General practice: Clarity over (A&E) crisis

In January MPs claimed that poor access to general practice was causing a crisis in A&E. However, a survey published in March by the King’s Fund paints a rather different picture. MARIE CAHALANE spoke to BECCY BAIRD, policy fellow at The King’s Fund, to ask what truth lies in this claim and what actions practice managers can take to alleviate the ‘crisis’

It’s been dubbed an A&E ‘crisis’ but will it have an impact on primary care? Amidst the bold headlines of January were claims that the finger of blame was being pointed at general practice. One news outlet reported that Theresa May planned to, ‘relieve the pressure on crisis-hit A&E units’ by having ‘GP surgeries meet the government’s pledge to open from 8am to 8pm, seven days a week’. The suggestion here – that poor GP access was, if only in part, responsible for the pressures faced in A&E units across the country – offers a very simple reading of a very complex situation.

In March the King’s Fund published its Quarterly Monitoring Report (QMR) which revealed that, despite the media’s focus on access to GPs, the majority of finance directors believe, ‘The rising number of patients with complex health needs is the key factor behind the increasing pressures on A&E departments’. So, why are A&E units under pressure, what part does general practice play in this and, importantly, what can general practice do to improve healthcare for the wider population?

Open access

Access clinics have been suggested as a means of boosting access to care but, as Beccy points out, if you’re going to run access clinics, practices need to consider who will staff them. While there are great innovations in general practice at present, and practices nationwide are finding ways to work smarter and enhance patient care – it is unrealistic to think that extending GP opening hours will solve an A&E crisis.

Root cause

To begin, we need to consider why extended access to GPs will not solve the problem – and this comes down to understanding that not all ailments are created equal. “It’s clear that A&E is under pressure but, what is also clear, is that the reason for this is mostly down to the kind of people who are coming into A&E – people who need admitting to hospital beds,” Beccy says, adding that such patients couldn’t have been managed in primary care at the time they were admitted. It’s at this point the bottle-neck occurs; patients need beds but, because they are already occupied, these are not available for patients-in-waiting.

It’s true that people are having trouble getting access to their GPs and services are stretched. However, it must be recognised, that it’s not those accessing A&E for minor issues who are causing the difficulties; it’s those who need beds, those with complex conditions who require A&E attention.

Beccy does point out that, if primary care services and other community health and social care services were more readily available, some patients might not have reached the point of needing hospitalisation. A 2015 report – Prime Minister’s Challenge Fund: Improving Access to General Practice – revealed a near 15% reduction in A&E admissions for minor illnesses where access clinics were available, for example. But, while this may alleviate the situation, it is more complicated than GP-registered patients not getting an appointment and choosing instead to present at A&E.

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High impact

It’s clear that action needs to be taken as the pressure on A&E services will, in turn, affect NHS-wide healthcare provisions. In the primary care arena, while there is no easy answer, there are a number of things that GP practices can do – things which some practices are already be doing. “One thing practice managers can undertake is to have a good understanding of their data. They can really scrutinise their information systems, ascertain what their flow is and understand how patients use their practice,” Beccy says.

This level of patient awareness can help practice managers structure their services more effectively, enabling them to better meet their patient’s needs. Take, for example, a telephone triage system; in Beccy’s experience efficient management is not so much the result of telephone interventions but more a result of understanding the demands, the flow and the capacity of such systems.

The advantage of understanding who’s coming through the practice door is that it’s then possible to direct them to the person who can best cater for their needs – whether that be a GP, a pharmacist, a nurse or another member of the wider primary care team – though Beccy advises that, if you use this approach, you must ensure that that information goes back and forth effectively between every member of the team.

Thinking about the wider primary care team, and how practices work with other services, is another aspect that can help practices improve care for patients, with GPs working differently – working more as part of a primary care team, Beccy says, rather than GPs working in an isolated way, just seeing the patient in front of them and not thinking beyond this. There are primary care home models being piloted across the country and these healthcare hubs are a positive move towards tackling – and managing – the health of our nation.

Practices coming together to pool their resources, consider their populations – and the needs of those populations – and identify practical ways of responding is certainly positive; it’s localised, and thus targeted, healthcare. “There’s a real balance in primary care between continuity and access,” Beccy observes, providing the example of a mother seeking one-off, immediate treatment for a young child compared with a patient requiring long-term care for diabetes – both of whom can get the treatment they require in primary care.

Fast figures*

80%

of NHS finance directors identified higher numbers of patients with severe illnesses and complex health needs as key reasons for A&E pressures

70%

of NHS finance directors cited delays in discharging patients from hospital as a reason for increased pressure on A&E

Relatively few finance directors identified either poor access to general practice or shortages of clinical staff in A&E as key factors in increased pressure on A&E services

*Information taken from The King’s Fund’s QMR

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