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Do patients really want extended hours?

Access to GPs is getting worse and frustrating patients, argues Dr Michael Dixon. But Dr Peter Bower believes only a minority of patients value extended opening – and that for most seeing a doctor they know is much more important.

Access to GPs is getting worse and frustrating patients, argues Dr Michael Dixon. But Dr Peter Bower believes only a minority of patients value extended opening – and that for most seeing a doctor they know is much more important.

YES

Our own complacency is the single biggest threat to the future of general practice.

Three things are beyond denial.

First, the ability of patients to access their own doctor has got worse over the past few years. Blame the new contract, the rapid rise in part-time GPs or the increasing complexity and workload of general practice outside of the consultation, but it remains a reality and a problem for our patients.

Second, although many of us argue that the greatest strength of general practice is its ability to provide continuing care close to a patient's home, we are less able to provide this ‘continuing' service when we are only open five days out of seven (four out of seven in weeks with bank holidays).

Third, the public perceive that we are better paid and less accessible than ever. They may hold us in high regard as their individual doctor but the GP brand is tarnished and our street credibility is at an all time low.

All of these add up to verbalised dissatisfaction, picked up by press and politicians, which the profession must now address proactively rather than protest that it is either not a problem or that it is someone else's problem.

This is not a time to quibble over patient surveys (which can be argued either way and mean little without examination of choice and consequences), nor is it a time to work to contract because we should aim – as we always have – to go the extra mile and work beyond the bare bones of any contract.

Access is an issue for many patients, whether we are talking about opening hours for any doctor or nurse, or access to personal care from your own doctor.

This is especially true for busy professional types, who contribute disproportionately in tax to the NHS (and thus our own earnings) and whose support for the NHS is crucial for its survival.

Walk-in services and full casualty departments are symbolic of our failure to tackle this problem.

I am not arguing for a return to my job as it was 25 years ago – with 24-hour responsibility, doing my own obstetrics and terminal care and a family who had to stay at home by the phone every time I was on call.

It was not safe, in modern terms, and led to sick doctors and difficult marriages.

Patients are hostile

But there is a balance and the pendulum has swung to the other extreme.

We should not be surprised that the Government, media and many patients are hostile to our apparent complacency and seek to remedy it with increased competition. We should listen.

I know of several practices where the partners still have a half day and take longer-than-average annual leave in exchange for time worked at nights, weekends and bank holidays.

Again, I am not saying that we have to retake responsibility for out-of-hours services (though we should have commissioning responsibility to make sure services work for our patients) but we owe it to our patients to be as available in-hours as we possibly can be.

In small practices, this might include shared arrangements to increase availability, while all practices should reasonably expect their PCT to support extra costs for staff time and so on.

The GP contract has done us and our patients great favours and we should be prepared to give a bit more of our own time for free.

The impact of doing this on our public profile would be magnificent and we would ensure ourselves (as accessible providers and ethical local leaders) a leading role in the future of primary care.

Extended opening is directly linked to the future of general practice.

I am as unenthusiastic as anyone else at the prospect of taking on extra work, but in this case, needs must.

Dr Michael Dixon is chair of the NHS Alliance and a GP in Cullompton, Devon

NO

Access to primary care is a major political issue.

Research indicates that patients in the UK find it more difficult to get to see their GP than their European counterparts1.

In 2003, GPs were asked to meet targets to provide appointments within 48 hours, and their response was impressive, although it led to additional problems as some patients found that booking appointments in advance was now more difficult.

Although its own survey shows 84% of patients are satisfied with current opening hours2, the Department of Health is not content, and has shifted the debate from waiting times to extended opening.

Should patients be forced to attend during normal office hours, or should GPs provide routine services in the evenings and weekends?

The CBI complains that working time lost due to GP appointments costs the UK economy £1bn a year3.

The guiding principle for the Department of Health is that ‘any member of the public can access GP services at any time between 8am and 8pm, seven days a week'4.

But is this what patients want?

Of course ideally everyone wants rapid access at a convenient time.

Taking time off work to visit the doctor seems somewhat anachronistic in these days of 24-hour opening and the delivery of goods and services to your door.

However, in a publicly funded service like the NHS, desire for rapid access must be weighed against other needs.

Sacrifices

Asking patients if they are satisfied with particular aspects of general practice simply invites demand for more of everything. What will we have to sacrifice to achieve 8am-8pm, seven-days-a-week services?

We recently conducted research on patient priorities, using a technique known as a discrete choice experiment5.

This asks patients to choose between consultations that vary on different attributes, such as access and quality of care.

We found that a choice of appointment times was rated as important as a reduction in overall waiting time of one day. So extended opening may be as effective as the 48-hour waiting time at improving patient satisfaction.

However, when compared with other issues, changing access arrangements comes off second best. Seeing a doctor who knew them well was valued nearly twice as highly as reducing waiting times.

Quality of care was valued five times as highly.

We are not alone in reporting these results. Turner and colleagues found that patients consulting with a condition they were uncertain about were willing to trade extra waiting time to see a professional they trust, and who has access to their full medical history6.

Rubin et al found waiting time for an appointment was most important if it was for a child or a new health problem, and choice of appointment time was most important to those in work. Other responders would be willing to wait in order to see their choice of doctor7.

Access is important. But it is important for some patients, some of the time.

Experience with the QOF has shown that GPs are very good at reacting to incentives, but that the resulting changes can have unintended consequences.

Providing incentives to extend opening hours will help meet the needs of some patients, but it is critical that incentives are sufficiently targeted and service development is sufficiently flexible to reflect the range of needs in the population.

Otherwise there is a danger that meeting the genuine needs of working adults will reduce satisfaction in those who need continuity of care.

Dr Peter Bower is a reader at the National Primary Care Research and Development Centre

Dr Michael Dixon

Full casualty is symbolic of our failure to tackle this problem

Dr Peter Bower

Compared with other issues, access comes second best

Waiting room

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