Impact of initiatives to improve access to, and choice of, primary and urgent care in England: A systematic review
Introduction
Internationally, health systems have pursued improvements in quality, access and responsiveness by expanding choice and widening access to providers in the last 25 years. However, evidence that greater choice widens access and improves quality is inconclusive. In Scandinavia, for example, greater choice was expected to increase competition but robust evidence of impact is scant; the evidence in relation to primary and urgent care has largely been limited to the rate of switching between providers, with uptake highest in densely populated urban areas and dependent on the quality of information available to patients [1]. After New Labour came to power in the UK in 1997, the government similarly sought to develop better quality, more accessible and more responsive patient-centred care in the English NHS. Traditionally, there were two ways to access primary and urgent care in England: patients were registered with a general practice for all routine and non-urgent care during normal business hours; or they could attend a hospital A&E department at any time (for care that was not always clinically appropriate), leaving considerable space for alternatives. Although much attention has been devoted to the quasi-market reforms in hospital care [2], [3], reform also included ‘modernising’ primary and urgent care by expanding the range of options between traditional general practice and local A&E departments. Here the focus was on correcting perceived problems in access to, and choice of, services, such as growing public concern about timely access to general practitioners (GP) during and outside clinic hours, and the perceived inflexibility of traditional general practice, leading to inappropriate use of different sources of urgent care, especially the hospital accident and emergency department (A&E). The coalition government that followed New Labour in 2010 has continued to focus on improving patient access to primary and urgent care; notably through a pilot where patients can either register with, or use, general practices beyond the catchment area of their local general practices [4], [5], with out of area registration becoming available across England from October 2014 [5] and pilots of extended general practice care including seven-day working [6], [7]. Fig. 1 and Appendix 1 summarise the reforms of 1997–2013.
Between 1997 and 2004, a series of initiatives was developed in response to the perceived limitations of access to primary and urgent care in the NHS. NHS Direct (1998) opened a new telephone access route for primary care advice, especially outside practice hours. NHS walk-in centres (1999) aimed to provide more convenient access to primary and urgent care without an appointment [8]; some were co-located with accident and emergency (A&E) departments (2004) to improve access where patients chose to attend for urgent care, and further walk-in centres were located at, or within walking distance of, commuter train stations from 2005. NHS Direct and walk-in centres established new pathways for primary and urgent care, and offered a protocol-driven service for patients who could not, or chose not to access their registered GP practice. The Advanced Access scheme (2000) intended to reduce waiting times for GP appointments. There was also investment in training additional GPs and modernising existing practices in the NHS Plan [9]. A new General Practice NHS contract (2004) was introduced to address issues in contracting and payment, standardise quality and modernise IT infrastructure. The new contract featured incentives to shorten waiting time for a GP appointment to 48-h and the Quality and Outcomes Framework (QoF) which included targets relating to levels of patient satisfaction. By 2005–2006, investment in primary medical care had increased by well over £2 billion when compared to the financial year 2002–2003 [10].
From 2007, further policies were introduced to support and offer greater patient choice, including in primary care. The NHS Choices website and GP extended hours access scheme were introduced in 2007. The introduction of PCT tendering for new GP practices and new health centres (from 2008), polysystems (2007–2009), urgent care centres (2010) and the NHS 111 service (2010), all designed to increase accessibility or patient choice of provider, rapidly followed. The 2008 NHS Next Stage Review outlined new opportunities for patients to choose their general practice and called for the removal of practice boundaries [11]. These plans have been taken forward in modified form by the coalition government through its general practice choice pilot of 2012–2013 [4]. Fig. 2 illustrates the current wide range of ways to access primary and urgent care in the English NHS.
This review assesses the initiatives designed to improve access and patient choice between 1997 and 2010 in terms of their impact on demand (uptake), equity, patient satisfaction, referrals, and costs, with a view to informing future policy in this area. These impacts were chosen on the grounds that they seemed likeliest to influence health system policymakers’ decisions to retain, expand or discontinue initiatives in this field.
Section snippets
Methods
We searched government documents to develop a list of the initiatives. We then systematically searched the published literature using bibliographic databases – Google Scholar, PubMed and the King's Fund Library Database. The initial search was undertaken from June to August 2012 and updated in November 2013. We used broad search terms, with combinations of initiative names (e.g., walk-in centres or Advanced Access) and “English NHS”. We conducted a further search using search terms “primary
Demand for telephone-based services
NHS Direct, a nurse-led telephone helpline, was introduced in 1998 to address unmet demand for health services, provide referral to appropriate care and deter inappropriate attendances at A&E departments [8]. A national evaluation found that calls to GP cooperatives fell after the introduction of NHS Direct, but there was no reduction in A&E department attendance. NHS Direct was rarely used (6% in 2001) for unplanned (i.e. potentially urgent) episodes of care [12], [13], [14].
In 2010, NHS 111
Discussion
This is the first study systematically to review the evidence on the impacts of the primary and urgent care initiatives introduced by the New Labour government between 1997 and 2010. We found 19 studies resulting in 40 relevant papers on ten initiatives to improve patient access to, and choice of, primary and urgent care. Most papers resulted from DH-commissioned studies. There were a handful of analyses that compared two or three initiatives. The evidence was restricted to between the first
Conclusion
New Labour's primary and urgent care initiatives resulted in an increasingly complex system with many overlapping initiatives. A wide range of new services was introduced to improve choice and access, but many were not well communicated to implementers or users. There remain substantial gaps in the evidence on their effects, particularly in terms of equity of use and their costs. Convenience improved, but, there was little evidence that these initiatives were cost-effective compared to previous
Competing interests
The authors declare that they have no competing interests.
Acknowledgements
This review was undertaken through the Policy Research Unit for Policy Innovation Research (102/0001), which is funded by the Department of Health Policy Research Programme. The views expressed in this presentation are those of the researchers alone and do not necessarily represent those of the Department of Health.
References (53)
- et al.
What do other local providers think of NHS walk-in centres? Results of a postal survey
Public Health
(2005) - et al.
Choice of primary care provider: a review of experiences in three countries
(2013) - et al.
Understanding New Labour's market reforms of the English NHS
(2011) - et al.
Evaluating Labour's market reforms, 2002–10
Journal of Health Services Research & Policy
(2012) Choice of GP practice: the patient choice scheme
(2012)NHS employers summary of 2014/15 GMS contract negotiations 2013
(14 November 2013)Prime Minister's Office. Seven day, 8am–8pm, GP access for hard working people
(2013)Seven million patients to benefit from Challenge Fund
(2014)Out-of-hours care: ensuring accessible high quality care for all groups of patients
The British Journal of General Practice
(2000)The NHS Plan: a plan for investment, a plan for reform
(2000)