Make sure extending GP access doesn't clog expanded services

Improving access to general practice and other primary care services is a key concern for policy makers and practitioners.

People are frustrated by difficulties contacting their GP surgery, long waits for appointments and the difficulty of seeing a doctor or nurse they know at a convenient time.

Both the Coalition government and the Labour Party have made better access to general practice a priority for reforming the NHS.

‘As services expand and become easier to use, will more people will attend with minor self-limiting conditions?’

Access points to primary care are changing.

Patients can access a GP through their registered practice, out of hours services and walk in centres. Assessment and advice is also available through NHS 111 and pharmacists with treatment for selected conditions available in minor injury units and urgent care centres.    

But is there a risk that, as services expand and become easier to use, more people will attend with minor self-limiting conditions?

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Supply induced demand

Jon Nicholl from Sheffield University found that for approximately 15 per cent of walk-in centre contacts, and 11 per cent of urgent care centre contacts, patients would not have used another service - induced demand - if the centre they used did not exist. 

In addition, 30 per cent of walk-in centre patients and 21 per cent of urgent care centre patients were referred onto a service that they could have accessed anyway - induced utilisation.

‘Extra demand can be stimulated both by easier access to new forms of primary care’

The data was presented during a recent talk at the Nuffield Trust. This concept is known as “supply induced demand”. 

Rooted in economic theory, it reflects the role of doctors as agents for patients, with the ability to shape their views about the services they want and need - supplier induced demand.

There is also evidence that geographic variations in the use of health services are linked to regional variations in their supply - supply induced demand.

More recent English research shows how extra demand can be stimulated both by easier access to new forms of primary care - induced demand - and primary care consultations which end with patients being referred to other services which they could have chosen to use in the first place - induced utilisation.

Matching services to improve

The revised NHS constitution removed the 48 hour access target, but the language of patient choice and rights is still evident.

In an intensely cash strapped system, to what extent should we consider it an absolute right to have repeated rapid access to services often providing reassurance or responding to low levels of clinical need? 

With limited resources, is there an argument to focus on timely access where diagnosis, treatment and continuity of care are most needed? 

Clinically, these needs are hard to disentangle and both professionals and service users have a part to play in matching needs to service use as we work on improving access.

Checking – or re-checking – a common, self-limiting ailment because an immediate access service is available, can reassure, but can also erode confidence to self-care.

‘Re-checking a common, self-limiting ailment because an immediate access service is available, can reassure, but also erode confidence of self-care’

Increased service use due to greater availability or easier access to care can be a good thing. It can result in checking a long neglected symptom and early detection of an underlying illness. 

Walk in facilities offer access to unregistered and homeless patients, and may be convenient for workers who cannot reach their registered doctor during working hours. 

But there are potential downsides too. Checking – or re-checking – a common, self-limiting ailment because an immediate access service is available, can reassure, but also erode confidence of self-care.

Patients can move around different providers if they access a service which lacks the infrastructure or incentives to meet all their care needs in as few episodes as possible. And with growing concerns about shortages of GPs and community nurses, spreading the existing workforce over longer hours, and providing easier access for acute symptoms which are often self-limiting, could divert limited resources away from patients with complex health needs.

The challenge of educating for the long term

Perhaps the most difficult challenge lies in changing patient behaviours and expectations about access to healthcare. 

Education campaigns about choosing the “right service” receive a mixed press, and if they do work, they are often slow to take effect.

Many are short lived – part of a local winter pressures campaign – and typically rely on posters and leaflets, rather than wider, multichannelled campaigns. This may explain why their impact is limited.

‘It is tricky to meet demand without inducing extra demand that clog up expanded services’

Patient education could focus on building long term capacity for individuals, families and communities to cope with minor and early stage illness, reducing the demand for professional care.

Small pilot services have had some success in this area but there have been few attempts to scale up this approach.

As Mr Cameron’s “challenge fund” sites prepare to go live, they have a complex and difficult task ahead of them. 

Extending access is relatively easy. However, doing it so that you meet more need will require designs that do not induce extra demand to clog up expanded services. That is far trickier. 

Rebecca Rosen is senior fellow of health policy at the Nuffield Trust