Paper of the Week: 4th November 2019

This week’s blog is brought to you by: Dr Tim Wilson

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Full reference and title from the journal:

Convenient primary care and emergency hospital utilisation, Edward W. Pinchbeck,  Journal of Health Economics 68 (2019) 102242.

Link to paper, click here

Authors conclusion:

Participation and utilisation decisions lie at the heart of many public policy questions. Convenience-oriented primary care services divert three times as many patients from emergency visits, largely because patients can attend without appointments.

3V bottom line:

High value interventions are neglected in favour of lower value interventions when we do not think of populations and outcomes that matter.

3VH – Implications for value:

This analysis in this interesting paper demonstrates that is people are offered convenient appointments in general practice then they will lead to a fall in A&E (ED) attendances. Providing alternatives access points for urgent care work has not always worked. The evaluations of walk in clinics demonstrated that they instead increased the demand for urgent care. Risk stratification linked to community interventions have also failed. [1]

Unlike people with trauma, people with an urgent problem form a disparate group with a range of complex needs. Break your tibia and it is clear what needs to happen and restructuring of trauma services in England in recent years has improved care.

But not everyone who attends an A&E for an urgent problem needs the full panoply of services that a hospital provides, nor does everyone who rings 999 have a healthcare problem, let alone one needing an ambulance. Indeed, findings from a major survey in the north of England identified several key risk factors of A&E attendance, including young age (indeed, being aged 18-24 was the greatest predictive factor), depression, high education, non-employment, poor housing, as well as longer distance from a GP and shorter distance to an A&E service.[2]

But the all focus of the NHS in regard to urgent care has been on the “four-hour wait” and ambulance “response times”. Both of these are important process measures, introduced at a time when waiting over 24 hours in A&E was not uncommon. But they do not reflect the need of people with an urgent care problem.

As a consequence of the focus on A&E (ED) waiting times, huge investments have been made in A&E services, whilst at the same time spending in primary care has fallen from 9% of the NHS budget to 8%. And yet as this paper shows, providing higher value primary care in the form of convenient appointments divert people with an urgent care problem away from A&E. And for many of those attending A&E it represents a low value service as they do not need the expensive infrastructure that comes with a modern emergency department.

The need for urgent care is unlike other healthcare needs. It is the belief that they need urgent care that defines the need, not the treatment they require once a diagnosis has been made. People with a problem that they believe is urgent want timely access to the right service. This is what health and social care organisation should be addressing. Health and social care organisations need to consider the whole population who have an urgent care need. Those people access a range of services in different ways and as this paper shows, often based on convenience not on the likelihood they will get the right support. Health and care organisations need to measure what matters to people with urgent care and only use narrow process measures like the four-hour wait, alongside a range of other process measures, to understand how the system is progressing towards achieving those outcomes.

[1] Roland M Abel G. Reducing emergency admissions: are we on the right track? BMJ 2012;345:e6017

[2] Giebel, C., McIntyre, J. C., Daras, K., Gabbay, M., Downing, J., Pirmohamed, M., … Barr, B. (2019). What are the social predictors of accident and emergency attendance in disadvantaged neighbourhoods? Results from a cross-sectional household health survey in the north west of England. BMJ Open, 9(1).

If we do this, then we can start to move resources from lower value interventions to higher value interventions, like convenient access clinics in primary care.