Evaluation of winter pressures on general practice in Manchester: a cross-sectional analysis of nine GP practices

Summary

Strong evidence for increased workload during the winter months was identified in both general practice and secondary care, with the burden of winter attendance appearing to lean more heavily on general practice.

In the study, secondary care experienced a 4% increase in A&E attendances and no difference in the volume of hospital admissions in winter.

In general practice the study has demonstrated a much greater seasonal variation with a 61% increase in both the number of problems seen and the number of GP face-to-face consultations. There was also an 81% increase in telephone consultations and more than double the number of home visits in winter.

The biggest seasonal variation in diagnosis were respiratory problems, accounting for 4% of the overall A&E attendance in summer and 10% in winter; the risk of attending A&E with a respiratory problem more than doubled in winter.

Wide variations in A&E attendance, GP referral rate, and hospital admission between the practices were identified. It was not the aim of this study to explain variations between individual practices; there may be many reasons for this including workforce ratios, population age, deprivation, and proximity to A&E. Further research into comparing performances between practices is urgently needed; identifying practices with low rates of A&E attendance, after adjusting for confounding factors, might enable their approaches to be replicated.

In the entire 6 months studied, GP referral accounted for only 7% of all A&E attendance. Self-referral accounted for 66% and increased by 16% in winter. In total, 18% of patients were discharged with no diagnosis or nothing abnormal detected, and 65% did not require follow-up. It, therefore, seems logical to expand the role of general practice to manage the bulk of these patients in the community.

Strengths and limitations

This study benefits from a large dataset, encompassing a population of >75 000 patients. Although selected on availability rather than at random, the practices were from six out of 12 neighbourhoods of Manchester, reflecting a representative sample of practice types and patient populations. The data sources are overall of high quality, routinely used for regional analysis.

One limitation is that significant variation is likely to exist between practitioners in how they record problems. Similarly, in some practices, a consultation may be recorded when patient contact does not occur; for example, when making administrative notes. Seasonal comparisons should not be affected by this but comparisons between practices may be more problematic.

Comparison with existing literature

This study benefits from direct comparison of general practice data to secondary care data for the same practice population. This has allowed the working relationship between general practice and secondary care to be scrutinised and activity to be directly compared, demonstrating for the first time the clear seasonal difference in workload between general practice and secondary care. It is perhaps unsurprising that GP’s see more patients in winter. Previous research has shown that patients with flu-like illnesses preferentially attend their GP; attendance rates for these illnesses are approximately 10 times higher in daytime primary care than A&E or out-of-hours (OOH) services.¹

The small increase in A&E attendance and no change in hospital admissions in winter indicates that the well-documented winter increases in A&E waiting times, hospital length of stay, and demand for winter pressures wards cannot be explained simply by an increase in attendance. Other contributing factors include sicker patients requiring longer admissions and a lack of social care beds,³ causing long delays in discharge from hospital, with a resultant impact on patient flow in A&E. Once bed occupancy reaches 92%, hospitals become increasingly unlikely to admit patients within the 4-hour A&E target.¹

The present study findings corroborate what has many times been demonstrated, that respiratory illness increases in the winter. Incidence of respiratory viruses increase in cold weather³ putting pressure on NHS services and more importantly, causing severe health consequences. For every 1^°C drop in temperature below the optimum threshold for different age groups, the risk of death from a respiratory condition increases by approximately 10%.¹ It follows that any winter pressures strategy should include plans to tackle respiratory illness. Evidence-based measures include optimising long-term condition management, achieving higher levels of influenza and pneumococcal vaccine uptake, smoking cessation, and ensuring patients have warm housing.^4,5

The main burden of attendance in A&E seems to be from self-referrals and the majority of attendences did not require follow-up, suggesting that many attendances might be better managed by general practice. This could have a beneficial effect on A&E attendance. A 2016 study examining extended access to general practice in Manchester provided evidence that additional primary care appointments, outside of working hours, may reduce attendance at emergency departments.⁶

A crude cost analysis was calculated using the weighted average cost of an A&E attendance in 2019–2020, based on service level activity monitoring files for Manchester University Foundation Trust, and average GP consultation cost as reported by NHS England.⁷ Scaled up to the combined practice population of Manchester, if 50% of the self-referrals to A&E in the winter period of the study were instead managed in general practice, taking into account the 7% GP referral rate to A&E, there would be a cost saving of just over £2.3 million.

There would need to be significant initial investment to support the expansion of general practice to accommodate these extra patients. This is likely to place workforce pressures on an already strained system. However, any barriers to expanding the role of general practice are highly likely to be worth overcoming. In addition to cost saving, the benefit of managing these patients in general practice is much more far reaching and important. There is evidence that continuity of care, encouraged in general practice and not possible in A&E, is associated with reduced mortality.⁸ A study of patients with type 2 diabetes demonstrated that higher levels of empathy from practitioners reduced all-cause mortality.⁹ In addition, GP empathy has been shown to have psychosocial benefits.¹⁰ Therefore, quite independent of the cost, there are important advantages to any health system for patients to be managed in general practice rather than A&E.

Implications for practice

The NHS Long Term Plan advises primary care networks (PCNs) to take a proactive approach to managing population health. To incentivise this a ‘shared savings’ scheme is proposed, under which networks will benefit financially from reductions in A&E attendances and hospital admissions.¹¹ It is suggested that any winter pressures strategy by a PCN or other organisational body, should target both respiratory illness and patients who self-refer to A&E.

Targeting respiratory illness in the community may reduce A&E attendance and prevent or better manage severe respiratory infections and exacerbations, which would normally result in long hospital admissions.

Targeting the large number of patients who self-refer would increase A&E’s capacity to overcome other factors that prolong waiting times in winter. Existing research can be used to inform initiatives to reduce A&E self-referrals. A systematic review reported that patients’ perceptions of access to and confidence in general practice were key factors in low-urgency A&E attendances.¹² One study found migrant populations often had no primary care provider and sought A&E care for non-urgent health problems owing to difficulties accessing primary health care.¹³

Targeting self-referrals by increasing provision in primary care would seem sensible. However, as general practice is already managing the vast majority of the NHS’s winter workload, significant new provision is needed.

There could be a combination of approaches. Commissioners could balance winter funding in accordance with the distribution of the workload demonstrated in this study, redirecting more towards general practice. In addition, novel methods enabling general practice to manage more patients with the same resources need to be identified and tested. These are likely to include triage systems and the wider use of allied healthcare practitioners. Successfully improving access to GP services is probably not merely a case of increasing the number of consultations offered to the public, but rather making general practice more accessible. This means making it easy to access timely healthcare advice and assistance for patients from all backgrounds, 24 hours a day, then, only if appropriate, face-to-face assessment.