Existing Literature
2.2 EMERGENCY HOSPITAL SERVICES
The annual number of visits to A&E departments in England increased by 19.2% between 2005-06 and 2014-15, from 18.8 million to 22.4 million.99 The annual number of emergency hospital admissions increased by 20.5%, from 4.7 million to 5.6 million, over the same period.100 I have previously reported that the percentage of emergency admissions that are via an A&E departmentm increased from 53.8% in 2001-02 to 68.6% in 2010-11.101,n These trends indicate increased use of emergency hospital services.
2.2.1 Reducing Use
These trends could be undesirable for several reasons. Increased use could reflect greater levels of illness and disease in the population. In addition to the harm associated with worse health, patients could be at greater risk of iatrogenic harm from requiring hospital treatment. Some changes in use may reflect substitution of A&E services for general practice; patients may have benefited more from seeing a GP because of the continuity of care it can provide, for example. The trends may also represent problems for providers of emergency hospital services. These providers may find it difficult to meet extra demand which could reduce the quality of service provided; an opportunity cost of treating additional patients with possibly minor complaints is being unable to focus on severely ill patients. Emergency hospital care, particularly for admitted patients, is also expensive to the NHS.
The Government expects that its plans for access to general practice will reduce use of emergency hospital services (table 1.1). Several causal mechanisms could help to explain this relationship. Section 2.1.4 suggested that a large number of A&E visits follow unsuccessful attempts to get suitable general practice appointments.25 Patients may also visit A&E departments without contacting their general practices first because they do not expect suitable appointments to be available. Many of these patients may have been treatable solely
m Other recorded emergency admission routes are: via a GP, via a Bed Bureau, via a consultant outpatient clinic, and via other means.
n This trend is driven by a 72% increase in the annual number of emergency admissions via A&E departments (2.1 to 3.6 million) and a 17% decrease in admissions via a GP (1.1 to 0.9 million) from 2001-02 to 2010-11.
within general practice. Some of the corresponding A&E visits might result in admission to hospital and therefore increase numbers of emergency admissions too.o
If patients cannot, or do not expect to, get convenient general practice appointments, they may prefer to see how their conditions develop before seeking further care. The conditions of some patients may deteriorate without treatment in general practice, to the point that they then require emergency treatment in hospital. This might occur with an acute infection or an acute exacerbation of a long-term condition, for example. Patients with improved access to general practice may seek care more often, thereby providing GPs with more opportunities to review patients’ long-term conditions and promote healthy behaviours. This could also help to reduce patients’ risks of emergency admission.
These mechanisms lead to the hypothesis that patients with better access to general practice should use emergency hospital services less, all else held constant. Numerous studies have examined this association at the practice-level using cross-sectional study designs and measures of access derived from the GP Patient Survey.
2.2.2 Associations with Access
Three studies23 27 30 have examined rates of A&E visits in the whole population. In my study of the 2010-11 financial year, the outcome measure only included emergency departmentp visits where patients had referred themselves and were discharged home without hospital admission.23 One study30 examined both this outcome measure and visits to minor A&E departments in 2012-13, while another study focused on all A&E visits in 2011-12.27 The analyses also differ in the variables adjusted for, the statistical methods used, and the presentation of results, which makes it difficult to compare the magnitudes of estimated associations across studies. However, all three studies suggest that practices with greater scores on measures related to access have lower adjusted rates of A&E visits. For example, my analysis estimated that the fifth of practices with the greatest percentages of patients able
o The assumption is that some patients admitted to hospital via A&E departments would not have been admitted if they had visited their general practice first. A&E doctors may be more likely to admit patients than GPs because the former are less likely to know patients’ medical histories, for example.
p Three categories of A&E department can be clearly distinguished: emergency departments are consultant-led 24 hour services with full resuscitation facilities; single specialty A&E services are consultant-led services focusing on a specific discipline; other A&E services are led by nurses or GPs and primarily treat minor injuries or illnesses (such as walk-in centres, minor injuries units, and urgent care centres).
to see a GP within two weekdays had a 10.2% (95% CI: 5.5% to 14.7%) lower adjusted rate of A&E visits than the fifth with the lowest values of the access measure.23
The findings of a further study102 that included A&E visits for patients aged less than 15 years old only are consistent with the above studies of the whole population. Respondents in the GP Patient Survey 2011-12 who were unable to get a general practice appointment on their last attempt were more likely to report calling an out-of-hours primary care service in the past six months.103 Two additional studies104 105 have examined associations between GP Patient Survey measures of access and rates of A&E visits in local areasq; these studies did not find evidence of a relationship, which could reflect a lack of statistical power, variation in results by English region, or different model specifications to the national studies.
I have previously investigated whether patients registered to more accessible practices are more likely to be admitted directly via a GP versus via an A&E department.24 Using GP Patient Survey data linked to administrative hospital records for 2011-12, I estimated that the adjusted odds of GP admission increased by 21% (95% CI: 21% to 22%) for a five point increase in the practice percentage of patients able to get an appointment.24 This provides evidence that A&E services and general practices substitute for one another in the context of more severe illness, as well as for minor conditions. Section 2.2.1 also hypothesised that better access to general practice may reduce numbers of emergency admissions.
Several studies19-22 26 28 29 have examined national associations between GP Patient Survey measures related to access and practice-level rates of emergency admissions for specific conditions.r These studies focused on two measures relating to patients’ abilities to see a GP within two weekdays and to get an appointment more than two days ahead; at least one of these measures was negatively associated with admission rates in all but one of these studies. A further study suggests that first-time admissions for cancer are more likely to be emergency admissions (versus elective) when practice percentages of patients able to see a GP within two weekdays are lower.18 One local analysiss did not find evidence of associations between practice-level rates of emergency admissions and measures related to access.106
q These areas covered 145 practices in Leicestershire and 68 practices in northwest London.
r These conditions include asthma, chronic obstructive pulmonary disease, dementia, diabetes complications, epilepsy, heart failure, and stroke.
The body of literature cited above has the three main limitations shown in table 2.4. The effects of specified changes in access to general practice on absolute total numbers of A&E visits and emergency admissions, in the whole population, have not been previously reported.
Table 2.4 Three Main Limitations of Existing Research into the Relationship between Patient
Experience and Use of Emergency Hospital Services
Limitation Why this is a limitation
1. Past studies typically restrict the study population or outcome variable so that it no longer reflects the whole population or total emergency hospital service use.
Policy makers will likely need to consider effects across total use of emergency hospital services when assessing the cost-effectiveness of interventions. Exploring effects only within certain populations or subsets of A&E visits or emergency admissions may underestimate the total impact of interventions.
2. Only variation in patient experience and use of emergency hospital services between general practices has typically been used to estimate associations.
Associations based solely on variation between practices can be confounded by unobserved factors that vary between practices and are constant for each practice over time. By using variation within practices over several time periods, these confounding factors can be accounted for, making findings more robust.
3. Findings are commonly left in an abstract mathematical form, such as relative differences in rates of A&E visits or emergency admissions, so it is difficult to understand the implications for
national policy.
Small relative differences could equate to large absolute changes, so different conclusions may be reached if relative differences are relied on alone. The expected absolute changes in total use of emergency hospital services with different changes in patient experience are unknown. Consequently, it is unclear whether related interventions are worthwhile to explore.