Elsevier

Health Policy

Volume 44, Issue 3, June 1998, Pages 191-214
Health Policy

Review article
Can primary care and community-based models of emergency care substitute for the hospital accident and emergency (A & E) department?

https://doi.org/10.1016/S0168-8510(98)00021-9Get rights and content

Abstract

This systematic review assesses the extent to which primary-secondary substitution is possible in the field of emergency care where the range of options for the delivery of care is increasing in the UK and elsewhere. Thirty-four studies were located which met the review inclusion criteria, covering a range of interventions. This evidence suggested that broadening access to primary care and introducing user charges or other barriers to the hospital accident and emergency (A & E) department can reduce demand for expensive secondary care, although the relative cost-effectiveness of these interventions remains unclear. On a smaller scale, employing primary care professionals in the hospital A & E department to treat patients attending with minor illness or injury seems to be a cost-effective method of substituting primary for secondary care resources. Interventions that addressed both sides of the primary-secondary interface and recognised the importance of patient preferences in the largely demand-driven emergency service were more likely to succeed in complementing rather than duplicating existing services. The evidence on other interventions such as telephone triage, minor injuries units and general practitioner out of hours co-operatives was sparse despite the fact that these interventions are growing rapidly in the UK. Quantifying the scope for substitution in any one health system is difficult since the evidence comes from international research studies undertaken in a variety of very different health settings. Simply transferring interventions which succeed in one setting without understanding the underlying process of change is likely to result in unexpected consequences locally. Nevertheless, the review findings clearly demonstrate that shifting the balance of care is possible. It also highlights a persistent gap in professional and lay perceptions of appropriate sources of care for minor illness and injury.

Introduction

The recent strategic policy shift towards a primary care-led National Health Service in the UK [1]has led to renewed interest in redefining the boundaries between primary and secondary care with the aim of shifting selected services traditionally provided in the acute hospital to less resource-intensive primary and community based alternatives.

This systematic review looks at the potential for substitution in the field of emergency care where innovation in health care delivery at the primary-secondary interface is very evident. For example, the UK has experienced a rapid increase in general practitioner out of hours co-operatives over the last 5 years. More generally, a government review of emergency pre-hospital care in England and Wales recently resulted in a series of pilot schemes to test interventions such as computer-driven telephone triage and advice 2, 3. Such developments are not surprising. Hospital emergency services are under increasing pressure as emergency admissions rise [4], junior staffing levels are constrained [5], and long-term trends in accident and emergency (A & E) attendance remain high [6]. Yet many attenders at A & E departments, perhaps around a quarter [7], attend with minor injuries or illness not requiring specialist attention. It has long been argued that these patients would be more appropriately treated in primary and community settings 8, 9, 10.

The current review aimed to assess the extent to which primary and community models of emergency care are likely to influence the demand for the A and E department and whether such shifts are likely to be cost-effective relative to traditional patterns of care. Although the review was undertaken primarily to contribute to policy in the UK, the findings are of general relevance.

Section snippets

Methods

A systematic review was undertaken of studies which quantified the impact of primary care or community-based interventions or service delivery on patterns of emergency demand across the primary-secondary interface. The review was carried out in accordance with guidelines published by the Cochrane Collaboration and the NHS Centre for Reviews and Dissemination, University of York 11, 12.

The study population was defined as patients experiencing conditions suitable for treatment in primary and

Results

Thirty-four studies were included for review covering a variety of interventions and forms of emergency care delivery. The studies have been grouped into three broad categories based on intervention type1 .

Discussion

In common with earlier reviews of developments at the primary-secondary interface 22, 89, we found that the evidence was patchy in coverage and quality. Credible research evaluating the impact of the emergency care interventions that are proliferating in the UK NHS, such as GP co-operatives and minor injuries units, was scarce. Moreover, with the exception of the research into general practitioners employed in A & E departments, there was virtually no evidence on the relative cost-effectiveness

Acknowledgements

We are indebted to Angela Coulter for her continued support and advice. We would also like to thank Anthony Harrison, Jennifer Dixon and Julian Le Grand of the King's Fund and Nick Freemantle of the University of York for their thoughtful and constructive comments. We gratefully acknowledge the help of Kathy Johnson of the King's Fund library. Finally, we are grateful to the anonymous referees who reviewed an earlier version of this paper for their very helpful comments. This review was funded

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