Systematic review of recent innovations in service provision to improve access to primary care

Personal medical services

PMS were designed to facilitate the provision of primary care services that targeted locally defined needs, and allowed for different arrangements of GP employment. PMS, as a policy, has the potential to impact on access in the following ways:

• by allowing primary healthcare teams to target services for specific population groups (for example, older people and mental health service users);

• by allowing the development of new or enhanced services in under-served deprived areas;

• by enhancing partnership working between primary care, social services, and the voluntary sector;

• by improving the recruitment and retention of GPs; and

• by skill mixing, to increase the capacity of teams to deliver health care; for example, substituting a nurse for a GP in chronic-disease management.

Some of this potential has been realised. PMS pilots made small but significant improvements in the quality of mental health care and the care of older people (where these were the focus of the pilot)12^,13 and there is some evidence that PMS sites are located in deprived areas.14

Partnership working between agencies has been slow to develop.13^,15^-18 However, there is some evidence that GP recruitment and retention has been improved, albeit modestly, with the option of salaried contracts.19 Salaried posts in PMS contracts have attracted the attention of the potential GP workforce, including inactive GPs and locums.19

PMS have allowed for nurse-led primary care18 to combat poor service access in areas having difficulties recruiting and retaining GPs. However, no studies looking at nurse-led PMS met the study inclusion criteria and so the impact of this initiative on access cannot be determined.

All published data related to first wave pilots. There is no evidence about the contribution of later PMS to primary care access.

GP-led telephone consultation in general practice

Five studies were found. The initiation of telephone consultations in general practice can positively influence both availability and use of primary care, although the use of the telephone may increase access inequalities for those who do not have access to a telephone, have language difficulties or communication impairments. Evidence suggests that both patients and providers view the telephone as an appropriate mode of communication about health care.20^,21 There is some indication that callers are using GP ‘phone-in’ services as an alternative to setting up an appointment or requesting a home visit.22 A system whereby all patients requesting same-day appointments are told that a GP will telephone them later may lead to a decrease in demand for GP face-to-face consultations,20 however one study showed subsequent increases in repeat consultations in the following weeks.23 This study was based on a small sample of individuals, however, and the response rates were low.23 Unsurprisingly, GP accessibility by telephone is dependent on the patient-to-telephone line ratio, and patient satisfaction with phone-in services is directly related to the ease in which they reach the GP on their first try.24

Nurse-led triage and telephone consultations in general practice

Four studies (five papers) were found. One study provided evidence that nurses can manage a high proportion of out-of-hours primary care calls safely and effectively,25^,26 without an increase in daytime surgery attendances within the following 3 days. No differences were found between GP and nurse triage relating to the number of patient deaths within 7 days, the number of emergency hospital admissions, or the number of accident and emergency attendances.25 Furthermore, nurse-led telephone triage may lead to reductions in GP workload.26^-28 Richards et al found that the number of GP consultations, and particularly the number of home visits, were reduced by the implementation of a system of nurse telephone triage.27 However, the same study provided evidence of increased numbers of routine appointments and heightened out-of-hours and accident and emergency attendances.27 Pinnock et al assessed the impact of nurse-led telephone consultations for routine asthma medication review and found telephone consultations used in this way to be significantly time saving and without any differential in adverse outcomes compared with face-to-face care.29

Nurse practitioner-led care in general practice

Four studies were found. There is some evidence that nurse-led care for minor conditions is as safe and effective as care by doctors; that is, resulting in similar clinical outcomes.30^-32 No data was found comparing the detection of rare and serious adverse health outcomes between both professional groups.33 There is evidence that nurses give longer consultations30^-33 and carry out more tests,32^,33 however, no difference has been found in referral rates to secondary care between doctors and nurse practitioners.30^,33 Findings on re-consultation rates are inconsistent. Venning et al report higher return rates for patients who have seen a nurse practitioner (0.49 versus 0.36)32 whereas Kinnersley et al did not find any evidence of a difference.30 Similarly, there is variable evidence regarding the proportion of cases that nurses can handle independently (73–96%).31^,32 There is consistent evidence that nurse-led care achieves high patient satisfaction rates.30^,32

Walk-in centres

Six studies were found. There is reasonable evidence to suggest that walk-in centres do enhance access to health care for a minority of the population and that they provide an acceptable, well used service. Walk-in centres provide convenient and quick access to good quality primary care,34 eliciting high patient satisfaction rates and resulting in onward referral rates of 19–26%.35^-38 (Referral rates to secondary care from walk-in centres [and NHS Direct] are higher than those from general practice.35) However, walk-in centres do not address access inequalities, attracting largely white middle-class patients with minor and self-limiting complaints.35^-38 Walk-in centres do appear to improve access for young and middle-aged men,36 who generally access primary care less than other population groups. People chose to attend walk-in centres because of their convenience,37^,38 because they feel that their GPs are too busy, and owing to the anonymity that the walk-in centre offers.38 The evidence of any reduced workload in neighbouring services is inconclusive.37^-40 Users generally view the walk-in centre as an alternative route to care — most users would have consulted a GP or accident and emergency services had the walk-in centre not existed.36 However, there is an indication that one-third of all users intended to make a GP appointment following their walk-in centre appointment.36 Walk-in centres may be duplicating existing service provision, creating new demand and not addressing access inequalities.

NHS Direct

One study (one report and one paper), based entirely on routine data, was found providing some evidence to suggest that NHS Direct provides an easily accessible professional service that is well used and of high quality, achieving high caller satisfaction rates, and is no less safe than other routes to care.41 There is some concern over delays in getting through and regarding the potentially inconsistent quality of the self-care advice provided.41 The impact of NHS Direct on other services is unknown, although some evidence suggests that it is halting increasing demand on out-of-hours cooperatives and deputising services.41^-42

Unfortunately, at this time NHS Direct callers appear to be the same people who already make use of pre-existing health services — the white, healthy middle class. NHS Direct is particularly underused by older people,41 possibly reflecting a lack of awareness of the service, perceived incompatibility of the service with health needs, or sensory difficulties. Additionally, the service is clearly less accessible to those who have linguistic or conversational impairments (although NHS Direct, with the help of Language Line, is making an effort to reduce such barriers).

Pharmacist-led interventions

Two studies (three papers) were found on pharmacist-led care. There is weak evidence that patients can be safely managed by pharmacists' advice and treatment, and prescribed over-the-counter medication with low rates of onward referral to GPs (4%)43 and normal reconsultation rates.43^-45 Patients perceive pharmacists as appropriate care providers and easily accessible, yet there is some concern about the lack of privacy in pharmacies.45 For those who are entitled to free prescriptions and cannot afford the cost of over-the-counter medication, a GP consultation is the only option.

Summary of main findings

Very little robust evidence was found. Even among the studies meeting inclusion criteria, few of them were of ‘gold standard’ quality and many were carried out on a small scale.

There is some evidence that new contractual arrangements in primary care can enable service provision in formerly under-served areas and populations (for example, PMS). Also, organisational flexibility and targeting services around locally defined needs (for example, PMS) appears to be effective in improving access for marginalised groups.

Substituting nurses for GPs, or the telephone for face-to-face consultations may be effective in improving access where GP recruitment and retention is problematic. However, maximising the use of skill mix does not necessarily improve access inconsequentially, involving as it does trade-offs between different sorts of access. For example, some patients would clearly prefer to wait longer to see their GP than see a nurse. Furthermore, it is important to note that any form of telephone consultation infringes on equality of access, particularly for people who do not speak English as a first language, people with hearing or speech impairments, and people without access to a telephone.

Recent nurse-led initiatives such as NHS Direct and walk-in centres are undoubtedly improving access in general, in the sense that they are new services that are being widely used. However, as both are used primarily by population groups already accessing primary care through other routes, their value in addressing access inequalities may be questioned, particularly if these services employ staff who might otherwise work in conventional primary care settings in under-served areas. There are also clear inequalities of access for people whose English is limited and for those with a sight, hearing, or learning disability.

Furthermore, the majority of users consulting walk-in centres and NHS Direct, present with self-limiting conditions. Therefore, this increased accessibility to the health service could also increase the total demand on the NHS with little health gain for those consulting.

Pharmacist-led care creates an alternative point of first-contact access for patients and allows for flexibility in access. However, for those who are entitled to free prescriptions and who cannot afford the cost of over-the-counter medication, a GP consultation is the only option. In this way initiatives with community pharmacists will not necessarily increase access equitably.

Limitations of evidence

Time constraints have imposed limitations on what this review has been able to cover. Firstly, only studies conducted within the UK were included. Although evidence from elsewhere could be illuminating, it would need to be interpreted within the UK context.46 Secondly, social science databases were not searched and hence informative studies may have been missed. Thirdly, there are substantial gaps in the literature for both studies investigating long-term clinical outcomes and the cost-effectiveness of the innovations discussed. Finally, methodological thoroughness of reporting, study focus, and outcome measures varied greatly and were often reported in insufficient detail. Indicators were rarely clearly defined (for example, patient satisfaction) raising issues of the appropriateness of comparing such variables. Comparing different service settings, providers, and users of often undefined characteristics must be considered problematic, hiding confounding factors and necessitating the making of assumptions. Moreover, many of the studies included in this review utilised routine data. Routine data is often incomplete, inaccurate and/or inconsistent, which limits the validity of the findings.

Dimensions of access

There is no universally agreed upon definition of access. Please refer to Box 1 for an explanation of the model used for the purposes of this review. While considering access, it is important to take into consideration the inherent potential contradictions between different components of access. Little is known about the relative importance of different components of access to different population groups. All of the innovations discussed above involve trade-offs between these different aspects of access. For instance, telephone consultations prioritise rapid access over the choice to see a healthcare professional in person.

Access versus access inequalities

Recent innovations to improve access to primary care scarcely address access inequalities. PMS, as a policy, is arguably the only innovation in which healthcare provision is explicitly based on locally defined needs. In fact, many recent innovations, such as walk-in centres and NHS Direct may be increasing access inequalities by expending resources to ease access for affluent patient groups who are already accessing care.

Addressing access inequalities necessitates a bottom-up approach, where services are developed based on a local needs assessment. Clearly, targeting inequalities requires flexible service provision and decentralised planning, with providers supported by guidelines or ‘tool kits’ arising from evidence of best practice. Furthermore, a more collaborative and cooperative effort between primary care, social services and the voluntary sector would be a useful lever in facilitating access especially for deprived groups.

Access: the trade-offs with costs

Policy makers would be well advised to handle the concept of access with care. There is a need to compromise between optimal and acceptable service provision targets, between patients' expectations and what is economically and politically feasible.47 Although improving access has obvious political and moral appeal it may conflict to some degree with other policy imperatives such as cost containment. In any healthcare system resource constraints mean that the demand for health care has to be ‘managed’; that is, kept within limits, particularly in the current climate of increasing patient expectations,48 where patients increasingly want to be actively involved in the decisions over their health care. It is necessary for healthcare professionals to try to balance their views of care needs and priorities with public perception. NHS Direct and walk-in centres are examples of how improving access may be expensive without resulting in measurable reductions in the use of other primary care services.

Implications for research

The quality of the literature on access to primary care is mediocre. Future studies should make use of reliable and validated quantitative and qualitative research tools and should consider the benefits of triangulation.

The RCT has been firmly established as the ‘gold standard’ in study design, however it has achieved supremacy predominantly in the assessment of therapeutic agents. It is important to note that an RCT is not always feasible49 nor necessarily appropriate. Recent work suggests that well-designed observational studies with either a case-control or cohort design may produce similar results to randomised controlled trials.50^-52 Moreover, there are difficult theoretical and operational challenges in using the RCT model for complex interventions whose performance depends on the social setting, such as is likely to be typical of attempts to improve access and, in particular, to reduce inequalities of access.

There are large conceptual gaps in the literature. No studies were found that based their evaluations on a theoretical model of access. Therefore, it is unclear how stated outcome measures relate to different components of access. The majority of studies have inferred a link between service availability and use with service accessibility and usability. Clearly, the case of access is not so straightforward.

Few studies were identified that looked at service relevance with respect to community health needs and priorities, and likewise service acceptability in relation to the cultural, social, and economic needs of the population served. Moreover, health-seeking behaviour and the link to access was rarely noted. An awareness of the context and complexity of health-seeking behaviour may help in redressing access inequalities.

Research is needed on the determinants of demand, on how patients choose between alternative services, and how specific services fit into the pathways of care that patients follow. Future studies may help determine whether and to what extent services are overlapping, whether they are equally cost-effective and successful in responding to the same need, whether they are accessed by the same population group, and which characteristics make them attractive to different population groups.

Longer-term studies are also needed, however, the lack of these in the current literature on access highlights more of a policy imperative than a research one.

Conclusion

Very little robust evidence was found on these innovations. In the light of these gaps, it is important to point out that the absence of strong evidence (or indeed, any evidence) does not mean that a particular initiative or intervention is ineffective or without value, only that we lack the evidence to be sure either way. The absence of negative evidence is as important as the absence of positive evidence. For many of these interventions there are neither conclusive reasons why an intervention should be attempted, nor conclusive reasons why it should not. In such a situation, it may well be legitimate to implement the intervention.

Overall, access to primary care may be improved by diversifying modes of provision, by enhancing the roles of staff and by implementing services more flexibly. In reducing access inequalities, the key may be to prioritise the allocation of limited resources in well-targeted services, serving previously assessed gaps in care and/or communities. In the future it is important that as new initiatives are conceived and implemented, well-designed studies and evaluations are commissioned.