Primary care and demand on Emergency Departments: understanding the role of access through an ethnographic study of GP practices

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The problem

There is an assumption that many patients attending Emergency Departments (EDs) could be treated in primary care. Accordingly, increasing the availability of primary care services could relieve the growing pressure on EDs. A 2014 systematic review found evidence for a relationship between primary care access and EDs was unclear. We conducted a detailed ethnography as part of a multi-method study which aims to evaluate how the organisation and delivery of primary care impacts on utilisation of unplanned hospital care.

The approach

We conducted ethnographic observation, informal and formal interviews with staff and patients, and documentary analysis in six general practice case studies across three Clinical Commissioning Groups in England. Cases were selected to provide diversity. Reception and waiting room areas were observed (69 hours). Nineteen practice staff and 29 patients with a recent ED attendance took part in formal interviews. Data for each case were analysed thematically to identify aspects of primary care that potentially influence use of unplanned care, with subsequent cross-case analysis integrating the case analysis.


Access to GP appointments-in terms of both supply (‘having access') and entry (‘gaining access')-was a central issue. The six GP practices adopted different approaches to managing demand for appointments depending on local context; often these reflected incremental changes over time, and changes were reactive rather than proactive. Appointment systems could be ambiguous and inflexible, making it hard for patients and staff to negotiate appointment booking, and potentially leading to inequitable access. These issues contributed to a sense among patients that primary care is not always an appropriate or easy place to seek help. Recurring themes included a gap in care created by a lack of appointments for non-urgent problems, patients being unsure about out of hours provision, and privileging telephone access to an extent that it obstructs access for some patients.


There is scope to improve primary care access and make it more equitable, which would help shift patient perceptions of where it is best to seek care in times of need. Practical changes related to simplifying appointments systems and making them more flexible and clear, as well as greater support for reception staff (who generally have responsibility for helping patients to access care), are important steps. Simply increasing access to primary care, for example through extended opening hours, is unlikely to reduce demand for ED.


  • Fiona MacKichan, University of Manchester, Manchester, UK
  • Emer Brangan, University of Manchester, Manchester, UK
  • Lesley Wye, University of Manchester, Manchester, UK
  • Katherine Checkland, University of Oxford, Oxford, UK
  • Helen England
  • Alyson Huntley, University of Manchester, Manchester, UK
  • Daniel Lasserson, BrisDoc Healthcare Services, Bristol, UK
  • Richard Morris, University of Manchester, Manchester, UK
  • Chris Salisbury, University of Manchester, Manchester, UK
  • Peter Tammes, University of Manchester, Manchester, UK
  • Sarah Purdy, University of Manchester, Manchester, UK