What are the fresh ideas to reduce A&E overcrowding? Dr Tom Monks CLAHRC Wessex Methodological Hub

Spring.  The headlines about A&E overcrowding are beginning to disappear just as a fresh wave of news reports burst forth with the NHS priorities for the next government.  We now have the luxury of a brief respite to reflect on how we can improve the lot of our hospital A&E’s before the seasonal cycle repeats itself.  I have spent my winter looking at A&E data examining the question – could the answer to A&E attendance lie in providing GP appointments for urgent – but non-emergency – care at the weekend?

There are clear positives for improved GP access: improved patient experience, continuity of care from a regular GP and potentially less conservative decision making regarding treatment.  But the evidence for the impact on A&E attendances is mixed in terms of outcomes and quality.

The proportion of A&E patients that could be seen by GPs turns out to be a hotly debated figure.  Some say it’s between 30-40% of all attendances while other, more conservative estimates, place it between 10-20%.

Over the darkened months here in CLAHRC Wessex – we surveyed a group of 200 of such patients (amidst data from thousands of NHS cases in the region).  We found that 25% of patients that took themselves to an A&E department with a minor illness said they would have considered seeing a local GP instead.  A further 10% were unsure.

Leaving aside whether people felt they were able to respond truthfully to the survey – we still have several unanswered questions about how opening up weekend appointments would affect these figures. How many GP appointment slots are needed?  What time of day do patients need appointments?  Will patients just turn up at a GPs surgery or will they ring 111? Are there other types of patient that will compete for appointments? And does the service itself create new demand?  We are now working to model these influences and understand their impact.

Another thing – often missed in news reports – is that A&E attendances are historically lowest in the winter months (the exception being Christmas which is very busy).  This doesn’t seem to make sense initially as it is the very time overcrowding hits the headlines.  That’s until we realise that patients tend to be sicker in winter – so have more complex treatment needs. That means more inpatient admissions and more difficulties in finding beds for patients waiting in A&E.  The result is that there may be less of an impact in winter in absolute terms than the busiest periods of summer. So despite some of the optimistic figures I quote – more GP appointments aren’t a simple answer. But improved access does have other important patient benefits and could be used as part of a larger solution. What is clear is that the costs and consequences of implementing improved weekend GP access should be measured as part of resilience planning.  Our rather nifty computer modelling offers a low risk way to bring together different sources of evidence and understand the impact on a local health economy – before commissioners commit money and resources. Maybe now is the time to seed those ideas, before the days get shorter and the demands on the system higher.

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