Reducing inappropriate accident and emergency department attendances:

Comment to 'Reducing inappropriate accident and emergency attendances. A systematic review of primary care service intervention'.

Ismail et al clearly show that interventions in primary care do not decrease the number of inappropriate attendance of accident and emergency departments (A&E), nor increase patient self-care.[1] In Belgium (Flanders), we observed a large increase in attendance of young children at primary care out-of-hours (PCOOH) services after implementation of a general practice cooperative (GPC).[2][3] Recently, data from new PCOOH services in colocation with A&E showed nearly identical findings. Patients increasingly use the GPC, while patient fluxes to the A&E remain stable. These observations can be partly explained, because implementing PCOOH services was not meant to improve overall efficiency of the healthcare system, but rather a response to increasing strain on OOH care: lowering numbers of GP equivalents, feminisation of workforce, and decreasing safety during home visits were principal drivers for these changes. From earlier work, we know that patients tend to choose PCOOH services based on their previous experiences and that they like a technical environment.[4] Modest co-payment does not significantly influence health seeking behaviour.[5] Patients do not tend to think in 'primary' and 'secondary' care when in (perceived) need for urgent care. To change patient behaviour, we need well-designed, multifaceted interventions envisaging high quality and sustainable health care, not in response to dissatisfied groups of professionals. This means that professionals and their payers collaborate to establish integrated models of care. In Belgium (Flanders) this would mean structural collaboration of A&E and PCOOH services, and not competition for the majority of the patients. Due to rapidly declining numbers of GPs and medical specialists working at A&E, our professionals seem ready for this. Financial issues of these services need to be tackled as stakes are high for all stakeholders. Raising public awareness about appropriate health services use is of major importance as well.[6] From the BBC Masterchef series we learn nearly every day that good cooking is possible for everyone. However, we did not observe any instructive series on how to deal with urgent needs within our health system.

Hilde Philips, PhD, Primary and Interdisciplinary Care Antwerp, University of Antwerp, Belgium. E-mail: hilde.philips@uantwerpen.be

Barbara Michiels, PhD, Primary and Interdisciplinary Care Antwerp, University of Antwerp, Belgium.

Samuel Coenen, Senior researcher, Primary and Interdisciplinary Care Antwerp, University of Antwerp, Belgium.

Roy Remmen, Senior lecturer, Primary and Interdisciplinary Care Antwerp, University of Antwerp, Belgium.

1. Ismail, S.A., D.C. Gibbons, and S. Gnani, Reducing inappropriate accident and emergency department attendances. British Journal of General Practice, 2013. 63(617): p. e813-e820.

2. Philips, H., et al., What's the effect of the implementation of general practitioner cooperatives on caseload? Prospective intervention study on primary and secondary care. BMC Health Services Research, 2010. 10: p. 222.

3. Streffer, M., et al., Rapport Huisartsenwachtpost Antwerpen Noord. 2013. http://www.ua.ac.be/main.aspx?c=hilde.philips&n=14&ct=onderze

4. Philips, H., et al., Experience: the most critical factor in choosing after-hours medical care. Qual Saf Health Care, 2010. 19(6): p. e3.

5. Philips, H., et al., Use of out-of-hours services: the patient's point of view on co-payment a mixed methods approach. Acta Clinica Belgica, 2013. 68(1): p. 1-8.

6. Philips, H., et al., Out of hours care: a profile analysis of patients attending the emergency department and the general practitioner on call. BMC Family Practice, 2010. 11: p. 88.

Conflict of Interest:

None declared