Search

Background: GP cooperatives are typically based in emergency primary care centres, and patients are frequently required to travel to be seen. Geography is a key determinant of access, but little is known about the extent of geographical variation in the use of out-of-hours services., Aim: To examine the effects of distance and rurality on rates of out-of-hours service use., Design of Study: Geographical analysis based on routinely collected data on telephone calls in June (n=14 482) and December (n=19 747), and area-level data., Setting: Out-of-hours provider in Devon, England serving nearly 1 million patients., Method: Straight-line distance measured patients' proximity to the primary care centre. At area level, rurality was measured by Office for National Statistics Rural and Urban Classification (2004) for output areas, and deprivation by The Index of Multiple Deprivation (2004)., Results: Call rates decreased with increasing distance: 172 (95% confidence interval [CI]=170 to 175) for the first (nearest) distance quintile, 162 (95% CI=159 to 165) for the second, and 159 (95% CI=156 to 162) per thousand patients/year for the third quintile. Distance and deprivation predicted call rate. Rates were highest for urban areas and lowest for sparse villages and hamlets. The greatest urban/rural variation was in patients aged 0-4 years. Rates were higher in deprived areas, but the effect of deprivation was more evident in urban than rural areas., Conclusion: There is geographical variation in out-of-hours service use. Patients from rural areas have lower call rates, but deprivation appears to be a greater determinant in urban areas. Geographical barriers must be taken into account when planning and delivering services.

Objective: To examine the implementation of 'Advanced Access' as a means of improving access to primary care., Methods: Qualitative case studies of eight English general practices undertaken as part of a mixed method study., Results: There was considerable variation in the interpretation and implementation of Advanced Access. Practices claiming to operate this system often did not follow its key principles. Differences between practice access systems centred on the use of 'same-day' appointments. The association of Advanced Access with same-day appointment systems was problematic as it both created antagonism to, and diverged from, the Advanced Access model. Practice staff did not necessarily share the conceptualisation of demand that underpinned Advanced Access. Other policies and targets provided further incentives to diverge from the model and these factors were compounded by informal organizational behaviours, notably the exercise of discretion, which led to adaptation., Conclusion: Advanced Access was diluted because it became confused with same-day appointment systems and other incentives and targets. Its guiding philosophy of 'manageable demand' appeared counter-intuitive to staff in the context of general practice, which made its implementation problematic. As a result, the system was adapted and modified.

Background: General practices in England have been encouraged to introduce Advanced Access, but there is no robust evidence that this is associated with improved access in ways that matter to patients., Aim: To compare priorities and experiences of patients consulting in practices which do or do not operate Advanced Access., Design of Study: Patient questionnaire survey., Setting: Forty-seven practices in 12 primary care trust areas of England., Method: Questionnaire administered when patients consulted., Results: Of 12,825 eligible patients, 10,821 (84%) responded. Most (70%) were consulting about a problem they had had for at least 'a few weeks'. Patients obtained their current appointment sooner in Advanced Access practices, but were less likely to have been able to book in advance. They could usually see a doctor more quickly than those in control practices, but were no more satisfied overall with the appointment system. The top priority for patients was to be seen on a day of choice rather than to be seen quickly, but different patient groups had different priorities. Patients in Advanced Access practices were no more or less likely to obtain an appointment that matched their priorities than those in control practices. Patients in both types of practice experienced problems making contact by telephone., Conclusion: Patients are seen more quickly in Advanced Access practices, but speed of access is less important to patients than choice of appointment; this may be because most consultations are about long-standing problems. Appointment systems need to be flexible to accommodate the different needs of different patient groups.

Background: Case studies from the US suggest that Advanced Access appointment systems lead to shorter delays for appointments, reduced workload, and increased continuity of care., Aim: To determine whether implementation of Advanced Access in general practice is associated with the above benefits in the UK., Design of Study: Controlled before-and-after and simulated-patient study., Setting: Twenty-four practices that had implemented Advanced Access and 24 that had not., Method: Anonymous telephone calls were made monthly to request an appointment. Numbers of appointments and patients consulting were calculated from practice records. Continuity was determined from anonymised patient records., Results: The wait for an appointment with any doctor was slightly shorter at Advanced Access practices than control practices (mean 1.00 day and 1.87 days respectively, adjusted difference -0.75; 95% confidence interval [CI] = -1.51 to 0.004 days). Advanced Access practices met the NHS Plan 48-hour access target on 71% of occasions and control practices on 60% of occasions (adjusted odds ratio 1.61; 95% CI = 0.78 to 3.31; P = 0.200). The number of appointments offered, and patients seen, increased at both Advanced Access and control practices over the period studied, with no evidence of differences between them. There was no difference between Advanced Access and control practices in continuity of care (adjusted difference 0.003; 95% CI = -0.07 to 0.07)., Conclusion: Advanced Access practices provided slightly shorter waits for an appointment compared with control practices, but performance against NHS access targets was considerably poorer than officially reported for both types of practice. Advanced Access practices did not have reduced workload or increased continuity of care.

Objectives: To quantify service integration achieved in the national exemplar programme for single call access to out of hours care through NHS Direct, and its effect on the wider health system., Design: Observational before and after study of demand, activity, and trends in the use of other health services., Participants: 34 general practice cooperatives with NHS Direct partners (exemplars): four were case exemplars; 10 control cooperatives., Setting: England., Main Outcome Measures: Extent of integration; changes in demand, activity, and trends in emergency ambulance transports; attendances at emergency departments, minor injuries units, and NHS walk-in centres; and emergency admissions to hospital in the first year., Results: Of 31 distinct exemplars, 21 (68%) integrated all out of hours call management. Nine (29%) achieved single call access for all patients. In the only case exemplar where direct comparison was possible, a higher proportion of telephone calls were handled by cooperative nurses before integration than by NHS Direct afterwards (2622/6687 (39%) v 2092/7086 (30%): P < 0.0001). Other case exemplars did not achieve 30%. A small but significant downturn in overall demand for care seen in two case exemplars was also seen in the control cooperatives. The number of emergency ambulance transports increased in three of the four case exemplars after integration, reaching statistical significance in two (5%, -0.02% to 10%, P = 0.06; 6%, 1% to 12%, P = 0.02; 7%, 3% to 12%, P = 0.001). This was always accompanied by a significant reduction in the number of calls to the integrated service., Conclusion: Most exemplars achieved integration of call management but not single call access for patients. Most patients made at least two telephone calls to contact NHS Direct, and then waited for a nurse to call back. Evidence for transfer of demand from case exemplars to 999 ambulance services may be amenable to change, but NHS Direct may not have sufficient capacity to support national implementation of the programme.

Objective: A study was undertaken to investigate patients' strength of preferences for attributes or characteristics associated with delivery of emergency primary care services available during usual GP surgery hours and to investigate the trade-offs between attributes., Methods: A discrete choice experiment was used to quantify patients' strength of preferences for several key attributes of usual-hours emergency primary care. The attributes were chosen to reflect the findings of previous research, current policy initiatives and discussions with local key stakeholders. A self-complete questionnaire was administered to NHS Direct callers and adult attenders at Accident and Emergency, GP services and the NHS Walk-in Centre in the locality. Regression analysis was used to estimate the relative importance to patients of the different attributes., Results: An overall response of 71% (n=432) was achieved. All but one of the attributes was a statistically significant predictor of preference. The attribute 'being kept informed about waiting time' was the most important. This was followed by 'quality of the consultation', 'having a consultation with a nurse', 'having a consultation with a doctor' and 'contacting the service in person'. Respondents were prepared to wait an extra 68 min to have a consultation with a doctor, but an extra 2 h 9 min for information about expected waiting time. There were no measurable preference differences between patients surveyed at different NHS entry points. Respondents younger than 45 years held strong preferences with respect to how they wanted to make contact with the system, whereas older respondents appeared not to hold strong preferences, seemingly indifferent between the alternatives. There was weak evidence which showed the younger group more strongly preferred accessing services via an integrated telephone system than making contact in person., Conclusions: This study showed that local solutions for reforming emergency primary care during hours when the GP surgery is open should take account of the strength of patient preferences. The discrete choice method was acceptable, and the results directly informed the development of a local service framework for such care.