheduled use of secondary care, measured by emergency department attendance and emergency hospital admissions.

The studies were combined by narrative description. The studies were from differing national healthcare systems and described very different types of patient populations, for example, all GP patients, specific groups such as people with diabetes, or paediatric patients. This makes it difficult to generalise findings, given differences in study populations and systems of care.

What did it find?

The researchers identified 48 relevant papers describing 44 unique studies.

  • More unscheduled use of secondary care was associated with factors associated with low socioeconomic status and a greater prevalence of acute illness, such as increasing age and chronic disease.
  • Less unscheduled use of secondary care was associated with more convenient primary care locations for patients and greater continuity of care, such as being able to see the same healthcare professional.
  • Overall, the findings for each factor varied by context, particularly by country and healthcare system.

What does current guidance say on this issue?

The 2012 NICE guideline on patient experience in adult NHS services suggests that continuity is vital to patients receiving effective, appropriate care. It recommends the assessment of each patient's requirement for continuity of care and how that requirement will be met. The Keogh Urgent and Emergency Care interim review reported the vision for planning services at the end of 2013. This is being delivered through local urgent and emergency care networks, a priority new model of care under the NHS Five Year Forward View strategy.

What are the implications?

There is the potential to reduce costly unscheduled use of secondary care by understanding factors associated with its use, but the relationships between factors are complex. The review did not cover patients’ views on barriers and facilitators to accessing and using healthcare, part of the picture. However, the results did suggest that NHS England’s policy guidance is a step in the right direction. This emphasises treating people as close to home as possible and suggests a return to named GPs for the vulnerable elderly.

Commissioners can use resources like the NHS Right Care programme’s atlas of variation to compare local emergency department attendance and unplanned admission rates with others and consider strategies for reducing avoidable admissions.

Citation

Huntley A, Lasserson D, Wye L, et al. Which features of primary care affect unscheduled secondary care use? A systematic review. BMJ open 2014 4;5:e004746. This project was funded by the National Institute for Health Research School for Primary Care Research.

Bibliography

Huntley A, Wye L, England H, Salisbury C, Purdy S, Lasserson D, Morris R, Checkland K. Primary care factors and unscheduled secondary care: a series of systematic reviews. 2014. Centre of Academic Primary Care, University of Bristol

NICE Guideline CG138 Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. CG138. London: National Institute for Health and Care Excellence; 2012

NHS Right care programme. London: NHS England and Public Health England; 2014/15

NHS England. Commissioning for Value – comprehensive data packs to support CCGs and NHS England in the regions. London: NHS England; 2015

NHS England. Transforming urgent and emergency care services in England. Urgent and Emergency Care Review. End of Phase 1 Report. London: NHS England; 2013

NHS England. Five Year Forward View: Chapter 3, New Models of Care. London: NHS England; 2014

O'Cathain A, Knowles E, Maheswaran R, et al. A system-wide approach to explaining variation in potentially avoidable emergency admissions: national ecological study. BMJ Qual Saf. 2014 Jan;23(1):47-55

Tian, Y. Data briefing: emergency hospital admissions for ambulatory care-sensitive conditions. Kings Fund report. 3 April 2012

Which features of primary care affect unscheduled secondary care use? A systematic review

Published on 27 May 2014

Huntley, A.,Lasserson, D.,Wye, L.,Morris, R.,Checkland, K.,England, H.,Salisbury, C.,Purdy, S.

BMJ Open Volume 4 , 2014

OBJECTIVES: To conduct a systematic review to identify studies that describe factors and interventions at primary care practice level that impact on levels of utilisation of unscheduled secondary care. SETTING: Observational studies at primary care practice level. PARTICIPANTS: Studies included people of any age of either sex living in Organisation for Economic Co-operation and Development (OECD) countries with any health condition. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was unscheduled secondary care as measured by emergency department attendance and emergency hospital admissions. RESULTS: 48 papers were identified describing potential influencing features on emergency department visits (n=24 studies) and emergency admissions (n=22 studies). Patient factors associated with both outcomes were increased age, reduced socioeconomic status, lower educational attainment, chronic disease and multimorbidity. Features of primary care affecting unscheduled secondary care were more complex. Being able to see the same healthcare professional reduced unscheduled secondary care. Generally, better access was associated with reduced unscheduled care in the USA. Proximity to healthcare provision influenced patterns of use. Evidence relating to quality of care was limited and mixed. CONCLUSIONS: The majority of research was from different healthcare systems and limited in the extent to which it can inform policy. However, there is evidence that continuity of care is associated with reduced emergency department attendance and emergency hospital admissions.

The Keogh Urgent and Emergency Care Review is ongoing, but five key elements for change have been published in the interim report: 1) to provide better support for self-care; 2) to help people with urgent care needs get the right advice in the right place, first time; 3) to provide highly responsive urgent care services outside of hospital, so people no longer choose to queue in A&E; 4) to ensure that those people with serious or life-threatening emergency care needs receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery; 5) to connect all urgent and emergency care services together so the overall system becomes more than just the sum of its parts.

Expert commentary

This review illustrates the difficulties facing policy makers drawing conclusions on what drives health system utilisation and the trends in such activity. Data are sparse, largely observational, and rarely conclusive. Why? Because health services research less often reports more robust, prospective, experimental, controlled comparator studies. Presumably because such research is less well supported. So what does this research tell us? That unscheduled emergency department attendance or hospital admissions are more likely to occur amongst those with a greater burden of disease (the poorer, more elderly, greater co-morbidity populations) or lower educational attainment and not much appears to moderate such activity other than possibly better continuity of care. There is a lot of face validity to these findings, but there is also a need to invest in better data.

Professor Richard Hobbs, Professor of Primary Care Health Sciences, University of Oxford

Expert commentary

Out of many possible factors looked at in this careful review, the clearest association with reduced unscheduled secondary care use is continuity of care. The likely mechanisms include the effects of patients’ trust in a known clinician allowing them to stay at home and wait rather than use expensive secondary care.

So the onus is on clinicians to help patients achieve better relationship continuity and for policy makers and managers to support them. We know from other research that patients already want this. The single most important challenge is discontinuity due to part-time working and the most plausible remedy is the introduction of microteams. These teams comprise a very small number of clinicians work closely together for a named patient list. A number of practices have already introduced microteams in some form.

Professor George K Freeman, Emeritus Professor of General Practice, Imperial College London