Access to primary health care in England: policy, theory, and evidence

Abstract

Background: The U.K. Government plans to improve access to general practice services in England, partly by extending the opening hours of these services. The Government expects this to enhance patient experience and reduce use of emergency hospital services. The thesis aims to provide empirical evidence relevant to these policy expectations. Methods: Three observational studies of a cross-sectional questionnaire-based survey—the GP Patient Survey—from 2011-12 to 2013-14 (2,912,535 respondents aged ≥18 years old and registered to 8,289 general practices in England). Respondent-level data were deterministically linked at the practice level to Hospital Episode Statistics Accident and Emergency (A&E) and Inpatient data and to routine data on practice characteristics. Multivariable regression estimated associations between: (1) participation in the Extended Hours Access Scheme and patient experience; (2) several patient experience measures; and (3) patient experience and rates of A&E visits and emergency hospital admissions. Results: Most patients were very (40.0%) or fairly (42.3%) satisfied with the opening hours of their practices; results were similar for experience of making an appointment and overall experience. Practices that participated in the Extended Hours Access Scheme had greater adjusted mean values of these measures than non-participants, but the mean differences were small (≤1.25 on 0-100 scales). Overall experience was most strongly associated with doctor interpersonal quality of care (standardised coefficient=0.38; 95% CI: 0.38 to 0.38). A standard deviation increase in the practice-level mean experience of making an appointment predicted a 2.7% decrease (rate ratio=0.973; 95% CI: 0.966 to 0.979) in A&E visit rates and a 1.7% decrease (rate ratio=0.983; 95% CI: 0.978 to 0.988) in emergency admission rates. Conclusions: Changes to opening hours under existing policies are unlikely to improve patient experience of general practice substantially. Realistic short-term improvements in experience would likely have modest effects on use of emergency hospital services.