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Conditions for extended hours DESs and LESs across the UK

The incentives for offering extended hours in England, Scotland and Wales vary wildly. Gareth Iacobucci outlines the differences

The incentives for offering extended hours in England, Scotland and Wales vary wildly. Gareth Iacobucci outlines the differences

The wide variation in uptake of extended hours across the UK is matched by an equal diversity in the conditions under which extended hours are offered.

Most GPs – 90% in the Pulse survey – have set up under LES, attracted by greater flexibility and, in some cases, more pay than DES.

This has irritated the Department of Health, with Mike Warburton, national director for the National GP Access Programme, hinting recently that LMCs may be hindering progress by adopting militant tactics in urging GPs to hold out for a better deal through local LESs.

But GPC deputy chair Dr Richard Vautrey told Pulse it was up to lagging PCTs to offer better incentives to GPs.

Below we look at different examples of LES and the varying terms and conditions for DES across the UK.

England

In England, the extended hours DES offers GPs a payment of £2.95 per patient.

Practices are expected to deliver an extra 30 minutes of consultation time per week per 1,000 patients, outside core hours.

Core hours are defined as 8am-6.30pm for GMS practices and whatever is in the individual contracts of PMS and APMS practices.

Extended hours have to be delivered in one-and-a-half-hour blocks in the evenings and on Saturday mornings.

PCTs are able to reduce this for practices with fewer than 3,000 patients and for appointments before 8am, but the DES – unlike many LESs – does not allow for extended access appointments to be carried out concurrently by

more than one GP at one location.

Despite the DH's bitter feud with the profession over this issue, as of the end of September, 8,275 practices – 51%– were offering extended hours.

Although they are unlikely to want to stop there, the DH has ruled out bringing in more flexible arrangements in England to further increase GP take-up.

Speaking at the Labour Party Conference last month, Prime Minister Gordon Brown predicted that, under the current DES, the majority of GP practices in England would be open even longer by the end of 2009.

Scotland

As in England, the Scottish DES pays GPs £2.95 per patient for offering extended hours and consultation time outside core hours is the same – 30 minutes a week per 1,000 patients.

But in Scotland, concurrent appointments are an option, so two GP-led parallel surgeries carried out for two hours in the extended hours period count for four hours towards the requirements.

The option to shift a core (daytime) surgery to parallel an extended hours surgery is also available.

In these circumstances only the extended hours surgery counts towards the requirements.

The Scottish Government also released an additional £2.95m in June to allow participating GP practices to fund nursing support during extended hours.

However, the award was controversial because it is funded out of the extra 1.5% promised as part of this year's contract negotiations, and intended for a mixture of clinical and access initiatives.

Like their English colleagues, Scottish GPs have been angry at the Government's negotiating methods over extended hours.

The Scottish Government said recently it would renew talks with GPs who have so far opted out of extended hours, raising the prospect of more flexible terms.

Although 51% of practices in Scotland are now operating some form of extended hours, health minister Shona Robinson said the Government would be monitoring uptake closely and holding talks with GPs who have opted out.

Wales

GPs in Wales received a £16m funding boost for extended opening and a string of other additional services.

Although the payment of £1.90 per patient is lower than the £2.95 offered in England and Scotland, the Welsh DES offers more flexibility in terms of staffing arrangements, with Welsh practices able to have up to 50% of the extended access time provided by nurses as long as a GP is present at the surgery.

The DES also requires GPs to work 20 extra minutes per 1,000 patients instead of the 30 in England and Scotland, and also offers GPs flexibility to offer a ‘menu' of enhanced services, commissioned according to local need.

The menu includes care of patients with diabetes, learning disabilities and mental health problems, and could include alcohol, heart failure and specialised sexual health services.

Practices with sufficient capacity are able to apply for funding to extend their opening hours into the evening and early mornings and at weekends.

The package also includes a £4.8m uplift for local health boards to support increased costs from factors like population growth and increased prices of drugs.

Dr David Bailey, chair of GPC Wales, agreed with ministers that the increased funding and flexibility was ‘a good deal for GPs and patients'.

Northern Ireland

GPs in Northern Ireland were told last year that they would not have to offer extended opening hours as part of this year's contract.

The Northern Irish Government has since shown no sign of any movement towards a national drive.

In stark contrast to their English peers, ministers were applauded by GPs for instead putting more money into frontline clinical DESs.

Case studies

Extended hours LESs in the UK

Walsall PCT (87.3% uptake)

• Funding: A level 1 service at £2.95 per patient per annum and a level 2 service at £4.95, with extra funding to enable the practice to employ nurses and to provide a range of services, including the management of long-term conditions.
• Appointment time requirement: 30 minutes of extended hours appointment time per week per 1,000 registered patients.
• Concurrent appointments? Yes, provided list size is more than 4,000.

NHS Forth Valley (86%)

• Funding: £2.95 per patient.
• Appointment time requirement: 30 minutes per week per 1,000 registered patients.
• Concurrent appointments? Yes – two GP-led parallel surgeries carried out for two hours in the extended hours period count for four hours.
• Other conditions: Additional consultation time is for weekday evenings, early mornings and Saturday mornings.

Bury PCT (53.1%)

• Funding: £2.95 per patient.
• Appointment requirement: 30 minutes per week per 1,000 patients.
• Concurrent appointments? Not allowed.
• Other conditions: Extended hours have to be covered by GPs, not GP registrars, and/or nurse practitioners.
• Perks: Early adopter incentive of 20p per patient was agreed for 4 August 2008 for practices to confirm intention to start extended hours on or before 1 September 2008.

Buckinghamshire PCT (48.3%)

• Funding: £2.95 per patient.
• Appointment time requirement: 30 minutes per week per 1000 patients. Sessions must average six to seven routine appointments per 90 minutes or four to five appointments per 60 minutes. Blocks of appointments must range from 30 minutes before 8am to 1.5 hours or more during evenings and/or weekends.
• Concurrent appointments? Yes. Two clinicians (maximum), including at least one GP, may work concurrently if agreed.
• Other conditions: The clinic must be GP-led. A maximum of one nurse per session will be accepted. The service can be offered on a weekly, fortnightly or monthly basis if preferred. Practices with two or more sites may offer the service from one or all sites.

Greenwich PCT (30.4%)

• Funding: £2.95 per patient.
• Appointment requirement: 30 minutes per week per 1,000 patients.
• Concurrent working? Yes, although a minimum of 50% of the extended hours requirement must be delivered as additional opening hours. Extended hours appointments must be provided in minimum blocks of one hour.
• Nurses or nurse practitioners can make up to 50% of the workforce - GPs must constitute the rest.
• Other conditions: Practices already providing GP consultations outside core hours can count them towards providing the extended hours access LES. Practices must be open for minimum of 45 hours during core hours; no half-day closing unless agreed with the PCT.

North East Essex PCT (25.6%)

• Funding: £4 per registered patient plus £35 for each nurse-led hour provided alongside the required GP-led extended hours provision.
• Appointment requirement: 30 minutes of appointment time per week per 1,000 registered patients. Appointments offered before 8am may be booked in minimum block of 30 minutes and appointments offered after 6.30pm or at weekends must be booked in minimum block of one hour. Saturday sessions can be held on alternate weeks.
• Concurrent working? Not usually (although PCT will consider this in some circumstances).

Extended hours DESs across the UK

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