Article Text

Access to primary care and the route of emergency admission to hospital: retrospective analysis of national hospital administrative data
  1. Thomas E Cowling1,
  2. Matthew Harris1,2,
  3. Hilary Watt1,
  4. Michael Soljak1,
  5. Emma Richards1,
  6. Elinor Gunning1,
  7. Alex Bottle1,
  8. James Macinko2,
  9. Azeem Majeed1
  1. 1Department of Primary Care and Public Health, Imperial College London, London, UK
  2. 2Department of Nutrition, Food Studies, and Public Health, New York University, New York, New York, USA
  1. Correspondence to Thomas Edward Cowling, Department of Primary Care and Public Health, Imperial College London, Reynolds Building, St Dunstan's Road, London W6 8RP, UK; t.cowling{at}


Background The UK government is pursuing policies to improve primary care access, as many patients visit accident and emergency (A and E) departments after being unable to get suitable general practice appointments. Direct admission to hospital via a general practitioner (GP) averts A and E use, and may reduce total hospital costs. It could also enhance the continuity of information between GPs and hospital doctors, possibly improving healthcare outcomes.

Objective To determine whether primary care access is associated with the route of emergency admission—via a GP versus via an A and E department.

Methods Retrospective analysis of national administrative data from English hospitals for 2011–2012. Adults admitted in an emergency (unscheduled) for ≥1 night via a GP or an A and E department formed the study population. The measure of primary care access—the percentage of patients able to get a general practice appointment on their last attempt—was derived from a large, nationally representative patient survey. Multilevel logistic regression was used to estimate associations, adjusting for patient and admission characteristics.

Results The analysis included 2 322 112 emergency admissions (81.9% via an A and E department). With a 5 unit increase in the percentage of patients able to get a general practice appointment on their last attempt, the adjusted odds of GP admission (vs A and E admission) was estimated to increase by 15% (OR 1.15, 95% CI 1.12 to 1.17). The probability of GP admission if ≥95% of appointment attempts were successful in each general practice was estimated to be 19.6%. This probability reduced to 13.6% when <80% of appointment attempts were successful. This equates to 139 673 fewer GP admissions (456 232 vs 316 559) assuming no change in the total number of admissions. Associations were consistent in direction across geographical regions of England.

Conclusions Among hospital inpatients admitted as an emergency, patients registered to more accessible general practices were more likely to have been admitted via a GP (vs an A and E department). This furthers evidence suggesting that access to general practice is related to use of emergency hospital services in England. The relative merits of the two admission routes remain unclear.

  • Health services research
  • Primary care
  • Ambulatory care
  • Emergency department
  • General practice

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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