Jones and Thornton's paper's conclusion—diverting funds from secondary care to offset the cost of after-hours primary care is unlikely to reduce emergency department presentations—is methodologically flawed and may be asking the wrong question.1The extent to which cost might be a barrier surely will vary depending on how high the cost of a GP visit might be, how big the cost of travel to the emergency department (ED) might be, and how poor the population being studied are. All of these vary considerably from place to place in New Zealand (Dunedin compared to Middlemore) and over time. Only two of the cited studies were more recent than 26 years ago. Prior to 1987 we had less child poverty and less income disparity. It is hard to draw any meaningful conclusions from such a temporally and geographically varied sample.The conclusion seems to be at odds with a recent report from Wellington that "Capital and Coast District Health Board has saved more than $1 million and avoided 400 emergency department admissions since free healthcare for under-6s was introduced."2 However the problem is the question asked. The cost barrier to accessing primary care for children led to more ambulatory sensitive admissions that cost the board a lot of money. The money saved was in the in-patient service not in the ED. If the question is whether a cost barrier affects visits to ED then with better data you might be able to conclude that it does not. If the question is whether a cost barrier leads to greater hospital costs in this instance that it does.EDs are not good places to provide primary care. Because there are so few of them they are a long way away from where many people live. They are designed to provide emergency care and in my experience tend to over-investigate and spend more time on primary care problems than a GP would. Whether the reasons for attendance are cost, ease of access or misunderstanding of the role of GP we should continue to discourage people with primary care problems from attending ED.The study addressed people who attended ED, not all those who had a need to attend ED. They noted that of those surveyed in the 2011–12 New Zealand Health Survey 14% (n=12,370) had an ‘unmet primary care need' due to cost and 7% had an ‘unmet after hours need' due to cost.The latest survey 2012–13)3 showed that 27% of adults and 21% of children had an unmet need for primary care for all reasons. For people without access to primary care many hospital services are not available. Our first priority should be removing cost and access barriers to ensure that everyone has access to primary care.Diverting money to primary care may not save ED costs but it has been shown to save overall hospital costs and is the best way to provide for unmet need in primary care. Ben Gray Senior Lecturer Primary Health Care and General Practice Otago University, Wellington

Jones and Thornton's paper's conclusion—diverting funds from secondary care to offset the cost of after-hours primary care is unlikely to reduce emergency department presentations—is methodologically flawed and may be asking the wrong question.1The extent to which cost might be a barrier surely will vary depending on how high the cost of a GP visit might be, how big the cost of travel to the emergency department (ED) might be, and how poor the population being studied are. All of these vary considerably from place to place in New Zealand (Dunedin compared to Middlemore) and over time. Only two of the cited studies were more recent than 26 years ago. Prior to 1987 we had less child poverty and less income disparity. It is hard to draw any meaningful conclusions from such a temporally and geographically varied sample.The conclusion seems to be at odds with a recent report from Wellington that "Capital and Coast District Health Board has saved more than $1 million and avoided 400 emergency department admissions since free healthcare for under-6s was introduced."2 However the problem is the question asked. The cost barrier to accessing primary care for children led to more ambulatory sensitive admissions that cost the board a lot of money. The money saved was in the in-patient service not in the ED. If the question is whether a cost barrier affects visits to ED then with better data you might be able to conclude that it does not. If the question is whether a cost barrier leads to greater hospital costs in this instance that it does.EDs are not good places to provide primary care. Because there are so few of them they are a long way away from where many people live. They are designed to provide emergency care and in my experience tend to over-investigate and spend more time on primary care problems than a GP would. Whether the reasons for attendance are cost, ease of access or misunderstanding of the role of GP we should continue to discourage people with primary care problems from attending ED.The study addressed people who attended ED, not all those who had a need to attend ED. They noted that of those surveyed in the 2011–12 New Zealand Health Survey 14% (n=12,370) had an ‘unmet primary care need' due to cost and 7% had an ‘unmet after hours need' due to cost.The latest survey 2012–13)3 showed that 27% of adults and 21% of children had an unmet need for primary care for all reasons. For people without access to primary care many hospital services are not available. Our first priority should be removing cost and access barriers to ensure that everyone has access to primary care.Diverting money to primary care may not save ED costs but it has been shown to save overall hospital costs and is the best way to provide for unmet need in primary care. Ben Gray Senior Lecturer Primary Health Care and General Practice Otago University, Wellington