Out of hours primary care has undergone radical reorganisation in recent years, with increasing numbers of general practitioner cooperatives operating from primary care emergency centres.1 A major issue continues to be equity of access, particularly in areas of socioeconomic deprivation where demand is high but access to transport is poor.2,3 In Glasgow, 52% of the population reside in areas of deprivation (Carstairs and Morris deprivation categories 6 or 7).4
The Glasgow Emergency Medical Service was established in February 1996: it covers around 950 000 patients and 95% of the city’s 219 general practices, and operates from six centres across the city. The service offers free transport for patients between their homes and the centres.
Subjects, methods, and results
We collected data on all patient contacts with the emergency service over one week in October 1996 (n=3193). The socioeconomic category of the patients was derived from their postcode sector of residence (depcats 1 and 2, affluent; 3-5, intermediate; 6 and 7, deprived).4 Time of first contact with the service was categorised as evening until midnight, night, and weekend daytime. To standardise the distribution of contacts over time, we calculated rates of contact per million person hours then analysed these by Poisson regression. We analysed service response by logistic regression. Independent variables for both models were age, socioeconomic category, and time of first contact.
Sociodemographic data were available for 2882 contacts (90.3%), giving a crude contact rate of 28.1 per million person hours (equivalent to 157.8 contacts per 1000 patients per annum). We found an interaction between socioeconomic category and age group (P=0.002), with 60% higher contact rates for children and adults from deprived areas (aged <5: affluent, 79.4 per million person hours; deprived, 130.9; schoolchildren: affluent, 19.4; deprived, 31.3; adults: affluent, 15.1; deprived, 24.1). In elderly people the contact rate was 38% higher for the affluent group (affluent, 51.7; deprived, 37.5).
Of the 3193 contacts, 1713 (53.7%) attended centres, 726 (22.7%) received home visits, 449 (14.1%) were given telephone advice, 63 (2.0%) were sent an ambulance, and 144 (4.5%) did not attend as arranged (unknown for 98 (3.1%)). Socioeconomic category influenced the probability of receiving a home visit (P=0.037), with adults and elderly people in deprived areas more likely to receive one. Socioeconomic category did not affect the likelihood of receiving telephone advice (P=0.42) or attending a centre (P=0.29) (table).
Full data were available for 1607 (93.8%) patients attending centres, of whom 304 (18.9%) used the patient transport service. Patients from deprived areas were four times more likely to use patient transport (affluent, 6.3%; deprived, 25.2%: P<0.0001): this trend was most apparent at night, when there was a sevenfold difference between affluent (6.3%) and deprived areas (44.6%: P<0.0001).
Comments
Socioeconomic category influenced the use of the Glasgow Emergency Medical Service, with increased contact rates by children and adults from deprived areas. For elderly people, the highest contact rate was among the most affluent. While the effect of affluence on raising expectations and service use has been reported, this association has not previously been linked to age.5
After contacting the emergency service, adults and elderly people from deprived areas were most likely to receive a home visit. The reasons for this are unclear and require further investigation. The lack of association between socioeconomic category and centre visit rates may be attributable to the provision of patient transport for anyone asked to attend a centre: those from deprived areas were far more likely to use the service. The cost of this service for 1998-9 will be around £240 000, yet may still be cheaper than taxi fares or home visits. While this requires economic evaluation, the evidence suggests that a free and accessible patient transport service may contribute to equity of access to out of hours primary care across the socioeconomic spectrum.
Table.
Response for different age groups by patient socioeconomic category (full data available for 2641/3193 (82.7%) contacts). Values are percentages (numbers) of patients
| Socioeconomic category |
Patients aged <5 years (n=620)
|
Patients aged 5-14 years (n=312)
|
Patients aged 15-74 years (n=1465)
|
Patients aged ⩾75 years (n=244)
|
|||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Home visit | Centre attendance | Telephone advice | Home visit | Centre attendance | Telephone advice | Home visit | Centre attendance | Telephone advice | Home visit | Centre attendance | Telephone advice | ||||
| Affluent | 0 | 79.2 (57) | 20.8 (15) | 7.9 (3) | 73.7 (28) | 18.4 (7) | 23.7 (46) | 59.3 (115) | 17.0 (33) | 75.9 (44) | 8.6 (5) | 15.5 (9) | |||
| No of patients in category | 72 | 38 | 194 | 58 | |||||||||||
| Intermediate | 3.7 (7) | 81.8 (153) | 14.4 (27) | 3.4 (3) | 83.1 (74) | 13.5 (12) | 26.2 (101) | 59.2 (228) | 14.6 (56) | 80.3 (61) | 9.2 (7) | 10.5 (8) | |||
| No of patients in category | 187 | 89 | 385 | 76 | |||||||||||
| Deprived | 3.9 (14) | 80.9 (292) | 15.2 (55) | 4.3 (8) | 78.9 (146) | 16.8 (31) | 29.0 (257) | 56.3 (499) | 14.7 (130) | 88.2 (97) | 2.7 (3) | 9.1 (10) | |||
| No of patients in category | 361 | 185 | 886 | 110 | |||||||||||
Acknowledgments
We thank Dr James O’Neil, John Easthope, and the staff of the Glasgow Emergency Medical Service for their cooperation; staff of the Robertson Centre for Biostatistics for data entry; Department of Health Information, Greater Glasgow Health Board for routine data; Ms Michere Beaumont for secretarial support; Professor Graham Watt for his discussions. Ethical approval was obtained from the Greater Glasgow Community and Primary Care Research Ethics Committee. The Public Health Research Unit is supported by the Chief Scientist Office of the Scottish Office Department of Health, but the views expressed in this paper are those of the authors alone.
Footnotes
Funding: Glasgow Emergency Medical Service contributed towards data entry costs.
Conflict of interest: None.
References
- 1.Payne F, Jessopp L, Dale J. Second national survey of GP co-operatives: a report. London: Department of General Practice and Primary Care, King’s College School of Medicine and Dentistry; 1997. [Google Scholar]
- 2.Hallam L. Out of hours primary care. BMJ. 1997;314:157–158. doi: 10.1136/bmj.314.7075.157. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Carlisle R, Groom LM, Avery AJ, Boot D, Earwicker S. Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey. BMJ. 1998;316:520–523. doi: 10.1136/bmj.316.7130.520. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Carstairs V, Morris R. Deprivation and health in Scotland. Aberdeen: Aberdeen University Press; 1991. [Google Scholar]
- 5.Pitts J, Whitby M. Out of hours workload of a suburban general practice: deprivation or expectation. BMJ. 1990;300:1113–1115. doi: 10.1136/bmj.300.6732.1113. [DOI] [PMC free article] [PubMed] [Google Scholar]