Access to General Practice and Emergency Department attendance in UK. A link to poverty?

The paper from Imperial College evaluating Emergency Department use with reference to access to a General Practitioner during the year 1 April 2011- 31 March 2012 here in England caused a small storm when it was published last week (June 13, 2013). At face value, the results play into the Government’s narrative that GPs are lazy, do not see enough patients, and Emergency Departments are overwhelmed by honest citizens who were not able to see there GP at the time of their choosing (Cowling et al, 2013). The perception was propagated elsewhere, including the fledgling The Conversation UK .

Here are some reasons why the conclusions are flawed in my opinion.

1. The General Practice Access Questionnaire surveying the percentage of people who stated that there was poor 48 hour access to see their general practitioner is widely discredited by general practices as bearing no relationship to the reality of access to their practices
   1. Too few non-British respondents compared with true practice profiles (84.9% white) and relatively too many men (49.8%) compared to usual pattern of GP utilisation
   2. Many respondents actually have no idea how their own practice operates, this particularly true of male patients who use GP infrequently.
   3. No stratification for illness episodes people felt required 48 hour (or less) access to GP
   4. No effort to look at patient outcomes from failure to see GP within 48 hours.
   5. < 4% practice population completed the forms which is arguably too low to be meaningful (2 million respondents of population of 56 million)
2. Hospital Episode Statistics ED minimum dataset too simplistic
   1. No detailed disease code for reason for attendance
   2. No outcome data as a result of (a)
3. Indicator variables for the Strategic Health Authority in which a general practice is located were included to account for unobserved variation in regional health system characteristics and policy. This is too crude to assess pockets of deprivation which every practice has, and some more than others.

Cowling et al observed that

The median percentage of a practice’s registered population that had tried to see a GP within two weekdays in the past six months was 59.3% (IQR: 54.9–63.6%). This demand was not always met: the median percentage that was subsequently able to do so was 82.0% (IQR: 74.0–89.3%).

You must keep in mind that this number refers to the GPAQ results, not actual numbers. The GPs I know do not recognise the result as properly describing the access to their practices.

In their discussion

In 2011-12, 9% of respondents to the GP Patient Survey who were unable to obtain a convenient appointment on their last attempt report subsequently going to an ED or walk-in centre, which accords with the results of our analysis.

Which simply validates their dataset rather than really telling us any more about the reasons for the behaviour.

And Cowling et al are dismissive of data which does not support their thesis suggesting to me that their minds were made up before this statistical paper was completed and the data have been made to fit the narrative.

Previous research of 68 general practices in London, England did not identify a statistically significant association between patient-reported access to general practice services and the rate of self-referred discharged ED visits, possibly due to insufficient statistical power. This explanation may also apply to a similar analysis of 145 practices in Leicestershire, England, which included all types of ED visit in the outcome variable.

Referring to North America data on GP access is not helpful because there is not universal coverage for primary health care like here in UK. In fact, it can be argued that the data confirms poverty and low social class as determinants of unplanned hospital (e.g. Emergency Department) use.

Looking at some common conditions which may influence ED

the prevalence of obesity in the registered population had a statistically significant positive association with the rate of ED visits (RR = 1.006; P = 0.021), whereas the prevalence of asthma and hypertension did not

indicates to me that the population who filled in the GPAQ do not properly represent disease prevalence or people who attend the practice regularly do know how to access their GP promptly and do so successfully. This mocks the conclusions of the study.

The results of this study do not support the hypothesis that timely access to GP could reduce self-referrals to the Emergency Department. What the study tells us is that some white English people cannot be bothered to wait to see their GP for self-limiting conditions. There is some evidence supporting the view that self-referral to Emergency Department is associated with low social class, poor education, and poverty. This is inferred from the observation that obesity has a positive association with ED attendance; obesity is closely linked to unfavourable social factors http://www.guardian.co.uk/news/datablog/2013/jan/23/fact-checking-obesity-poverty-link This is exacerbated in the current economic climate and further worsened by a Government pushing much and more onto General Practices since 2004 a lot of which is clinically useless. For example, Health Checks, GP access initiatives, ambulatory blood pressure recording to diagnose hypertension, routine reviews of people with long term conditions who are stable.

I believe part of the problem of perceived poor access to see a GP has been created by the UK Government fanning flames of expectation by the worried well. Practices must make more routine appointments available for people with long term conditions, must not turn away anyone who wishes to be seen in hours, and can no longer depend on expert community nursing to help out. Finally, the hardships many of my patients face in their living conditions because of unscrupulous landlords and local authorities turning blind eye to the tenants’ grievances is exacerbating the problem.

The paper by Cowling et al does support the Government’s assertion that General Practice and GPs are not working hard enough. It is clear to me that the research is flawed and the main conclusion is unfounded.

June 2013

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