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Access

In the second in our new series of subjects that might crop up in the MRCGP exam, Dr Victoria Hunter looks at the politically charged issue of access to health care

In the second in our new series of subjects that might crop up in the MRCGP exam, Dr Victoria Hunter looks at the politically charged issue of access to health care

Access is a buzzword and covers many different topics. It may well come up in the oral and the written paper ­ and it's worth thinking about in the clinical scenarios.

Time

  • The Government states patients should see a health professional within 24 hours and a doctor within 48 hours
  • There are issues regarding continuity of care ­ should the patient see their own doctor or 'any doctor quickly'?
  • Advanced access is supposed to improve waiting times, aims to clear the backlog, then match capacity with demand
  • There has been a lot in the media recently about surgeries only allowing patients to book same-day appointments

How

Telephone triage

  • By nurse - a study compared GP activity before and after the introduction of nurse triage and found it increased (British Journal of General Practice March 2004, 54, 207-10)
  • GP-led telephone triage for same-day appointments reduced surgery appointment demands by 39 per cent, the majority of patients were satisfied with the service (British Journal of General Practice 2002, 52, 390-1)

Telephone consultation

  • Many doctors worry about missing cues, especially non verbal
  • Neighbour's consultation model is particularly useful ­ especially safety-netting (do commit consultation models to memory)

E-mail

  • Impersonal, may miss cues
  • Disadvantages those without computer access ­ the inverse care law
  • But quick and easy for minor queries

Who

Nurse practitioners

  • Issues ­ skills vs protocols, two-tiered health service, who is legally responsible?
  • Evidence shows high satisfaction rates, consultation rates longer with nurses, similar prescribing rates (BMJ 2000;320:1038). Nurses carry out more tests and ask patients to return more often, but patients are more satisfied (BMJ 200;320:1048-53)

NHS Direct

  • Aims to be the single access point for out-of-hours care by 2006
  • Evidence ­ National Audit Office report 2002 found that NHS Direct is used less by ethnic minorities, people over 65 and disadvantaged groups (inverse care law again) and the time taken to answer a call is too long. However, patients are satisfied. There has been a small reduction in out-of-hours use but not for A&E/GP

Walk-in centres

  • Cater for minor illness/injury
  • Worry that they encourage help-seeking behaviour for minor problems
  • Tend to attract healthy advantaged population (inverse care law again)

When

Out-of-hours care

  • Lots of issues since new contract came in ­ more freedom/quality of life for GPs, but concerns regarding continuity of care, communication, training and keeping up skills
  • The Carson Report 2000 key proposals: single access point through NHS Direct, full course of medication provided at the time, electronic records available to out-of-hours care providers, PCTs to be responsible

Access to secondary care

Choose and Book

When referred patients should be offered a choice of four to five providers (may include NHS hospitals, private and GPSI) and a choice of time and date.

Advantages for patients include flexibility, certainty of appointment time, reduced anxiety and greater autonomy. Advantages for doctors include reduction in DNA rates, being able to see where patients are in the system, and a reduction in administration for chasing appointments.

Disadvantages for patients include being overwhelmed by choice ­ if they live in remote areas, they may have further to travel to exercise meaningful choice of hospital.

Disadvantages for GPs are increased workload, more pressure on consultation time, how to advise patients on choosing a hospital ­ are 'league tables' of hospitals reliable? Other linked topics include GPSIs and practice-based commissioning.

Victoria Hunter has recently passed summative assessment and the MRCGP and is now a salaried GP in Soham, Cambridgeshire

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