Failures in patient access to primary care has been suggested as a root cause of the current A&E crisis and was one of the motivating factors for the Government’s 7-day GP services policy. The logic was that improved access would help to relieve pressure on A&E and other emergency services. But is this best use of NHS resources and can it reduce that pressure? William Whittaker, who led a quantitative evaluation of the Greater Manchester scheme, takes a look at its findings.
The 7-day NHS policy includes changes to both primary and secondary care in England. Secondary care has received the greater attention, mainly due to arguments about the so-called ‘weekend effect’ suggesting higher mortality rates for patients admitted on weekends, as well as the junior doctors contract which has led to a long-running union dispute and industrial action.
Responses to proposals for 7-day routine access to primary care, by contrast, have been more muted but some GP leaders and MPs have questioned the feasibility and value of the policy. Recently, this policy has been piloted across parts of England giving policy makers the opportunity to examine whether proposed 7-day primary care plans are likely to be worthwhile.
Greater Manchester was somewhat ahead of the curve here. Throughout 2014, NHS England (Greater Manchester) funded four pilot schemes in Bury, Central Manchester, Heywood, and Middleton covering some 346,000 patients across 56 practices in the region. A common aim of these schemes was to offer increased access to primary care, met by extending GP hours beyond the normal working week to include evenings and weekend.
The NIHR CLAHRC Greater Manchester team carried out a qualitative and quantitative evaluation of the scheme, looking at the implementation and impact of the initiative. Our recently published paper in the journal PLOS Medicine presents the results of the quantitative analysis and adds to what is still a sparse evidence base of the effects of improving access in primary care on A&E attendance.
Our study found extended GP opening hours were associated with a 26.4% reduction in patient-initiated A&E attendances for minor problems. This amounts to an absolute drop of approximately 11,000 A&E attendances in 2014. The analysis used a number of innovative data analysis methods. Changes in attendances were compared to changes in practices with similar characteristics but without extended access. Care was taken to ensure our results did not reflect historic differences in trends of attendances between the two groups.
The findings of our study have several implications for policy surrounding a 7-day primary care service.
First, 7-day primary care looks to relieve pressures on A&E attendance. But note that this is a particular type of attendance, namely attendances for minor problems where patients made the decision to attend themselves, rather than being referred by someone else. These attendances only constitute approximately a third of total A&E attendances. More major problems – such as road traffic accidents or serious illness – are unlikely to be influenced by the availability of GP services. When we look at the impact on total attendance, including more serious problems, a small 3% reduction is found. So whilst the number of 26.4% sounds large, we need to be wary that the volumes we are talking about might not be.
Second, not all minor A&E attendances were prevented by the provision of extended opening hours in primary care. There is evidence that approximately 26.5% of all A&E attendances (minor and more serious) are by patients who had tried but failed to obtain a primary care appointment. These might be the people who would benefit from extended primary care opening hours, but we cannot tell whether the patients who did attend A&E for minor problems in our study had previously tried to get a GP appointment, nor whether such an appointment would have satisfied them.
Third, patients like the service, or are at least using it. We found on average that 65% of available appointments were used, and there was an increase in the proportion of appointments used as the year progressed which may represent increasing awareness of the service. Patients in the UK are used to appointments only being available during usual working hours, and so are unlikely to have spontaneuously asked for an evening or weekend appointment, suggesting that good publicity and proactive communication by general practice is important.
Finally , two years of NHS deficits highlight the issue of whether 7-day primary care services is a policy that makes the best use of NHS resources. We do not know whether 7-day primary care is cost-effective. Our study presented a partial cost-effectiveness assessment by comparing the cost reductions associated with reductions in A&E attendances with the costs of providing 7-day appointments.
In our study the reductions in A&E attendances amounted to a cost-reduction of £767,976, and the service as a whole cost £3.1m to provide. However, the reduction in A&E costs is only one measure of the impact of the initiative, and does not include a measure of any improvements in health resulting from the initiative. So, patients making use of the extended access may have obtained various benefits from attending, via reassurance, disease management, the start of early disease prevention or diagnoses, the value of which is very difficult to capture in the short term. Furthermore, the costs associated with providing the extra appointments may have included significant set up costs, making it very difficult to be sure what the ongoing longer term costs might be.
Establishing whether or not the extended hours services are cost effective is difficult but vitally important if we are to really know the effectiveness of such a far-reaching policy.
- Under devolution of health and social care funding in Greater Manchester and building on the learning acquired through this initiative, 7-day access is being extended across the whole of Greater Manchester, supported in some areas by other national initiatives such as the GP Access Fund and the New Care Model vanguard sites.
- The evaluation referred to in this post was funded by NHS England (Greater Manchester) and NIHR CLAHRC Greater Manchester http://clahrc-gm.nihr.ac.uk/
- The CLAHRC-GM team is now working on a broader evaluation which should offer answers to the deeper questions of cost-effectiveness and sustainability.