After a week of grim news about NHS emergency services, weekend newspapers shifted the focus onto primary care, with reports that the Prime Minister had apparently pointed the finger of blame at general practice. The Telegraph reported that she planned to “relieve the pressure on crisis-hit Accident & Emergency units" by demanding “that GP surgeries meet the government’s pledge to open from 8am to 8pm, seven days a week”.
A look at the evidence suggests that increasing seven-day access to GP appointments may reduce the total number of people coming to A&E. However, it is unlikely to affect the rising tide of patients waiting on trolleys in hospital corridors, and there is a risk that it might take GPs away from work that addresses the root causes of these problems.
Behind the numbers: the difference between ‘major’ and ‘minor’ A&E units
Understanding why extended access to GP appointments will not solve the A&E crisis first requires an understanding of the difference between major and minor A&E services. In many hospitals, patients are assessed (‘triaged’) at the front door of A&E. Those with less serious problems are streamed into ‘minor’ A&E units – also known as ‘urgent care’ services or type 3 services – which are often run by GPs. Those with more serious problems are streamed into the main A&E departments (type 1).
If extended GP access was the answer to the current problems in A&E, it would follow that these problems are largely due to patients presenting at A&E with conditions that should have been dealt with by GPs. But this is not the case.
Between 2003/04 and 2013/14, the rise in A&E attendances was driven by an increase in attendances at so-called type 3 units – smaller, less acute services such as walk-in centres and minor injury units (that tend to see patients with relatively minor, self-limiting problems).
By 2013/14, however, attendances at both type 3 and type 1 were increasing at a similar rate.
It is this rise in type 1 attendances that has coincided with hospitals struggling to meet the four-hour target. The most recent A&E data from NHS England (Nov 2016) show that the majority of so-called ‘breaches’ of the four-hour wait target occur in type 1 departments (where 14 per cent of patients breached) rather than in the type 3 units (where only 0.5 per cent of patients breached the four-hour wait).
For patients with a relatively minor illness, attending a community-based GP appointment is no doubt better than sitting in a crowded hospital. There is evidence of up to a 15 per cent reduction in A&E attendances for minor illness associated with the access clinics established by groups of GPs in centralised, community ‘hubs’ in response to David Cameron’s access challenge fund. But for patients with serious and urgent enough problems to be seen in a type 1 A&E, general practice is not a realistic alternative.
So, instead of improving performance on A&E targets, increasing access to GP appointments will tend to remove the more minor attendances that shore up performance figures – making performance against the four-hour target appear worse. Ministers may want to be careful what they wish for.
How will extended GP access clinics affect A&E attendance?
So what impact could extended access GP clinics have on patients with the severe, longer-term conditions that tend to drive type 1 A&E attendance? The concept of ‘ambulatory care sensitive conditions’ is important here. These are conditions like diabetes and chronic lung disease, which underlie numerous A&E attendances, for which high quality primary care can prevent symptoms from becoming so severe that they require hospital attendance.
Here lies a paradox, for this kind of ongoing care is the cornerstone of traditional general practice – with its long-term, high trust relationship between GP and patient – that may be lost if we divert too many resources to rapid access appointments delivered by doctors who don’t know the patients they are seeing. And a relentless focus on delivering extra appointments may distract GPs from developing the kind of multi-professional response to early clinical deterioration that can prevent hospital admissions.
Beware of the unintended consequences
The unintended consequences don’t end there. If more GPs spend their time in extended access clinics for acute health problems, fewer will be available during office hours when multi-disciplinary team meetings for patients with complex problems are organised and held.
And if GPs are staffing extended hours services that are typically used by people with relatively minor acute problems, then their high level clinical skills are directed at the kind of minor, self-limiting illness that many say should be managed by other professional groups, such as pharmacists taking on new primary care roles.
The workforce problem
Even if extended GP access was unequivocally the answer to problems at A&E, the practicality of achieving it would be a huge challenge given the already serious shortage of GPs. Plans for 5,000 extra GPs by 2020 will be hard to achieve with 7 per cent of current training posts unfilled, and many GPs working part time or retiring early. Forcing GPs to work extended hours in ‘hub clinics’ spreads the current workforce more thinly, rather than increasing capacity. There are many excellent initiatives to diversify the workforce who deal with patients in core hours and extended-access GP services. However, evidence from one current 8am-8pm clinic shows that patient demand for other clinicians is lower than for GPs.
Complex problems require sophisticated solutions
Many of the current ‘magic bullet’ solutions to problems in general practice raise additional challenges. For example, while tech-enabled consultations can help improve access to GPs, it can cause duplication of work and evidence suggests that up to 30 per cent of contacts may reflect ‘supply-induced demand’.
There are examples where integrating urgent and routine general practice does work well – including some of the GP access clinics established through the challenge fund – and the Alzira health system in Valencia, Spain. But adopting this kind of model takes time and investment.
The problems in A&E have many underlying causes and there is no single solution. Homing in on GP access hours can offer only a partial solution – and handled badly, it may even worsen the problem. There are many commentators who will no doubt be offering advice on what would really help. For my part I’ll head off to my weekend-access clinic session to put a sticking plaster on the problem.
Rebecca is a Senior Fellow in Health Policy at the Nuffield Trust and a General Practitioner in Greenwich.