Abstract: Background: Over 70% of the health-care budget in England is spent on the care of people with long-term
conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in
people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer
physical health outcomes, increased health costs and service utilisation.
Objectives: The aim of this programme of research was to examine the relationship between
psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial
intervention that would have the potential to reduce unscheduled care use. We focused largely on
emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).
Design: A three-phase mixed-methods study. Research methods included systematic reviews; a
longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED
admission; a replication study in primary care using routinely collected data; an exploratory and feasibility
cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons
for the use of unscheduled care and factors in routine consultations in primary care that may influence
health-care use. People with lived experience of LTCs worked closely with the research team.
Setting: Primary care. Manchester and London.
Participants: People aged ≥ 18 years with at least one of four common LTCs: asthma, coronary
heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included
health-care staff.
Results: Evidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled
care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people
with asthma and COPD. The results of the prospective study were that depression, not having a partner
and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were
independent predictors of EHA and ED admission. Approximately half of the cost of health care for people
with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in
London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to
low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that
patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent
need for care, and following previous experience that unscheduled care had successfully and unquestioningly
met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled
care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues
during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews.
The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the
way in which practices manage patients with COPD and developed a targeted psychosocial treatment for
patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high
acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be
unlikely to be cost-effective, limiting the value of detailed health economic modelling.
Limitations: The findings of this programme may not apply to all people with LTCs. It was conducted in
an area of high social deprivation, which may limit the generalisability to more affluent areas. The response
rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.
Conclusions: Prior use of unscheduled care is the most powerful predictor of unscheduled care use in
people with LTCs. However, psychosocial factors, particularly depression, are important additional
predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity.
Patients and health-care practitioners are unaware that psychosocial factors influence health-care use,
and such factors are rarely acknowledged or addressed in consultations or discussions about use of
unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has
shown high levels of acceptability when delivered in a primary care context. An intervention at the level of
the GP practice showed little evidence of acceptability or cost-effectiveness.
Future work: The potential benefits of case-finding for depression in patients with LTCs in primary care
need to be evaluated, in addition to further evaluation of the targeted patient intervention.