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Long term health conditions drive A&E visits, not lack of GP services

Rising accident and emergency attendance rates are driven by patients’ long term health conditions, and are not related to lack of GP provision, according to a study by Queen Mary University of London of more than 800,000 patients in east London.

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Lead researcher Dr Sally Hull from Queen Mary said: “The pressures on emergency departments, especially during winter, are enormous. When departments are very busy, with long waits and difficulties finding beds for people needing admission, it is easy to seek scapegoats and suggest that poorly functioning GP services are to blame for the crisis.

“Contrary to the popular narrative that people are using emergency departments rather than their GP surgery, our research shows that this is not the case. The same people who attend their GP surgery a lot also attend their emergency department a lot. This is largely because they have multiple long term health conditions, both mental and physical, and it is these conditions, along with an ageing population, which are driving the high attendance rates.

“These effects are exacerbated by socioeconomic deprivation. People in the most socially deprived areas develop long term health conditions 10 years earlier than those who are least deprived. These factors combine to put pressure on emergency departments.”

Linking GP and A&E records for the first time

Rates of emergency department (ED) attendance have more than tripled over the past 50 years, from 105/1,000 population in 1961 to 373/1,000 population in 2015-6. Previous studies found that socioeconomic deprivation was a major influence on ED attendance, but the studies were based on GP practice level and population data.

For the first time in the UK, the study, published in the British Journal of General Practice, looks at anonymised data from individual patients, and links their separate GP and ED records to get a more accurate picture of attendances over a two year period.

The team analysed data from 819,590 GP registered patients in 136 practices in the east London Clinical Commissioning Groups of Newham, Tower Hamlets and City & Hackney and found:

  • Having multiple long term health conditions, including asthma, cancer, heart disease or diabetes, was the strongest predictor of ED attendance. This and social deprivation are the major drivers of ED attendance.
  • There was a six-fold increase in ED attendance rates in those with four or more long term health conditions, compared to those with no such conditions.
  • People in the most deprived areas with four or more long term conditions, who also smoked, had almost three times the rate of ED attendance, compared to the same type of person living in the least deprived areas.
  • Attendance rates for the most deprived population group (366/1000 population) were 52 per cent higher than those for the least deprived (240/1000).
  • Patients with more attendances at EDs also have higher GP consultation rates - this suggests that the year on year rise in ED attendance is not explained by poor access to primary care.
  • Patient experience of GP access, reported at practice level, did not predict use of ED, unlike findings from previous studies.

Investment in social care and community health services

Dr Sally Hull added: “There are suggestions that emergency department units can be reduced and replaced with community-based support. This would require investment in both social care and community health services, and close alignment with the perceived needs of patients seeking urgent care. It is crucial that we carry out studies like this to understand why people attend emergency departments, and to identify the services which can be safely taken over by GP and community services.”

The authors caution that, as the study is set in east London, it is not representative of the country as a whole. The findings are relevant to other inner urban areas with similar levels of material deprivation and ethnic minority populations.

More information

  • Research paper: Population and patient factors affecting Accident and Emergency Department attendance in London: an analysis of linked primary and secondary care records. Sally A Hull, Kate Homer, Kambiz Boomla, John Robson, Mark Ashworth. British Journal of General Practice. doi: 10.3399/bjgp18X694397
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