Out-of-hours primary care and demand for emergency medical services

Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 6 OUT-OF-HOURS PRIMARY CARE AND DEMAND FOR EMERGENCY MEDICAL SERVICES By: Anna Sagan and Erica Richardson Summary: Major trauma and medical emergencies often constitute only a proportion of the workload of emergency medical services, as they also have to deal with many patients suffering from conditions better treated within primary care. This has renewed focus on urgent care as a means of reducing demand for emergency care services. While demand for emergency care is closely related to changes in population health trends and improvements in medical technologies, improving access to primary care through the provision of urgent care services has the potential to improve quality of care and financial efficiency. Keywords: Emergency Medical Services, Primary Care, Access, Urgent Care Anna Sagan and Erica Richardson are Researchers at the European Observatory on Health Systems and Policies, London Hub, at the London School of Economics & Political Science and the London School of Hygiene and Tropical Medicine, United Kingdom respectively. Email: A.Sagan@lse.ac.uk Introduction Emergency departments (EDs) provide highly visible and critical services that often form the frontline of health care systems for patients facing difficult circumstances. 1 The 2007 World Health Assembly Resolution 60.22 “Health Systems: Emergency Care Systems” highlighted the role that strengthened emergency care systems can play in reducing the burden of disease from acute illness and injury. Further, it called on governments and WHO to take specific and concrete actions. However, in many OECD countries, the number of visits to EDs has increased since 2007 (see Figure 1), which poses questions about the efficient use of ED resources, especially as a significant proportion of patients attend EDs for non-urgent conditions that could be managed in primary and community care settings. According to an OECD review, a lack of access to primary care and a shortage of out-of-hours (OOHs) services are the main supply-side factors influencing demand for emergency care. 1 On the demand side, ED visits are influenced by individual preferences (EDs are convenient to access, especially OOHs), health needs (population ageing and increased prevalence of chronic conditions) and socio-economic factors (deprivation and lack of social support are associated with increased ED use). Bottlenecks in other parts of the health system can also affect the demand for emergency care. Shortages of specialist beds can contribute to overcrowding in EDs as patients cannot be moved on from emergency care services to the appropriate department for further specialist care (e.g. in France and the UK) and staff shortages in other parts of the system can put greater pressure on emergency care services as they can reduce accessibility. Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 7 Blurred line between urgent care within primary care and emergency care There is often not a strict delineation between urgent care to be provided through primary care and emergency care. In many EDs, major trauma comprises only a part of the overall workload, with many patients suffering from minor ailments that could be better treated within primary care. 2 In many of those cases primary care provision is superior also in terms of lower costs, better continuity and improved coordination. 3 However, patients may not realise this and primary care services may not be accessible when they need them, for example at evenings or weekends, and emergency services by their nature are often the most accessible points in the system. ‘‘ major trauma comprises only a part of EDs' workload Primary care providers, such as General Practitioners (GPs)/family doctors, are generally required to have space in their schedule to provide urgent care to patients in normal working hours and to make provisions for primary care services to be available OOHs. The most common models in OOHs care seem to be non-practice-based provision (see Table 1). Where there are weaknesses in the provision of urgent and OOHs primary care, the patient traffic to emergency medical care will be greater – either because patients will access these services instead, or because they will delay treatment and will need to access them as a medical emergency. The extent to which EDs contribute to OOHs care varies across Europe, but it is notable that in countries such as Cyprus, Estonia, Latvia and Lithuania EDs have the sole responsibility for OOHs primary care service delivery (see Table 1). A by-product of overuse is overcrowding of EDs and long waiting times. This is a particular problem where EDs are part of the social safety net 4 as these services are often free of charge, whereas patients have to pay out-of-pocket to access care elsewhere in the system (e.g. as in the USA, Canada, Cyprus and Bulgaria). In some countries, certain population groups, such as undocumented migrants, only have access to emergency care and not to other forms of care. 5 It has been argued that gate-keeping may lead to inappropriate use of EDs at acute hospitals with patients using emergency care directly in order to bypass referrals to specialists. 5 However, while increasing numbers of non-emergency visits at EDs have been observed in several gate- keeping countries, such as England, Portugal and Spain, the same trend is also evident in Germany and Switzerland, where gate-keeping remains weak. 6 Moreover, in Norway, where patients can access EDs only with a referral from primary care or by ambulance, inappropriate use of EDs has not been eliminated. According to one analysis of emergency referrals from a single OOHs primary care centre, around a fifth of all referrals could have been avoided. 7 The Netherlands is one country where gate-keeping by GPs plays a major role in low ED attendances, but it is supported by a number of other measures. Many Dutch hospitals collaborate with GP posts (centrally located offices with a GP present after hours) to provide emergency care in lieu of EDs, reducing the number of unnecessary cases. Collaboration between these GP posts and EDs is encouraged and the majority of hospitals have a GP post. In addition, financial incentives are being developed to keep patients out of EDs. For example, as part of the health insurance system, a compulsory annual deductible of €375 for accessing health services includes ED care but excludes GP services, thus incentivising the use of a GP. Moreover, a recent proposal has suggested that insurers do not need to cover patients going to EDs without a referral from a GP, if it turned out that emergency care was not required. In the Netherlands, co-payments for patients using emergency services unnecessarily have been deemed unlawful but such co-payments already exist in Belgium and Italy; however, there is no conclusive evidence of any change in inappropriate use of ED after their introduction. 8 The way forward? A 2009 survey among key informants from 25 countries found that most of the countries had plans to reform OOHs care, mainly by centralising the provision of OOHs care: moving toward larger scale organisations, integrating primary care Figure 1: Number of ED visits per 100 people in European OECD countries, 2007 and 2012 Source: Based on data from Table A3 in Ref. 3 Notes: 2007 and/or 2012 data was not available for all countries included in the figure. Due to different definitions and identification of emergency care services, caution is needed when comparing countries. 0 10 20 30 40 50 60 70 80 -5% 0 5% 10% 15% 20% 25% 30% 35% 2012 Change 2007–2012 (%)2007 Po la nd Ne th er la nd s Ge rm an y Cz ec h Re pu bl ic Sw itz er la nd Be lg iu m Fr an ce Ire la nd UK – E ng la nd Es to ni a Gr ee ce Sp ai n Po rtu ga l Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 8 with EDs and introducing one national telephone number for OOHs calls and triage for emergency calls. The major reasons given for these changes were work dissatisfaction among family doctors, a shortage of family doctors and lack of motivated family doctors to provide OOHs care. Other reasons were the overcrowding of EDs by primary care patients (self- referrals), reducing costs and improving safety, quality and continuity of care. 10 Primary care telephone services have been developed in some countries in order to reduce the burden on emergency care and to improve the accessibility of timely primary care services (e.g. France, the UK, and Hungary). In Spain, Hungary and Table 1: Ease of access to OOHs primary care in selected EU countries Country Provision of OOHs primary care Ease of access : low Belgium Practice-based services (mainly) and hospital EDs. There are also primary care cooperatives providing OOHs care and rather fewer OOHs primary care centres Bulgaria Urban areas: GPs working in single practices or organised in a group of practices or outsourcing. Rural areas and small towns: hospital EDs Cyprus Telephone consultation with private GPs and private and public hospital emergency rooms France Voluntary GPs in practice-based services, primary care cooperatives known as SOS médecins and hospital emergency units Greece GPs and nurses in their centres Ireland GP cooperatives/OOHs services Latvia Hospital EDs, OOHs primary care centres (occasionally) Luxembourg Hospital EDs and (since December 2008) GP walk-in centres Malta Public primary health care centres Ease of access: medium Austria Urban areas: primary care cooperatives (sponsored by City Councils) and/or hospital departments. Rural areas: GPs within one practice or organised in a group of practices on OOH schedules Estonia Medical emergency service or ambulance service Finland Increasingly organised in conjunction with hospitals; often, a health centre GP provides services from 4 p.m. to 10 p.m. in their own health centre. Some of these services are also outsourced (and provided by specially trained staff) Germany Outpatient emergency services, hospital ED Italy OOHs physicians (special type of physician) usually working in different premises (such as independent ambulatories of local health authorities) Romania Family physicians have to provide medical assistance, including in emergency situations, for all insured persons on their own list Slovakia Walk-in centres and (limited) special deputising services*or hospital EDs Sweden Hospital based acute wards; a few primary health providers have organised OOHs care Ease of access: high Czech Republic OOHs services are organised by local authorities and GPs are obliged to provide these services (it may be on a rotation basis or by finding substitute GPs) Denmark Primary care cooperatives (includes telephone triage and advice, an office for face-to-face contact and house calls) Hungary Usually outsourced to deputising services* Lithuania Hospital EDs Netherlands General practice (usually within large-scale primary care cooperatives) Poland Can be contracted (by the National Health Fund) directly with specialised services or with primary care physicians (the latter can use a rota with the neighbouring practices or subcontract with the deputising service*) Portugal Practice based GPs within one practice or organised in a group of practices available all night when there is no hospital nearby or only in the evening if there is a hospital nearby Spain Primary health centres (open 24 hours a day, 365 days a year in rural areas. In urban areas there is always a primary health care centre on duty within a 30-minute radius; also call-centre triage units, which coordinate and activate the most appropriate health care service for each consultation United Kingdom GPs, walk-in centres, minor injuries units, urgent care centres, NHS 111 or equivalent, local pharmacists, local mental health teams, Accident and Emergency (A&E) departments at general hospitals, and ambulance services Source: Based on References 9 , 3 and 1 . Notes: Hospital-based provision of OOHs primary care is marked in bold. * This is a form of outsourcing whereby centres/companies employ doctors to take over provision of after-hours care. Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 9 France such advice lines are essentially integrated with dispatcher services, as clinical teams are on hand to advise patients and make triage decisions to direct them to OOHs care, emergency care or dispatch an ambulance. In England, NHS Direct (with calls answered by a non-clinical call handler and assessed by a nurse either immediately or with a later call back), established in 2000 was not found to reduce demand for either hospital or primary care; it did, however, improve patient satisfaction. 2 NHS Direct was fully replaced in 2014 by NHS 111, a more easily recognisable phone number, where calls are answered and assessed immediately by a trained non-clinical call handler (preventing waiting or call backs) and some calls are then assessed by a nurse. In addition, the assessment system is integrated with some services, enabling direct referral and appointments. Despite these improvements, NHS 111 did not deliver the expected system benefits of reducing calls to the 999 ambulance service or shifting patients to urgent rather than emergency care. Studies also found that this type of service had the potential to increase overall demand for urgent care without reducing the demand for emergency care (See the article by Turner et al, in this issue). Coordination of care, in particular for chronic conditions and emergency care, remains problematic in most countries. Particularly in northern Europe, there is a trend to reorganise the OOHs primary care system to better support and cooperate with EDs (i.e. Denmark, the Netherlands, the UK, and Germany). In Denmark, some past attempts at strengthening collaboration between primary health care and hospitals have not always been easy to achieve in practice. 11 The most recent solution being implemented in the Capital Region (Hovestsaden) involves the co-location of urgent and emergency care services, as well as the integration of OOHs primary care with EDs into a single entry point, reachable by dialling a designated telephone number, co- ordination and delivery of urgent and emergency care, and nurses (rather than doctors) becoming the first point of contact for patients; they decide whether the patient will be re-directed to a doctor on the phone, be attended by a doctor, go to an ED or stay at home. The new scheme has been heavily debated and has raised substantial criticism from GPs and the Danish Medical Association, prompting an evaluation in August 2014 that has yet to be concluded. 12 There is also some evidence that closer cooperation of GPs with local nursing homes in Norway (and the proximity of nursing homes to the GP practice) may contribute to reduced referrals to EDs. 13 A good example of successful cooperation with other health care providers is the Capio St Göran (CSt) hospital in Stockholm. CSt has developed a good dialogue and cooperative relationship with several geriatric hospitals, whereby patients requiring direct admission from EDs are clearly defined and more elderly patients are sent directly to external geriatric care providers. There is also an active dialogue about the opposite flow, where geriatric hospitals can send patients with greater care needs directly to the relevant department at CSt. CSt now has the largest share of direct admissions to geriatric hospitals of all acute hospitals in Stockholm. 14 Conclusions A shift towards developing urgent care and reorganising OOHs primary care has been taking place in many European countries in order to relieve pressure on high cost emergency care services. While this shift cannot address the demand- side factors which are so closely related to changes in population health trends, such as population ageing and increased prevalence of chronic conditions and improvements in medical technologies, it does have the potential to improve efficiency and quality of care. References 1 Berchet C. Emergency Care Services: Trends, Drivers and Interventions to Manage the Demand. OECD Health Working Papers, No. 83. Paris: OECD Publishing, 2015. 2 McKee M, Healy J (eds). Hospitals in a changing Europe. European Observatory on Health Systems and Policies. Buckingham and Philadelphia: Open University Press, 2002. Available at: http://www. euro.who.int/__data/assets/pdf_file/0004/98401/ E74486.pdf?ua=1 3 Kringos DS, Boerma WGW, Hutchinson A, Saltman RB (eds). Building primary care in a changing Europe. Copenhagen: World Health Organization, 2015 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies). 4 WHO. Emergency medical systems in the European Union. Report of an assessment project co-ordinated by the World Health Organization, 2008. 5 Paris V, Devaux M and Wei L. Health Systems Institutional Characteristics: A Survey of 29 OECD Countries. OECD Health Working Papers, No. 50. Paris: OECD Publishing, 2010. 6 van Ginneken E, Blümel M, Cylus J, et al. Trends and patterns in EU28 health systems and Iceland, Norway and Switzerland. Copenhagen: European Observatory on Health Systems and Policies, 2016 forthcoming. 7 Lillebo B, Dyrstad B, Grimsmo A. Avoidable emergency admissions? Emergency Medicine Journal 2012; doi:10.1136/emermed-2012-201630 8 KCE. Evaluatie van forfaitaire persoonlijk bijdrage op het gebruik van spoedgevallendienst. [Evaluation of the effect of the fixed personal contribution on the use of emergency service]. KCE reports vol.19A, 2005. Federaal Kenniscentrum voor de Gezondheidszorg [Belgian Health Care Knowledge Centre]. 9 Kringos DS, Boerma WGW, Hutchinson A, Saltman RB (eds). Building primary care in a changing Europe. Case studies. Copenhagen: World Health Organization, 2015 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies). 10 Huibers L, Giesen P, Wensing P, Grol R. Out- of-hours care in western countries: assessment of different organizational models. BMC Health Services Research 2009;9:105. Available at: http://www. biomedcentral.com/1472-6963/9/10 11 Magnussen J, Vrangbaek K, Saltman RB. Nordic health care systems. Recent reforms and current policy challenges. Maidenhead, England: Open University Press, 2009. Available at: http://www.euro.who.int/__data/assets/pdf_ file/0011/98417/E93429.pdf?ua=1 12 Nielsen AJ. New organization of the emergency medical services in the Capital Region. Health Systems and Policy Monitor. Published on 17 December 2013. Available at: http://www.hspm. org/countries/denmark 13 Lappegard Ø, Hjortdahl P. The choice of alternatives to acute hospitalization: a descriptive study from Hallingdal, Norway. BMC Family Practice 2013;14:87. 14 UK Government. International comparisons of selected service lines in seven health systems. ANNEX 16 – Case studies: Emergency pathway at Capio St Goran Hospital. Evidence Report October 27th, 2014. Available at: https://www.gov.uk/government/ uploads/system/uploads/attachment_data/ file/382842/Annex_16_Capio_St_Goran_ Emergency_pathway.pdf