NIHR Signal Extended hours in primary care linked to reductions in minor A&E attendances

Published on 13 December 2016

Practices which offered additional appointments showed a reduction in the number of their patients attending emergency departments (also known as A&E) for minor conditions. There was no overall reduction in emergency visits. Costs were reduced for emergency departments but by less than the cost of the additional appointments. The study did not evaluate whether or not this is cost saving to the health service as a whole nor if health outcomes were improved.

Emergency departments are increasingly busy and patients are waiting longer to be treated. Commissioners and providers have been interested in interventions which may help to reduce these hospital pressures.

This NIHR-funded study funded 56 general practices in Manchester to offer extra appointments during evenings and weekends as part of a larger programme to improve primary care. There was a 26.4% relative reduction in “minor” A&E visits (10,933 fewer visits), compared to 469 practices which did not offer additional appointments.

Nationally, policy-makers aim to encourage patients with minor conditions to attend alternative services, including primary care. These findings suggest additional appointments may help reduce minor A&E visits but may be more costly overall.

Extended hours in primary care linked to reductions in minor A&E attendances

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Why was this study needed?

A 2014 study found that many people attending emergency departments for minor complaints have experienced problems seeing their GP. Policy makers have provided incentives to commissioners and providers through the Prime Minister’s Challenge Fund to extend access within primary care. A counter argument, presented in a recent Nuffield Trust report, suggested increased hours in primary care could create more demand.

Whilst earlier research has suggested a link between access to primary care and emergency department visits, a recent systematic review found the quality of studies was relatively low. Often, studies have used a before and after analysis, with no comparison, which makes it hard to establish a clear link between A&E visits and extended access. Few studies have explored the effects of evening or weekend appointments.

Given the increasing pressures on hospitals, it is important to understand the impact of changes in primary care on patients, costs and health outcomes and these researchers sought to shed some light on this issue.

What did this study do?

This study is part of a programme in Greater Manchester to test changes to primary care services. The study focuses on extended access within four local communities. In total, 56 practices offered additional routine and urgent appointments during evenings and weekends in 2014.

The additional appointments lasted 10 to 15 minutes and amounted to an average of 35 hours per week. Staffing arrangements varied: two communities worked with practice staff and two contracted with out of hour’s providers.

A total of 51,465 additional appointments were offered. This equated to 152 extra appointments per 1,000 people registered over the year.

Researchers compared hospital data of A&E visits for people registered at these practices compared to 469 other local practices with a focus on minor complaints.

Health outcomes were not assessed in this study, which is an important limiting factor when considering the implications of this research. This means that we cannot compare the quality of care offered by these models of delivery.

What did it find?

  • 65.1% of the extra appointments were used. Uptake was initially slow but increased over time.
  • For 33,159 GP appointments booked there were 10,933 fewer emergency department visits for minor problems (95% confidence interval [CI] ‑15,995 to ‑5,886). This was a 26.4% relative reduction in patient initiated visits and amounts to approximately one avoided A&E attendance for every three additional GP appointments.
  • There was no difference in overall emergency department visits (relative reduction ‑3.1%, 95% CI ‑6.4% to 0.2%).
  • These practices reduced their combined emergency department costs by £767,976 (95% CI £405,184 to £1,130,767). Measured against the £3.1 million investment, this suggests an overall increased cost rather than saving.
  • Patients seemed to prefer appointments with a GP from their practice, rather than an out of hour’s provider, suggesting continuity of care is important.

What does current guidance say on this issue?

The 2014 NHS England Five Year Forward View highlighted an extended role for primary care, promoting improved access to services in local communities to reduce demand on hospitals. Many commissioners have worked with local practices to provide extended access, with funding from the 2015 Prime Ministers Challenge Fund which was set up to improve access to GPs. The 2016 NHS England General Practice Forward View sets out further investment for improvements to primary care, including access.

What are the implications?

The study supports the premise that extended hours in primary care can reduce visits to emergency departments for minor problems. However, costs may be higher and health outcomes were not assessed. 

The variations across the communities in this study also demonstrate the potential impact of local constraints, notably capacity within primary care. Commissioners and providers will need comprehensive data on costs and health outcomes to make an informed judgement on the best approach to take locally to extend access. 

It is likely that an extended hour’s scheme will need to be part of a broader system-wide approach to managing hospital pressures.

Citation and Funding

Whittaker W, Anselmi L, Rud Kristensen S, et al.  Associations between extending access to primary care and emergency department visits: a difference-in-differences analysis.  PLoS Med. 2016;13(9):e1002113.

The study was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester and by NHS England (Greater Manchester).

Bibliography

Cowling TE, Harris MJ, Watt HC, et al. Access to general practice and visits to accident and emergency departments in England: cross-sectional analysis of a national patient survey. Br J Gen Pract 2014;64(624):e434-e439.

Mott MacDonald. Prime Minister’s Challenge Fund: Improving Access to General Practice First Evaluation Report: October 2015. London: NHS England; 2015.

NHS England. Five Year Forward View. London: NHS England; 2014.

NHS England. General Practice Forward View. London: NHS England; 2016.

NIHR CLAHRC Greater Manchester. NHS Greater Manchester Primary Care Demonstrator evaluation. Manchester: NIHR Collaboration for Leadership in Applied Health Research and Care, Greater Manchester; 2015.

Rosen R. Meeting need or fuelling demand? Improved access to primary care and supply-induced demand. London: Nuffield Trust; 2014.

Tan S and Mays N. Impact of initiatives to improve access to, and choice of, primary and urgent care in England: a systematic review. Health Policy 2014;118(3):304-15.

Why was this study needed?

A 2014 study found that many people attending emergency departments for minor complaints have experienced problems seeing their GP. Policy makers have provided incentives to commissioners and providers through the Prime Minister’s Challenge Fund to extend access within primary care. A counter argument, presented in a recent Nuffield Trust report, suggested increased hours in primary care could create more demand.

Whilst earlier research has suggested a link between access to primary care and emergency department visits, a recent systematic review found the quality of studies was relatively low. Often, studies have used a before and after analysis, with no comparison, which makes it hard to establish a clear link between A&E visits and extended access. Few studies have explored the effects of evening or weekend appointments.

Given the increasing pressures on hospitals, it is important to understand the impact of changes in primary care on patients, costs and health outcomes and these researchers sought to shed some light on this issue.

What did this study do?

This study is part of a programme in Greater Manchester to test changes to primary care services. The study focuses on extended access within four local communities. In total, 56 practices offered additional routine and urgent appointments during evenings and weekends in 2014.

The additional appointments lasted 10 to 15 minutes and amounted to an average of 35 hours per week. Staffing arrangements varied: two communities worked with practice staff and two contracted with out of hour’s providers.

A total of 51,465 additional appointments were offered. This equated to 152 extra appointments per 1,000 people registered over the year.

Researchers compared hospital data of A&E visits for people registered at these practices compared to 469 other local practices with a focus on minor complaints.

Health outcomes were not assessed in this study, which is an important limiting factor when considering the implications of this research. This means that we cannot compare the quality of care offered by these models of delivery.

What did it find?

  • 65.1% of the extra appointments were used. Uptake was initially slow but increased over time.
  • For 33,159 GP appointments booked there were 10,933 fewer emergency department visits for minor problems (95% confidence interval [CI] ‑15,995 to ‑5,886). This was a 26.4% relative reduction in patient initiated visits and amounts to approximately one avoided A&E attendance for every three additional GP appointments.
  • There was no difference in overall emergency department visits (relative reduction ‑3.1%, 95% CI ‑6.4% to 0.2%).
  • These practices reduced their combined emergency department costs by £767,976 (95% CI £405,184 to £1,130,767). Measured against the £3.1 million investment, this suggests an overall increased cost rather than saving.
  • Patients seemed to prefer appointments with a GP from their practice, rather than an out of hour’s provider, suggesting continuity of care is important.

What does current guidance say on this issue?

The 2014 NHS England Five Year Forward View highlighted an extended role for primary care, promoting improved access to services in local communities to reduce demand on hospitals. Many commissioners have worked with local practices to provide extended access, with funding from the 2015 Prime Ministers Challenge Fund which was set up to improve access to GPs. The 2016 NHS England General Practice Forward View sets out further investment for improvements to primary care, including access.

What are the implications?

The study supports the premise that extended hours in primary care can reduce visits to emergency departments for minor problems. However, costs may be higher and health outcomes were not assessed. 

The variations across the communities in this study also demonstrate the potential impact of local constraints, notably capacity within primary care. Commissioners and providers will need comprehensive data on costs and health outcomes to make an informed judgement on the best approach to take locally to extend access. 

It is likely that an extended hour’s scheme will need to be part of a broader system-wide approach to managing hospital pressures.

Citation and Funding

Whittaker W, Anselmi L, Rud Kristensen S, et al.  Associations between extending access to primary care and emergency department visits: a difference-in-differences analysis.  PLoS Med. 2016;13(9):e1002113.

The study was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester and by NHS England (Greater Manchester).

Bibliography

Cowling TE, Harris MJ, Watt HC, et al. Access to general practice and visits to accident and emergency departments in England: cross-sectional analysis of a national patient survey. Br J Gen Pract 2014;64(624):e434-e439.

Mott MacDonald. Prime Minister’s Challenge Fund: Improving Access to General Practice First Evaluation Report: October 2015. London: NHS England; 2015.

NHS England. Five Year Forward View. London: NHS England; 2014.

NHS England. General Practice Forward View. London: NHS England; 2016.

NIHR CLAHRC Greater Manchester. NHS Greater Manchester Primary Care Demonstrator evaluation. Manchester: NIHR Collaboration for Leadership in Applied Health Research and Care, Greater Manchester; 2015.

Rosen R. Meeting need or fuelling demand? Improved access to primary care and supply-induced demand. London: Nuffield Trust; 2014.

Tan S and Mays N. Impact of initiatives to improve access to, and choice of, primary and urgent care in England: a systematic review. Health Policy 2014;118(3):304-15.

Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis

Published on 6 September 2016

Whittaker, W.,Anselmi, L.,Kristensen, S. R.

PLoS One Volume 13 Issue 9 , 2016

BACKGROUND: Health services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends. Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators. METHODS AND FINDINGS: Throughout 2014, 56 primary care practices (346,024 patients) in Greater Manchester, England, offered 7-day extended access, compared with 469 primary care practices (2,596,330 patients) providing routine access. Extended access included evening and weekend opening and served both urgent and routine appointments. To assess the effects of extended primary care access on hospital services, we apply a difference-in-differences analysis using hospital administrative data from 2011 to 2014. Propensity score matching techniques were used to match practices without extended access to practices with extended access. Differences in the change in "minor" patient-initiated emergency department visits per 1,000 population were compared between practices with and without extended access. Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for "minor" problems (95% CI -38.6% to -14.2%, absolute difference: -10,933 per year, 95% CI -15,995 to -5,866), and a 26.6% (95% CI -39.2% to -14.1%) relative reduction in costs of patient-initiated visits to emergency departments for minor problems (absolute difference: - pound767,976, - pound1,130,767 to - pound405,184). There was an insignificant relative reduction of 3.1% in total emergency department visits (95% CI -6.4% to 0.2%). Our results were robust to several sensitivity checks. A lack of detailed cost reporting of the running costs of extended access and an inability to capture health outcomes and other health service impacts constrain the study from assessing the full cost-effectiveness of extended access to primary care. CONCLUSIONS: The study found that extending access was associated with a reduction in emergency department visits in the first 12 months. The results of the research have already informed the decision by National Health Service England to extend primary care access across Greater Manchester from 2016. However, further evidence is needed to understand whether extending primary care access is cost-effective and sustainable.

Emergency departments (also known as A&E) routinely record the source of referral and the intensity of a patient’s problem. Sources of referral include: self-referral, GP, social services, emergency services and health care providers. The intensity of the problem is recorded as minor, standard or high. This study is focused on visits where patients self-referred for “minor” problems, for example, sprains and strains which can be managed in community settings.

Expert commentary

This study provides clear evidence that improving access to primary care outside routine working hours reduces A&E attendance, particularly for patients with less serious conditions. This is important because it supports a current component of healthcare policy in England that aims to reduce the pressure on A&E Departments by improving access to primary care. This is a contentious issue, so clear research evidence is welcome. Whilst there are some weaknesses in this study, and the need for a cost effectiveness analysis is clearly described, the findings will further inform current initiatives to provide extended access to primary care.

Jonathan Benger, Professor of Emergency Care, University of the West of England, Bristol