Extending primary care hours in Brazil as health policy
The primary care scenario described by Marshall (1) in the United Kingdom is very different from that of Brazil, where access to primary care is a serious problem (2) and the rate of emergency department visits for non-urgent problems is much higher than desirable – situations that are currently complicated by a historical recession, which entails the need for innovative solutions. In the city of Porto Alegre, capital of the southernmost state of Rio Grande do Sul, with a population of 1.4 million (3), 75% of emergency visits are classified as "blue" or "green" according to the Manchester Triage System. This is most likely the result of some health units offering fewer than 30 hours of medical care per week (1), associated with fairly high staff absenteeism.
There is evidence that advanced access reduces wait times for primary care appointments (4), time to third-visit (5), and hospitalization of patients with cardiovascular diseases (6). Also, differently from what is reported by Marshall (1), in other contexts both patients and health professionals seem satisfied with the notion of advanced access (7). Nevertheless, little progress has been made in our city to implement this type of system and improve access to and the quality of primary care.
This was changed as we took office in January 2017. We began an immediate effort to increase the supply of medical consultations and reduce waiting time as well as staff absenteeism. As a first step, on March 24th, one initial primary care facility began to offer extended hours, providing service from 6:00 to 10:00 p.m. from Mondays through Fridays. Laboratory tests, vaccination and dental care are also provided during these hours. New general practitioners (GPs) were hired for this additional shift, reflecting a decision to prioritize primary care as a health policy – something which had not been done before.
Since that day, this first Night and Day Unit has provided more than 1,100 medical consultations (45 consultations/day) during the additional shift. Only 7.5% of these patients were referred to other levels of care – a 92.5% resolution rate, suggesting that the investment in additional GPs will translate into savings down the road. The second Night and Day Unit began to offer the additional shift two weeks later, and has since provided 314 medical consultations during the extended hours, with 89% resolution. At this unit, the number of people seeking care usually exceeded the capacity for 100 consultations during regular hours (on average, 120 people per day). In the first 10 days of extended hours, that number dropped to 110 on most days (73 on one day), reflecting a more even distribution of consultations through the entire period of regular plus extended hours. These pilot units were chosen based on their security level, accessibility, proximity to public transportation, and infrastructure to accommodate the increased number of professionals and consultations.
Although this experience is very new, we expect less overcrowding in emergencies units, as verified in previous studies (1, 8), and hope to decrease unmet demand for primary care in the city. We intend to open six additional Day and Night Units (one for each municipal health region) following evaluation of the initial experience based on demand patterns, resolution rate, and impact on the number of urgency/emergency consultations. Although this is a simple measure, it reflects the decision to address primary care as a health policy: extending hours, increasing the number of GPs, and expanding the portfolio of services. This is the first step towards the implementation of real advanced access, as well as a measure of the value placed on primary care as the main strategy for solving health problems, even in contexts of economic crisis and great social inequality.
1. Marshall M. Seven day access to routine care in general practice. BMJ 2017;357:j2142.
2. Harzheim E, Oliveira MMC, Agostinho MR, Hauser L, Stein AT, Gonçalves MR, et al. Validação do instrumento de avaliação da atenção primária à saúde: PCATool-Brasil adultos. Rev Bras Med Fam Comunidade 2013; 8(29):274-84.
3. Instituto Brasileiro de Geografia e Estatística (IBGE). @Cidades. Rio Grande do Sul: Porto Alegre. 2017. http://cidades.ibge.gov.br/xtras/perfil.php?codmun=431490&lang=_EN
4. Ansell D, Crispo JAG, Simard B, Bjerre LM. Interventions to reduce wait times for primary care appointments: a systematic review. BMC Health Serv Res 2017;17(1):295.
5. Rose K, Ross JS, Horwitz LI. Advanced access scheduling outcomes: A systematic review. Arch Intern Med 2011;171(13):1150-9.
6. Degani N. Impact of advanced (open) access scheduling on patients with chronic diseases: an evidence-based analysis. Ont Health Technol Assess Ser 2013;13(7):1–48.
7. Groulx A, Casgrain I, Melancon AP, Huneault L. Adoption of an advanced access model by residents: pilot project at the Gaspe family practice unit. Can Fam Physician 2015;61(1):e66-7, 89–91.
8. National Audit Office. Improving patient access to general practice. 2017. https://www. nao.org.uk/report/improving-patient-access-to-general-practice/
Competing interests: No competing interests