7-day GP opening cuts weekend A&E visits in Britain

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The UK government’s pilot of seven-day GP opening has significantly reduced weekend A&E visits, hospital admissions and ambulance call-outs, University of Sussex research has found.

Spread across the whole week, A&E visits were down 10% among patients of pilot surgeries in central London. The greatest effect was seen on Saturdays and Sundays, with a drop of 18% recorded across weekends.

Crucially, for squeezed National Health Service (NHS) budgets, expensive hospital stays and ambulance call-outs also dropped significantly.

The reductions were almost entirely driven by fewer elderly patients with moderate injuries or illnesses – not, as the government expected, by minor cases being diverted away from A&E.

The researchers believe this is because A&E doctors take fewer risks with elderly patients they don’t know and choose to admit them to a ward to be "on the safe side", whereas GPs have an intimate knowledge of their patients’ medical history and can send the less serious cases home after treatment. Essentially, GPs make far more effective ‘gatekeepers’ to more expensive treatments.

Many of the minor cases in A&E are the so-called frequent flyers – people who visit A&E on multiple occasions. Very few of these people took up the option to visit a GP instead. This suggests that a nationwide roll-out of seven-day opening would not only reduce pressure on stretched A&E services as a whole, but that the impact would be biggest among the most costly cases.

Professor Peter Dolton and Dr Vikram Pathania of Sussex’s School of Business, Management and Economics led the study. Pathania said: “There is clearly evidence of unmet demand for weekend GP opening.

“Seven-day opening for GPs appears to make a dent in two major sources of A&E expense – admissions and ambulance usage. The latter alone shows a significant drop of nearly 20% on weekends. Costs aside, there is also strong evidence that patient healthcare, in many cases, could be better delivered by a visit to a GP. Patients may automatically equate the size and complexity of a large hospital-based A&E unit with higher quality care. But typically A&E doctors are junior to GPs, who are equivalent to hospital consultants in terms of their medical training and expertise. Plus GP treatment is based on direct past experience with the patient and access to their medical records.”

The research has potentially large implications for NHS finances, with an unplanned hospital admission costing around 30 times as much as a GP visit: A&E visits have risen 32% over the past decade to 21.8m a year; each A&E visit costs the NHS £114; an ambulance call-out adds £220 to the bill; an unplanned hospital admission costs an eye-watering £1489; and this compares to just £45 for the average GP visit.

The researchers caution that the long-term impacts are still unknown. People may respond to less crowded A&Es by visiting them more, for example. It is also clear that demand is highest among older people and, as the research also shows, the more affluent. In fact, some practices have already curtailed their weekend opening, citing insufficient demand.

It may be, therefore, that seven-day opening should only be implemented in strategically located surgeries and may not be optimal for all surgeries. Dolton said: “These findings suggest the need for a careful rethink about the efficiency of redirecting patients to extended GP surgeries to lighten the load in A&E – although this would need to be accompanied by a redirection of NHS funding to Primary Care.”

Restricted access to primary care can lead to avoidable, excessive use of expensive emergency care. Since 2013, partly to alleviate overcrowding at the Accident & Emergency (A&E) units of hospitals, the UK has been piloting 7-day opening of General Practitioner (GP) practices to improve primary care access for patients. We evaluate the impact of these pilots on patient attendances at A&E. We estimate that 7-day GP opening has reduced A&E attendances by patients of pilot practices by 9.9% with most of the impact on weekends which see A&E attendances fall by 17.9%. The effect is non-monotonic in case severity with most of the fall occurring in cases of moderate severity. An additional finding is that there is also a 9.9% fall in weekend hospital admissions (from A&E) which is entirely driven by a fall in admissions of elderly patients. The impact on A&E attendances appears to be bigger among wealthier patients. We present evidence in support of a causal interpretation of our results and discuss policy implications.

Peter Dolton, Vikram Pathania

University of Sussex material Journal of Health Economics abstract

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