General Practice Appointments Research Articles

Association between emergency department attendances, sociodemographic factors and long-term health conditions in the population of Norfolk and Waveney, England: Cross sectional study.

Demand for urgent and emergency health care in England has grown over the last decade, for reasons that are not clear. Changes in population demographics may be a cause. This study investigated associations between individuals' characteristics (including socioeconomic deprivation and long term health conditions (LTC)) and the frequency of emergency department (ED) attendances, in the Norfolk and Waveney subregion of the East of England. The study population was people who were registered with 91 of 106 Norfolk and Waveney general practices during one year from 1 April 2022 to 31 March 2023. Linked primary and secondary care and geographical data included each individual's sociodemographic characteristics, and number of ED attendances during the same year and, for some individuals, LTCs and number of general practice (GP) appointments. Associations between these factors and ED attendances were estimated using Poisson regression models. 1,027,422 individuals were included of whom 57.4% had GP data on the presence or absence of LTC, and 43.1% had both LTC and general practitioner appointment data. In the total population ED attendances were more frequent in individuals aged under five years, (adjusted Incidence Rate Ratio (IRR) 1.25, 95% confidence interval 1.23 to 1.28) compared to 15-35 years); living in more socioeconomically deprived areas (IRR 0.61 (0.60 to 0.63)) for least deprived compared to most deprived,and living closer to the nearest ED. Among individuals with LTC data, each additional LTC was also associated with increased ED attendances (IRR 1.16 (1.15 to 1.16)). Among individuals with LTC and GP appointment data, each additional GP appointment was also associated with increased ED attendances (IRR 1.03 (1.026 to 1.027)). In the Norfolk and Waveney population, ED attendance rates were higher for young children and individuals living in more deprived areas and closer to EDs. In individuals with LTC and GP appointment data, both factors were also associated with higher ED attendance.

Supporting people with learning disabilities to attend general practice appointments

Supporting people with learning disabilities to attend general practice appointments

Characteristics and general practice resource use of people with comorbid cancer and dementia in England: a retrospective cross-sectional study

BackgroundCancer and dementia are common in older people and management of the conditions as comorbidities can be challenging, yet little is known about the size or characteristics of this group. We aimed to estimate the prevalence, characteristics and general practice resource usage of people living with both conditions in England.MethodsAnonymised electronic healthcare records from 391 National Health Service general practices across England using the TPP SystmOne general practice system were obtained from ResearchOne. Data included demographic and clinical characteristics, and general practice healthcare useage (appointments, prescriptions, referrals and secondary care contacts) for people aged 50 and over with a cancer and/or dementia diagnosis consistent with the Quality and Outcomes Framework between 2005 and 2016. Multi-level negative binomial regression was used to analyse the association between having cancer and/or dementia and the number of general practice appointments.ResultsData from 162,371 people with cancer and/or dementia were analysed; 3616 (2.2%) people were identified as having comorbid cancer and dementia. Of people with cancer, 3.1% also had dementia, rising to 7.5% (1 in 13 people) in those aged 75 and over. Fewer people with both conditions were female (50.7%) compared to those with dementia alone (65.6%) and those with comorbid cancer and dementia were older than those with cancer alone [mean ages 83 (sd = 7), 69 (sd = 12) respectively]. Those with both conditions were less likely to have lung cancer than those with cancer alone (7.5% vs. 10.3%) but more likely to have prostate cancer (20.9% vs. 15.8%). Additional comorbidities were more prevalent for those with both conditions than those with cancer or dementia alone (68.4% vs. 50.2% vs. 54.0%). In the year following the first record of either condition, people with cancer and dementia had 9% more general practice appointments (IRR:1.09, 95% CI:1.01–1.17) than those with cancer alone and 37% more appointments than those with dementia alone (IRR: 1.37, 95% CI: 1.28–1.47).ConclusionsA significant number of people are living with comorbid cancer and dementia in England. This group have additional comorbidity and higher general practice usage than those with cancer/dementia alone. The needs of this group should be considered in future general practice care planning and research.

Use of a pharmacy-based GP video consultation service: a mixed methods study.

Little is known about private general practice appointment services offered via video. This study aimed to explore which patients are using a video pharmacy-based general practitioner (GP) appointment service, including patterns of use, reasons for using the service, and satisfaction with the service. Descriptive statistics and parametric and nonparametric tests were used to conduct a retrospective cross-sectional analysis of routinely collected data on consultations, and postconsultation questionnaires. Interviews were conducted with patients and GPs. A total of 7,928 consultations were included in the analysis. More than half of appointments were booked for the same day, with lunchtime appointments being popular. The most common health condition was respiratory conditions, and 9% of consultations were used by patients using the service more than once. At least one prescription was issued in over half of all consultations. Overall, satisfactions of consultations were high. The characteristics of those patients using the video consultation service match data on who uses online services in general practice. This study shows that some patients are willing to pay to use this private service because they feel it is more convenient, NHS services do not have capacity to see them at the time they need, or they do not have access to regular GP services.

Meeting the challenges of new roles for general practice nursing

Even before the pandemic, the pressures on general practice were well known and innovative ways were needed to meet the growing demand for appointments. England’s 2019 Additional Roles Reimbursement Scheme aimed to recruit 26,000 staff in general practice by 2023-24 to increase the number of annual general practice appointments by 50 million.

A general practice intervention for people at risk of poor health outcomes: the Flinders QUEST cluster randomised controlled trial and economic evaluation.

ObjectiveTo determine whether a multicomponent general practice intervention cost‐effectively improves health outcomes and reduces health service use for patients at high risk of poor health outcomes.Design, settingClustered randomised controlled trial in general practices in metropolitan Adelaide.ParticipantsThree age‐based groups of patients identified by their general practitioners as being at high risk of poor health outcomes: children and young people (under 18 years), adults (18–64 years) with two or more chronic diseases, and older people (65 years or more).InterventionEnrolment of patients with a preferred GP, longer general practice appointments, and general practice follow‐up within seven days of emergency department and hospital care episodes. Intervention practices received payment of $1000 per enrolled participant.Main outcome measuresPrimary outcome: change in self‐rated health between baseline and 12‐month follow‐up for control (usual care) and intervention groups. Secondary outcomes: numbers of emergency department presentations and hospital admissions, Medicare specialist claims and Pharmaceutical Benefits Scheme (PBS) items supplied, Health Literacy Questionnaire scores, and cost‐effectiveness of the intervention (based on the number of quality‐adjusted life‐years [QALYs] gained over 12 months, derived from EQ‐5D‐5L utility scores for the two adult groups).ResultsTwenty practices with a total of 92 GPs were recruited, and 1044 eligible patients participated. The intervention did not improve self‐rated health (coefficient, –0.29; 95% CI, –2.32 to 1.73), nor did it have significant effects on the numbers of emergency department presentations (incidence rate ratio [IRR], 0.90; 95% CI, 0.69–1.17), hospital admissions (IRR, 0.90; 95% CI, 0.66–1.22), Medicare specialist claims (IRR, 1.00; 95% CI, 0.91–1.09), or PBS items supplied (IRR, 0.99; 95% CI, 0.96–1.03), nor on Health Literacy Questionnaire scores. The intervention was effective in terms of QALYs gained (v usual care: difference, 0.032 QALYs; 95% CI, 0.001–0.063), but the incremental cost‐effectiveness ratio was $69 585 (95% CI, $22 968–$116 201) per QALY gained, beyond the willingness‐to‐pay threshold.ConclusionsOur multicomponent intervention did not improve self‐rated health, health service use, or health literacy. It achieved greater improvement in quality of life than usual care, but not cost‐effectively.Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN12617001589370 (prospective).

Lessons from experiences of accessing healthcare during the pandemic for remobilizing rheumatology services: a national mixed methods study.

ObjectivesTo understand the impact of the coronavirus disease 2019 pandemic on access to healthcare services for patients with inflammatory and non-inflammatory musculoskeletal (MSK) conditions.MethodsThree established cohorts that included individuals with axial SpA, psoriatic arthritis and MSK pain completed a questionnaire between July and December 2020. In parallel, a subset of individuals participated in semistructured interviews.ResultsA total of 1054 people (45% female, median age 59 years) were included in the quantitative analyses. Qualitative data included 447 free-text questionnaire responses and 23 interviews. A total of 57% of respondents had tried to access care since the start of the UK national lockdown. More than a quarter reported being unable to book any type of healthcare appointment. General practice appointments were less likely to be delayed or cancelled compared with hospital appointments. Younger age, unemployment/health-related retirement, DMARD therapy, anxiety or depression and being extremely clinically vulnerable were associated with a greater likelihood of attempting to access healthcare. People not in work, those reporting anxiety or depression and poorer quality of life were less likely to be satisfied with remotely delivered healthcare. Participants valued clear, timely and transparent care pathways across primary care and specialist services. While remote consultations were convenient for some, in-person appointments enabled physical assessment and facilitated the development and maintenance of clinical relationships with care providers.ConclusionsWe identified patient factors that predict access to and satisfaction with care and aspects of care that patients value. This is important to inform remobilisation of rheumatology services to better meet the needs of patients.

Public perception of NHS general practice during the first six months of the COVID-19 pandemic in England

Background: In March 2020, the delivery of NHS general practice consultations was rapidly modified to mitigate the spread of COVID-19. Remote triage and consultations became the default, with adapted models for face-to-face contact if clinically required. This study aimed to gain insight into public perception of these adaptations. Methods: Two online surveys were developed, and conducted in August and September 2020. Survey A, open to adults (>18 years) receiving the link to it, considered respondents’ perspectives on healthcare contacts since March 2020, and their understanding of the adapted delivery. Survey B, open to survey A respondents only, then considered how healthcare communication had been received and individual preferences for this. Survey participation was voluntary. Results: The perceptions of 150 members of the public were obtained. 105 had considered contacting general practice, although half avoided this or delayed doing so for longer than usual. While some patients did so ‘to help the NHS’, others experienced reduced access for reasons including concerns about telephone consultations and about COVID-19 safety. Some however reported benefitting from remote consultation availability and regular texts/emails from their practice. 68% (102/150) of respondents were unaware that patients with COVID-19 were seen separately from other patients during general practice appointments. 27% in survey B who had avoided or delayed contact said they would have felt more comfortable contacting general practice had they known this. Conclusions: Experience and use of the adapted general practice models varied. Some patients felt their access to healthcare was reduced, often due to technological requirements. For some who found attending face-to-face appointments difficult however, remote contact was advantageous. Most of those surveyed were unaware of the COVID-19 control measures in place during face-to-face general practice consultations. Assessment of adapted delivery model accessibility and clearer public messaging about the changes may help reduce inequalities.

Impact of COVID-19 containment measures on patients with rheumatic and musculoskeletal disease in the UK and Europe: the REUMAVID study (phase1).

ObjectivesThe aim was to compare the impact of the first wave of the coronavirus disease 2019 (COVID-19) pandemic and lockdown measures on patients with rheumatic and musculoskeletal diseases (RMDs) in the UK and other European countries (OEC).MethodsREUMAVID was an online cross-sectional survey of seven European countries. The data collected included the following: demographics, lifestyle, employment, access to health-care services, disease-specific characteristics, the World Health Organization five well-being index (WHO-5), hospital anxiety and depression scale (HADS), visual analogue scale (VAS) disease activity, and the perceived acceptable symptom scale.ResultsOne thousand eight hundred responses were received between April and July 2020 [UK, n = 558 (31.0%); OEC, n = 1242 (69.0%)]. UK patients were more likely to be older [mean (S.d.): UK 58.5 (13.4) years; OEC 50.0 (12.2) years], university educated [UK n = 302 (54.1%); OEC n = 572 (46.1%), quit smoking [UK n = 92 (59.4%); OEC n = 65 (16.2%)] and continue exercise [UK, n = 216 (49.2%); OEC, n = 228 (33.1%)], although, conversely, alcohol consumption increased [UK n = 99 (36.3%); OEC n = 98 (12.1%)]. UK patients felt informed about COVID-19 (UK 72.7%, OEC 57.4%) and kept their planned rheumatology [UK n = 87 (51.2%); OEC n = 213 (38.6%)] and/or general practice appointments [UK n = 87 (76.3%); OEC n = 310 (53.9%)]. Almost half the patients with RMDs reported a decline in health and well-being, although this was less common in UK patients [UK n = 214 (38.4%), OEC n = 618 (50.2%)], who reported better perceived acceptable symptom scale, VAS pain and HADS scores, but worse WHO-5 scores.ConclusionsUK RMD patients performed better in the physical and mental health domains tested, possibly owing to a less restrictive lockdown and better health-care access. These findings have implications for health-care services globally in planning patient care after the COVID-19 pandemic.

A pilot study to identify elderly patients with cognitive impairment for clinical pharmacist polypharmacy review in General Practice

BackgroundPolypharmacy in elderly patients is common with potential for harm. Cognitive impairment is postulated as the biggest contributor to poor medication management with increased risk of hospital admission. There is limited information about approaches to identify high risk patients for polypharmacy review. ObjectivePilot study to determine if a new patient prioritisation tool would identify appropriate patients for pharmacist polypharmacy review. MethodPrioritisation tool developed to rank community-dwelling elderly patients prescribed 10 or more medications with cognitive impairment for pharmacist polypharmacy review. Tool used General Practice (GP) appointments, Emergency Department attendances, repeat medications and cognitive impairment to create a score to prioritise review invitations. Reviews were completed by GP clinical pharmacists who recorded interventions and measured outcome assessments using the adapted RiO scoring tool. ResultsPolypharmacy reviews completed for 34 patients from three GP practices. Demographic results were 62% female (n = 21), median 78 years [IQR 72–80], median 3 comorbidities [IQR 2–4] with most reviews conducted face-to-face (n = 29; 85%). Pharmaceutical care interventions were hospital admission possible or likely prevention for the majority of patients (85%, n = 29) which contrasts with the historical level of 33% (n = 228) patients with traditional processes. ConclusionPilot study demonstrated that the new tool identified appropriate patients for review prioritisation as patients had complex pharmaceutical care needs.

Public perception of NHS general practice during the first six months of the COVID-19 pandemic in England.

Background:In March 2020, the delivery of NHS general practice consultations was rapidly modified to mitigate against the spread of COVID-19. Remote triage and consultations became the default, with adapted models for face-to-face contact if clinically required. This study aimed to gain insight into public perception of these adaptations. Methods:Two online surveys were developed, and conducted between August and September 2020. Survey A, open to anyone receiving the link to it, considered respondents' experiences of healthcare contacts since March 2020, and their understanding of the adapted delivery. Survey B, open to survey A respondents only, then considered how healthcare communication had been received and individual preferences for this. Survey participation was voluntary. Results:The views and experiences of 150 members of the public were obtained. 105 had considered contacting general practice, although half avoided this or delayed doing so for longer than usual. While some patients did so 'to help the NHS', others experienced reduced access for a variety of reasons including COVID-19 safety concerns. Some however reported benefitting from remote consultation availability and regular texts/emails from their practice. 68% (102/150) of respondents were unaware that patients with COVID-19 were seen separately from other patients during general practice appointments. 27% of those in survey B who had avoided or delayed contact said they would have felt more comfortable contacting general practice had they known about this. Conclusions: Experience and use of the adapted general practice models varied. Some patients felt their access to healthcare was reduced, often due to technological requirements. For some who found attending face-to-face appointments difficult however, remote contact was advantageous. Most patients surveyed were unaware of the COVID-19 control measures in place during face-to-face general practice consultations. Assessment of adapted delivery model accessibility and clearer public messaging about the changes may help reduce inequalities.

Reducing missed appointments in general practice: evaluation of a quality improvement programme in East London.

BackgroundMissed appointments are common in primary care, contributing to reduced clinical capacity. NHS England has estimated that there are 7.2 million missed general practice appointments annually, at a cost of £216 million. Reducing these numbers is important for an efficient primary care sector.AimTo evaluate the impact of a system-wide quality improvement (QI) programme on the rates of missed GP appointments, and to identify effective practice interventions.Design and settingPractices within a clinical commissioning group (CCG) in East London, with an ethnically diverse and socially deprived population.MethodStudy practices engaged in a generic QI programme, which included sharing data on appointment systems and Did Not Attend (DNA) rates. Fourteen out of 25 practices implemented DNA reduction projects, supported by practice-based coaching. Appointment data were collected from practice electronic health records. Evaluation included comparisons of DNA rates pre- and post-intervention using interrupted times series analysis.ResultsIn total, 25 out of 32 practices engaged with the programme. The mean DNA rate at baseline was 7% (range 2–12%); 2 years later the generic intervention DNA rates were 5.2%. This equates to a reduction of 4030 missed appointments. The most effective practice intervention was to reduce the forward booking time to 1 day. The practice that made this change reduced its mean DNA rate from 7.8% to 3.9%.ConclusionForward booking time in days is the best predictor of practice DNA rates. Sharing appointment data produced a significant reduction in missed appointments, and behaviour change interventions with patients had a modest additional impact; in contrast, introducing structural change to the appointment system effectively reduced DNA rates. To reduce non-attendance, it appears that the appointment system needs to change, not the patient.

Are the needs of people with multiple long-term conditions being met? Evidence from the 2018 General Practice Patient Survey

ObjectivesTo investigate individual, practice and area level variation in patient-reported unmet need among those with long-term conditions, in the context of general practice (GP) appointments and support from community-based services...

Longitudinal evaluation of a countywide alternative to the Quality and Outcomes Framework in UK General Practice aimed at improving Person Centred Coordinated Care

ObjectivesTo evaluate a county-wide deincentivisation of the Quality and Outcomes Framework (QOF) payment scheme for UK General Practice (GP).SettingIn 2014, National Health Service England signalled a move towards devolution of...

Is your waiting area patient friendly?

Patients attending a general practice appointment have many and varied needs, but are you catering for them? Dave Hancock looks at the range of requirements for your waiting room

Morbidity, mortality and missed appointments in healthcare: a national retrospective data linkage study

BackgroundRecently, studies have examined the underlying patient and practice factors for missed appointments, but less is known about the impact on patient health. People with one or more long-term conditions who fail to attend appointments may be at risk of premature death. This is the first study to examine the effect of missed primary healthcare appointments on all-cause mortality in those with long-term mental and physical health conditions.MethodsWe used a large, nationwide retrospective cohort (n = 824,374) extracted from routinely collected general practice data across Scotland over a 3-year period from September 2013 until September 2016. This data encompasses appointment history for approximately 15% of the Scottish population, and was linked to Scottish deaths records for patients who had died within a 16-month follow-up period. We generated appointment attendance history, number of long-term conditions and prescriptions data for patients. These factors were used in negative binomial and Cox’s proportional hazards modelling to examine the risk of missing appointments and all-cause mortality.ResultsPatients with a greater number of long-term conditions had an increased risk of missing general practice appointments despite controlling for number of appointments made, particularly among patients with mental health conditions. These patients were at significantly greater risk of all-cause mortality, and showed a dose-based response with increasing number of missed appointments. Patients with long-term mental health conditions who missed more than two appointments per year had a greater than 8-fold increase in risk of all-cause mortality compared with those who missed no appointments. These patients died prematurely, commonly from non-natural external factors such as suicide.ConclusionsMissed appointments represent a significant risk marker for all-cause mortality, particularly in patients with mental health conditions. For these patients, existing primary healthcare appointment systems are ineffective. Future interventions should be developed with a particular focus on increasing attendance by these patients.

Sixty seconds on . . . missed GP appointments.

NHS England has sparked a fresh debate on this well trodden matter by releasing new figures on “did not attend” (DNA) appointments. It claims that 15 million general practice appointments are being “wasted” each year because patients do not turn up and fail to warn surgeries that they will not be attending. With lengthy waiting times and practices …

The association between body mass index, primary healthcare use and morbidity in early childhood: findings from the Born In Bradford cohort study.

The objective of the article was to examine the association between body mass index (BMI), health and general practice (GP) healthcare use in early childhood. This study is a prospective cohort study. Multivariate Poisson and logistic regression models were used to explore the association between BMI and health outcomes using data from the Born In Bradford cohort study, linked to routine data capturing objective measures of BMI at age 5 years, alongside GP appointment rates, GP prescriptions and specific morbidities in the subsequent 3-year period. Compared with healthy weight, children who were obese at the age of 5 years had significantly higher rates of GP appointments (incident rate ratio 1.14, 95% confidence interval [CI]: 1.06-1.23), GP prescriptions (incident rate ratio 1.15, 95% CI: 1.04-1.27), asthma (odds ratio 1.46, 95% CI: 1.21-1.77), sleep apnoea (odds ratio 2.50, 95% CI: 1.36-4.58), infections (incident rate ratio 1.19, 95% CI: 1.08-1.30), antibiotic prescriptions (incident rate ratio 1.25, 95% CI: 1.10-1.42) and accidents (incident rate ratio 1.20, 95% CI: 1.01-1.42) in the subsequent 3 years. Underweight children were found to have higher rates of GP appointments (incident rate ratio 1.25, 95% CI: 1.04-1.52), but there were no differences between overweight and healthy weight children. Childhood obesity was found to be associated with increased primary healthcare use and a range of poorer health outcomes at the age of 8 years, underlining the importance of reducing childhood obesity in early childhood.

Telephone announcements encouraging common cold self-management reduce demand for general practice appointments

BackgroundPatients consulting with the common cold contribute to seasonal demand for general practice appointments. Seeing a community pharmacist or using self-management may have been more appropriate options. The study aimed...

'The Doctor doesn't need to see you now': reduction in general practice appointments following group pain management.

Patients living with chronic, non-malignant, musculoskeletal pain are frequent visitors to general practice (GP) services, placing a large burden on resources. Pain management programmes (PMPs) are recommended for chronic pain patients and aim to teach self-management techniques. While there is evidence for their clinical effectiveness, few studies have explored whether there is a reduction in primary care healthcare use after attending a PMP. This study sought to address this by gathering data on pain-related primary care appointments before and after attending a PMP. Medical records of 50 patients attending a group outpatient PMP were obtained to determine whether the number of pain-related GP appointments differed 1 year after attending the programme compared with the year beforehand. Robust data were obtained from GP appointment systems and a retrospective observational design was utilised. The results indicated a 43.9% decrease in the number of GP appointments in the year following a PMP, a change that was statistically significant. The findings of the study show that there are fewer pain-related appointments in primary care in the year following a group outpatient PMP compared with the preceding year. It is possible that the self-management techniques taught on the programme lead to a reduction in patient's need to consult their GP as frequently about their pain. However, limitations in the current research mean that the reduction in appointments cannot be definitively attributed to PMP attendance and suggestions for future research are discussed.