Skip to main content
SpringerLink
Log in

Access to Primary Care: A Complex Adaptive Systems Lens on Acuity

  • Chapter
  • First Online:
Book cover The Value of Systems and Complexity Sciences for Healthcare

Abstract

Rationale, Aims and Objectives. Pressures on hospital emergency services, hospital wards and many adverse health outcomes are deemed avoidable through timely access to primary care (PC). This paper analyses the problem of PC practices providing access, to mitigate avoidable emergency hospital utilization, within the context of the delivery of comprehensive primary care.

Methods. An iterative scoping review was conducted on PubMed (Medline), Google and other online general search engines, and hand searching of “access” and “primary care” literature. This paper analyzes key concepts and themes identified in the reviews on “access”, “acuity” and “scheduling” through a complex adaptive systems framework.

Findings. Primary care is a comprehensive system that aims to provide timely access and continuity of care according to need and convenience for acute, minor and long-term problems, as well as health promotion. First-contact and longitudinal care are delivered across the lifespan for most personal health care needs. Scheduling requires the meeting of acute needs for patients whose journeys are at-risk of hospital emergency presentations with disease, frailty, disability and social vulnerability; and minor acute presentations in otherwise stable patients. On the other hand, PC needs to address: convenience; relational continuity; health promotion; chronic stable and/or complicated disease/multimorbidity; and indeterminate presentations. Competing and changing priorities exist between planned ahead and same day acute care access, if resources are constrained. A greater priority for accommodating acuity requires adaptation of scheduling, internal work practices, shifting of roles among providers and shifting of the external boundaries of PC practice. Awareness of the dynamics of complex adaptive systems domains would assist current human sense-making scheduling. Non-linear dynamic modelling may be an option for larger practices. Innovation may stretch currently inelastic human resources through: increased out-of-hours care; e-health initiatives; predicting deteriorations in the high risk journeys; and more efficient prevention and chronic care delivery.

Conclusion. Primary care delivery of access for different levels of acuity as part of a comprehensive whole requires ongoing internal adjustments and external elasticity. This aligns with CAS theory that human systems require dynamic adaptive and sense-making activities to meet changing acuity pressures.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Ismail SA, Gibbons DC, Gnani S. Reducing inappropriate accident and emergency department attendances: a systematic review of primary care service interventions. Br J Gen Pract. 2013;63(617):e813–20

    Article  PubMed  PubMed Central  Google Scholar 

  2. Cowling TE, Harris MJ, Watt HC, Gibbons DC, Majeed A. Access to general practice and visits to accident and emergency departments in England: cross-sectional analysis of a national patient survey. Br J Gen Pract. 2014;64(624):e434–9

    Article  PubMed  PubMed Central  Google Scholar 

  3. Haggerty J, Martin CM. Evaluating primary health care in Canada: the right questions to ask!. Ottawa: Publications Health Canada; 2005

    Google Scholar 

  4. Starfield B. Measuring the attainment of primary care. J Med Educ. 1979;54(5):361–9

    CAS  PubMed  Google Scholar 

  5. Haggerty JL, Levesque JF, Santor DA, Burge F, Beaulieu C, Bouharaoui F, et al. Accessibility from the patient perspective: comparison of primary healthcare evaluation instruments. Healthcare Policy/Politiques de sante 2011;7(Spec Issue):94–107

    Google Scholar 

  6. Haggerty JL, Pineault R, Beaulieu M-D, Brunelle Y, Gauthier J, Goulet F, et al. Practice features associated with patient-reported accessibility, continuity, and coordination of primary health care. Ann Fam Med. 2008;6(2):116–23

    Article  PubMed  PubMed Central  Google Scholar 

  7. Starfield B, Shi L, Macinco J. Contribution of primary health care to health systems and health. Milbank Q 2005;83(3):457–502

    Article  PubMed  PubMed Central  Google Scholar 

  8. Britt H, Miller GC, Charles J, Henderson J, Bayram C, Pan Y, et al. General practice activity in Australia 2009–10. General practice series no. 27. Cat. no. GEP 27. Canberra: AIHW; 2010

    Google Scholar 

  9. Land L, Meredith N. An evaluation of the reasons why patients attend a hospital Emergency Department. Int Emerg Nurs. 2011;21(1):35–41

    Article  Google Scholar 

  10. Sampson F, Pickin M, O’Cathain A, Goodall S, Salisbury C. Impact of same-day appointments on patient satisfaction with general practice appointment systems. Br J Gen Pract. 2008;58(554):641–3

    Article  PubMed  PubMed Central  Google Scholar 

  11. Mehrotra A, Keehl-Markowitz L, Ayanian JZ. Implementing open-access scheduling of visits in primary care practices: a cautionary tale. Ann Intern Med. 2008;148(12):915–22

    Article  PubMed  PubMed Central  Google Scholar 

  12. Schall MW, Duffy T, Krishnamurthy A, Levesque O, Mehta P, Murray M, et al. Improving patient access to the Veterans Health Administration’s primary care and specialty clinics. Jt Comm J Qual Saf. 2004;30(8):415–23

    PubMed  Google Scholar 

  13. Ozen A, Balasubramanian H. The impact of case mix on timely access to appointments in a primary care group practice. Health Care Manag Sci. 2013;16(2):101–18

    Article  PubMed  Google Scholar 

  14. Olsen KR, Gyrd-Hansen D, Sorensen TH, Kristensen T, Vedsted P, Street A. Organisational determinants of production and efficiency in general practice: a population-based study. Eur J Health Econ. 2013;14(2):267–76

    Article  PubMed  Google Scholar 

  15. Bankart MJ, Anwar MS, Walker N, Mainous AG, Baker R. Are there enough GPs in England to detect hypertension and maintain access? A cross-sectional study. Br J Gen Pract. 2013;63(610):e339–44

    Article  PubMed  PubMed Central  Google Scholar 

  16. Jones KR, Kaewluang N, Lekhak N. Group visits for chronic illness management: implementation challenges and recommendations. Nurs Econ. 2014;32(3):118–34

    PubMed  Google Scholar 

  17. Bower P, Roland M, Campbell J, Mead N. Setting standards based on patients’ views on access and continuity: secondary analysis of data from the general practice assessment survey. Br Med J 2003;326(7383):258

    Article  Google Scholar 

  18. Sweeney L, Halpert A, Waranoff J. Patient-centered management of complex patients can reduce costs without shortening life. Am J Manag Care 2007;13(2):84–92

    PubMed  Google Scholar 

  19. Wright PN, Tan G, Iliffe S, Lee D. The impact of a new emergency admission avoidance system for older people on length of stay and same-day discharges. Age Ageing 2014;43(1):116–21

    Article  PubMed  Google Scholar 

  20. Department of Health VG, Australia. Hospital Avoidance Reduction Program (HARP); 2009. http://www.health.vic.gov.au/harp/index.htm

  21. Lewis GH. “Impactibility Models”: identifying the subgroup of high-risk patients most amenable to hospital-avoidance programs. Milbank Q 2010;88(2):240–55

    Article  PubMed  PubMed Central  Google Scholar 

  22. O’Malley AS. After-hours access to primary care practices linked with lower emergency department use and less unmet medical need. Health Aff. 2013;32(1):175–83

    Article  Google Scholar 

  23. Ng JY, Fatovich DM, Turner VF, Wurmel JA, Skevington SA, Phillips MR. Appropriateness of healthdirect referrals to the emergency department compared with self-referrals and GP referrals. Med J Aust. 2012;197(9):498–502

    Article  PubMed  Google Scholar 

  24. Wennberg D, Siegel M, Darin B, Filipova N, Russell R, Kenney L, et al. Combined predictive model. London: King’s Fund Publication; 2006. http://www.kingsfund.org.uk/sites/files/kf/field/field_document/PARR-combined-predictive-model-final-report-dec06.pdf. Accessed 21 Dec 2015

  25. Solaligue DES, Martin C, Hederman. L. What weekday? an analysis of planned and unplanned GP visits by older multi-morbid patients in the Patient Journey Record System database. An acuity of GP care utilisation study. J Eval Clin Pract 2014;20(4):522–26

    Article  Google Scholar 

  26. Roland M, Abel G. Reducing emergency admissions: are we on the right track? Br Med J 2012;345:e6017

    Google Scholar 

  27. Roland M, Dusheiko M, Gravelle H, Parker S. Follow up of people aged 65 and over with a history of emergency admissions: analysis of routine admission data. Br Med J. 2005;330(7486):289–92

    Article  Google Scholar 

  28. Rezende EJ, Tavares EC, Alves HJ, dos Santos Ade F, de Melo Mdo C. Teleconsultations in public primary care units of the city of belo horizonte, Brazil: profile of patients and physicians. Telemedicine 2013;19(8):613–18

    Article  Google Scholar 

  29. Standing C, Gururajan R, Standing S, Cripps H. Making the most of virtual expertise in telemedicine and telehealth environment. J Organ Comput Electron Commer 2014; 24(2–3):138–56

    Google Scholar 

  30. Martin C. Self-rated health—patterns in the journeys of patients with multi-morbidity and frailty. J Eval Clin Pract 2014;20(6):1010–6

    Article  PubMed  Google Scholar 

  31. Martin M, Hin PY, O’Neill D. Acute medical take or subacute-on-chronic medical take? Ir Med J 2004;97(7):212–4

    CAS  PubMed  Google Scholar 

  32. Martin C. Do ‘complex’ non-specific states predict hospital utilization? Patterns in a cohort of ‘at risk’ patients. North American Primary Care Research Group Conference Paper; 2013. www.napcrg.org

  33. Hammond RA. Complex systems modeling for obesity research. Prev Chronic Dis 2009;6(3):A97

    PubMed  PubMed Central  Google Scholar 

  34. Bjorkelund C, Maun A, Murante AM, Hoffman K, De Maeseneer J, Farkas-Pall Z. Impact of continuity on quality of primary care: from the perspective of citizens’ preferences and multimorbidity—position paper of the European Forum for Primary Care. Qual Prim Care 2013;21(3):193–204

    PubMed  Google Scholar 

  35. Starfield B, Weiner J, Mumford L, Steinwachs D. Ambulatory care groups: a categorization of diagnoses for research and management. Health Serv Res 1991;26(1):53–74

    CAS  PubMed  PubMed Central  Google Scholar 

  36. Balasubramanian H, Biehl S, Dai L, Muriel A. Dynamic allocation of same-day requests in multi-physician primary care practices in the presence of prescheduled appointments. Health Care Manag Sci 2014;17(1):31–48

    Article  PubMed  Google Scholar 

  37. Murray M, Tantau C. Same-day appointments: exploding the access paradigm. Fam Pract Manag. 2000;7(8):45–50

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Public Health and Primary Care, Trinity College Dublin, College Green, Dublin 2, Ireland

    Carmel M. Martin

  2. 34/72 Lorimer Terrace, Kelvin Grove, Brisbane, Qld, 4059, Australia

    Carmel M. Martin

  3. Max Plank Institute Bad Nauheim, MBML (Molecular Biology and Medicine of the Lung), 63 Unterhof, Apartment 7712, 32395, Giessen, Hessen, Germany

    David Emanuel Surate Solaligue

Authors
  1. Carmel M. Martin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. David Emanuel Surate Solaligue
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Carmel M. Martin .

Editor information

Editors and Affiliations

  1. Department of General Practice, Newcastle University, Newcastle, New South Wales, Australia

    Joachim P. Sturmberg

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Martin, C.M., Solaligue, D.E.S. (2016). Access to Primary Care: A Complex Adaptive Systems Lens on Acuity. In: Sturmberg, J. (eds) The Value of Systems and Complexity Sciences for Healthcare. Springer, Cham. https://doi.org/10.1007/978-3-319-26221-5_20

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-26221-5_20

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-26219-2

  • Online ISBN: 978-3-319-26221-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation