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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

One positive finding from this review of a broad range of observational studies was that being able to see the same doctor in primary care was associated with fewer emergency department visits and emergency hospital admissions.

Other factors associated with less unscheduled secondary care were younger age, higher socioeconomic status, not having a chronic disease or multiple health conditions, shorter distance to primary care compared with secondary care, and easier access to primary care.

Because studies were from a number of countries with differing health systems, some of the findings are less directly relevant to the UK.

Why was this study needed?

Unscheduled use of secondary care rose 8.5% between 2010 and 2011 in the UK. Some think people accessing secondary care in an unscheduled way could be seen more cost-effectively in primary care, saving up to £238 million per year, according to the Kings Fund. There is also wide variation in unscheduled use of secondary care between different general practices. This review wanted to find out some of the reasons for this.

What did this study do?

The systematic review used Cochrane review methodology to identify individual observational studies from the UK, US, Canada, South America and Europe. Most were-cross sectional designs, with some longitudinal, case control, and one before-and-after study. The main outcome of interest was unscheduled use of secondary care, measured by emergency department attendance and emergency hospital admissions.

The studies were combined by narrative description. The studies were from differing national healthcare systems and described very different types of patient populations, for example, all GP patients, specific groups such as people with diabetes, or paediatric patients. This makes it difficult to generalise findings, given differences in study populations and systems of care.

What did it find?

The researchers identified 48 relevant papers describing 44 unique studies.

  • More unscheduled use of secondary care was associated with factors associated with low socioeconomic status and a greater prevalence of acute illness, such as increasing age and chronic disease.
  • Less unscheduled use of secondary care was associated with more convenient primary care locations for patients and greater continuity of care, such as being able to see the same healthcare professional.
  • Overall, the findings for each factor varied by context, particularly by country and healthcare system.

What does current guidance say on this issue?

The 2012 NICE guideline on patient experience in adult NHS services suggests that continuity is vital to patients receiving effective, appropriate care. It recommends the assessment of each patient's requirement for continuity of care and how that requirement will be met. The Keogh Urgent and Emergency Care interim review reported the vision for planning services at the end of 2013. This is being delivered through local urgent and emergency care networks, a priority new model of care under the NHS Five Year Forward View strategy.

What are the implications?

There is the potential to reduce costly unscheduled use of secondary care by understanding factors associated with its use, but the relationships between factors are complex. The review did not cover patients’ views on barriers and facilitators to accessing and using healthcare, part of the picture. However, the results did suggest that NHS England’s policy guidance is a step in the right direction. This emphasises treating people as close to home as possible and suggests a return to named GPs for the vulnerable elderly.

Commissioners can use resources like the NHS Right Care programme’s atlas of variation to compare local emergency department attendance and unplanned admission rates with others and consider strategies for reducing avoidable admissions.


Huntley A, Lasserson D, Wye L, et al. Which features of primary care affect unscheduled secondary care use? A systematic review. BMJ open 2014 4;5:e004746. This project was funded by the National Institute for Health Research School for Primary Care Research.


Huntley A, Wye L, England H, Salisbury C, Purdy S, Lasserson D, Morris R, Checkland K. Primary care factors and unscheduled secondary care: a series of systematic reviews. 2014. Centre of Academic Primary Care, University of Bristol

NICE Guideline CG138 Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. CG138. London: National Institute for Health and Care Excellence; 2012

NHS Right care programme. London: NHS England and Public Health England; 2014/15

NHS England. Commissioning for Value – comprehensive data packs to support CCGs and NHS England in the regions. London: NHS England; 2015

NHS England. Transforming urgent and emergency care services in England. Urgent and Emergency Care Review. End of Phase 1 Report. London: NHS England; 2013

O'Cathain A, Knowles E, Maheswaran R, et al. A system-wide approach to explaining variation in potentially avoidable emergency admissions: national ecological study. BMJ Qual Saf. 2014 Jan;23(1):47-55

Tian, Y. Data briefing: emergency hospital admissions for ambulatory care-sensitive conditions. Kings Fund report. 3 April 2012

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The Keogh Urgent and Emergency Care Review is ongoing, but five key elements for change have been published in the interim report: 1) to provide better support for self-care; 2) to help people with urgent care needs get the right advice in the right place, first time; 3) to provide highly responsive urgent care services outside of hospital, so people no longer choose to queue in A&E; 4) to ensure that those people with serious or life-threatening emergency care needs receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery; 5) to connect all urgent and emergency care services together so the overall system becomes more than just the sum of its parts.


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