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How we make extended hours work for us

A practice near London extended its opening hours so successfully Prime Minister Gordon Brown and health secretary Alan Johnson looked in to see how things are done. Dr Charles Alessi explains

A practice near London extended its opening hours so successfully Prime Minister Gordon Brown and health secretary Alan Johnson looked in to see how things are done. Dr Charles Alessi explains

When new arrangements for out-of-hours provision were implemented, we at the Churchill Medical Practice did not change our availability when most practices opted out. Saturday morning surgeries for emergency consultation were never stopped and we chose to opt in to out-of-hours provision, judging that this aspect of unscheduled care was best retained by the practice.

The rationale for maintaining Saturday morning access was that our population was particularly deprived (we are in receipt of level 3 deprivation payments for part of our population) and we needed to maintain access for these vulnerable patients. We are a PMS training practice with 30,000 patients and a history of innovation, one of the 2% of practices in England and Wales that holds the quality practice award.

Notwithstanding this, we operate from a converted shop. This was turned into a primary care facility and subsequently slightly extended in the late 1990s, but space has always been at a premium and attempts to interest the PCT in providing alternative enhanced accommodation were unsuccessful.

Kingston is viewed as a leafy suburb of London with low overall levels of deprivation. With the new arrangements for extended primary care services such as minor operations, in-house clinics for dermatology and managing anticoagulation and diabetes in primary care, the limitations of space within the existing infrastructure started to become more and more apparent throughout 2005 and 2006.

By the beginning of 2007 our ability to offer access was about to fail. Also patients were blocking the phone systems once the phones became operative, given the limited hours of availability. We determined that there was only one way for us to manage the requirements for access and that was by extending hours of availability. In essence this gave us more space without the need for a new building.

Result of extended hours

We now offer services to patients from 8am to 8pm weekdays, when the full complement of services within the medical centre is available for patients. Our Saturday services run between 9am to 12.30pm and we offer a two-doctor, one-nurse, booked and open access service.

The implications of this are that the doctors, nurses and healthcare assistants are now working shifts during the day. We break our days into around five segments and people choose which portion of the day they would like to cover. We have also employed an extra part-time PMS doctor to handle late evenings as this was a portion of the day that was proving difficult to cover.

We expected that it was going to be difficult to recruit to provide this service and were pleasantly surprised by the number and quality of the doctors who wanted to join us. We funded the part-time extra doctor ourselves. We are using extended hours as a mechanism for offering core services, given the inflexibilities of space we are working within.

We felt it appropriate we manage this enhancement to the service we provide in the same way we manage most other similar enhancements. The practice now works far more smoothly. Patients know they can be seen on the same day at any time between 8am and 8pm. Our telephone systems are now operating more effectively. There is also a tangible difference in the way consultations are being conducted. The lack of pressure associated with a more managed reception and a less crowded environment is feeding through to better and more productive consultations. Patient satisfaction has also improved.

Challenges faced – and avoided

Certainly we have had a few problems, particularly around patient expectations and availability of named doctors at specific times. It is clearly impossible for all doctors and nurses to be available throughout the entirety of the opening times on all days of opening. We feel we are making significant headway around this issue with patients. A learning point for any practice proposing to extend opening hours would be to manage this actively at the initiation of the project.

Again partners and other health professionals are not in the practice at the same time, so pooling information can be a problem. To resolve this we have initiated a series of regular meetings to ensure we get enough time to interact. We have also set up a half day away afternoon over the next few weeks as part of a rolling programme.

We thought that increased availability would increase our patient numbers. This has not been the case. It seems patients are incredibly loyal to their general practices.It is probably true to say extended opening hours are easier to provide in a large practice because of economies of scale.

We consider this enhancement of access to be something we need to do to continue to offer the best services to patients. We are not sure how much further we will push access, and seven-day working is a possibility. To a large extent this will depend on how well our new systems for access work. It is also true that if our population and their needs change, we would look at this initiative again and make the required modifications.

Dr Charles Alessi is a GP in Kingston, Surrey

Pros and cons of extending opening Dr Charles Alessi: now offers services to patietns from 8am to 8pm on weekdays

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