This site is intended for health professionals only

At the heart of general practice since 1960

Longer GP opening hours needed to boost productivity, says Monitor

GP should open longer and expand their surgeries to take on an additional 16m appointments from hospitals and plug a £30bn NHS funding gap, Monitor has said.

The health regulator said that GPs should be asked to increase their productivity by 10% to 20%, enabling them to see an extra two to four patients a day.

In a report out today, it said that by revising the appointment system, changing job roles and using telephone triage and telephone appointments GPs could free up time to do this.

The report comes after the Government announced pilots of extended access in the evening and at weekends with the aspiration of extending GP hours nationally.

The report, titled Closing the Gap, also said consolidating GP practices to reduce running costs and make better use of estates could save the NHS between £200m and £300m annually.

Monitor predicted that the NHS will face a £30bn funding gap by 2021 and listed a range of saving and productivity measures that could make up the difference in the report. Overall, Monitor suggested primary care could save between £1.2bn and £2.5bn annually just by improving productivity.

The document said: ‘Increasing the size of GP practices, reducing running costs and making more use of the estate, for example, by having longer opening hours, could improve asset utilisation for GPs’ practices. Consolidating practices will not always be feasible or even desirable in some areas. But new forms of collaboration between practices could deliver similar advantages. For example, smaller practices could collaborate to form networks serving 50,000 to 70,000 people. This would maximise the use of skills, co-ordinate care better and increase capacity.’

It adds: ‘Operational improvements in general practice could be achieved through a combination of revising appointment processes, changing job roles within primary care and using telephone triage and telephone appointments. Taking such measures could enable a typical practice with an average list size of 6,500 to add an extra 50 to 95 appointments a month. Measures to rework appointment and diagnostic processes could also free up GPs’ time, allowing them to focus on more complex patients and help meet future demand. The gains for patients from these measures could be considerable.’

However, Monitor also suggested GPs practices could take on an extra 10-16 million patients currently treated as hospital outpatients.

The report said: ‘Shifting outpatient activities to primary care settings, where they could be delivered by GPs with a special interest could realise gains of £0.7 billion. An estimated 10 million to 16 million outpatient attendances in hospitals could take place in primary care.’

David Bennett, chief executive and chair of Monitor, commented: ‘Over the next eight years, the health sector faces its greatest financial challenge in recent times. We are all going to have to strain every sinew to meet it. While there are individual things the sector can do - like be more efficient in its procurement or introducing new ways of working in hospitals - what is required is a step-change. In short, the NHS must undergo radical change if it is to survive. Monitor, as the health sector regulator, will not only be supporting, but actively enabling changes that deliver better services for patients and reduce costs.’

Readers' comments (29)

  • Yawn............ maybe cutting funding for monitor would be a step to saving some cash.......

    Unsuitable or offensive? Report this comment

  • If you really want to increase productivity remove home visits completely, a gp could see 6 patients in the time it takes to do 1 home visit and achieve better outcomes.

    Unsuitable or offensive? Report this comment

  • why dont we do just EVERYTHING in primary care!...
    Gp practices are at bursting point already. there is no funding. yet they want us to take on OOH, provide 24/7 care for the patients, open 7 days a week, provide extended hours opening, triage all the appointments, manage hospital out-patient ...
    Clearly, these people have got nothing better to do than to come up with such absurd and unworkable suggestions. We dont even have a big enough workforce in the first place!. I agree with the first comment, get rid of costly organisations like Monitor and invest in primary care.

    Unsuitable or offensive? Report this comment

  • yeah , why not join up with that phone company EE , everthing every where , certainly good marketing opportunity as I sit here during an extrended hours session when thankfully half the patients sensibly remained in bed and didnt show up!

    Unsuitable or offensive? Report this comment

  • Doing everything in Primary Care is obviously the way to go. I am happy to lead this exciting initiative and have asked my good friend Jeremy to send the NHS Budget to my address in the Cayman Islands.

    Unsuitable or offensive? Report this comment

  • And what the hell did 'Monitor 'have to say about increasing out put and productivity in secondary care !!!!!!!
    Whats more - any overpriced comment form them about the controllers ( cameron + hunt) reporting the positive effects of a pilot scheme soon to be rolled out which actually has not seen any patients !!
    I despair.........

    Unsuitable or offensive? Report this comment

  • I have two words to say to monitor and neither of them are nice

    Unsuitable or offensive? Report this comment

  • Ashley Liston

    Reading this article it was so predictable that it would be met with a stream of angry, nihilistic comments from GPs only seeing more work coming their way.
    Is it possible that with a little imagination we could work smarter? Our practice has adopted the rapid response telephone consulting model with all requests for appointments resulting in a telephone consultation which in over 60% of cases resolves the problem to the satisfaction and convenience of the patient. I can now spend far more time in face to face consultations for those who need to see me. Patients also are booked with nurse practitioners or registrar or their own doctor depending on the problem, it's urgency and whether it needs continuity of care.
    Result--very happy patients, staff and doctors. Efficient use of NHS resources and massively reduced A+E and unplanned admissions.
    We need to adapt to changing times. Our patients deserve it and the NHS needs it.

    Unsuitable or offensive? Report this comment

  • There is a strange agenda going on with telephone access. The last comment suggests 60% can be dealt with over the phone. That leaves 40% that need face to face assessment following telephone triage and therefore duplicates work. I cannot see how there are any 'net' savings in practice time from this approach. This would only be of interest if there is an effective way to get the right patients to the right appointment rather than duplicating work.

    Unsuitable or offensive? Report this comment

  • Monitor are probably correct in what they are saying but we do not have the resources to fulfil their ideas. Next year a load of money will be removed from QoF and given to access, announced as 'funding' we'll be vilified for taking more money to provide what the 'modern' world need 24/7/365. Most of us will [Baa!!!] comply as we have mortgages and bills to pay like the rest of the country. Until we negotiate a contract that isn't open ended and unilaterally able to be altered we need to lube up, shut up and get on with whatever is thrust at us. We are useless at negotiating with the government when we are essentially contractors. Now is the time to say what we will provide and for what remuneration or withdraw from negotiations and close our surgeries. Mortgage be damned-rock/hard place.

    Unsuitable or offensive? Report this comment

  • Ashley Liston

    Believe me it works! Sometimes you have to dare to think differently. 60-70% problems dealt with on phone with consultations lasting approx 5 mins. 10-20% sorted by nurse practitioner. 20-25% F2F consultations. Same day appts are the norm. Patient satisfaction soars. A+E attendance plummets.
    It's about being imaginative, courageous and above all patient centred.

    Unsuitable or offensive? Report this comment

  • This is not the work of Monitor. It is acting as a mouthpiece for the work of KPMG, the accountancy firm, who believed that cutting GP appointment times from 10 minutes to 8 minutes was an efficiency saving.

    Yes I could see more patients, but I would go insane. After 16 patients I develop 'compassion fatigue'. What they don't appreciate is that neither the GP or patients are 'widgets'.

    Successful General practice is the interaction between the patient and the GP to diagnose and treat malaise. Often it is 'the gift of the physician,themselves' that makes the crucial difference. We can empower the patient to make a change in their own life . This is mentally very exhausting for the doctor. This is why psychotherapists need regular psychotherapy themselves to de-stress.

    So this is not going to happen, at least not by me. Make me see even more patients and I will quit. The beauty of it is that I CAN. Many of us have paid off our mortgages and have no debts. We have a choice. I am so sorry for those who are trapped in this system because they are younger.

    The government needs to watch it's step. It may believe that GPs will not strike but it cannot control the action of individual GPs who will retire and emigrate. We are reaching a tipping point. But perhaps this may be what the government wants. Unfortunately they may not be able to control the chaos that ensues and then all the spin and PR in the world will not save it from the wrath of the voters.

    Unsuitable or offensive? Report this comment

  • I dont beleive telephone triage works. I have tried this from the gp surgery and from the OOH setting. The fact is that a lot of these patients need some form of examination, especially the ones that call that morning requesting an urgent appointment. Many of these patients have had symptoms that are on-going, they have been to the chemist and they have also been on the internet. Its different for a patient who wants to be seen for a runny nose or a fever for the last day or two, but for someone who has had a cough for a week and not getting better, I as a doctor would want to examine them. You might also get away with those patients who have non urgent queries, that might be resolved over the phone. I think this needs more than the imagination, there is no real evidence that telephone triage eases pressures. Like the comment before, it often results in duplication of services. The flip side to this is that nowadays, patient are very quick to make complaints and sue the doctor. Doctors often simply cover themselves by asking pts tci for an examination esp in the OOH setting, too worried that they'll be sued!. This has to be addressed also.

    Unsuitable or offensive? Report this comment

  • Dear Ashley,
    we already have the shortest consultations in Western Europe, we see 90% NHS patient contacts with 9% budget. medico legal prewssures increasing with lots trying to get something for nothing causing spurious claims increase. Your complaint is inbound, not sure when or why but with youer emphasis on telephone triage it is certain to happen. You never mentioned the training required to be certain about patient selection.
    Not all primary care has Nurse practitioners, F2s and regitrars to help. Some practices depend on the classically trained , coal faced GPs who work untiul the job is finished. I simply cannot buy into this call centre mentality which is not well evidence based to date

    Unsuitable or offensive? Report this comment

  • Unfortunately for Monitor we are doing telephone triage and telephone consultations already ( for years !! ) and so won't be able to gain any appointments, squeezing in more appointments won't improve compassion or efficiency. The most inefficient thing we do time-wise is home visits. . .

    Unsuitable or offensive? Report this comment

  • Ashley Liston

    Hi anonymous
    Telephone consulting and triage are very different. Triage tends to performed by non clinical (such as reception/NHS111) or nurses and is usually risk averse. Telephone consulting by the most skilled clinician in the team (experienced GP) draws on one our greatest skills--risk management. It does need training (as does F2F consulting), is efficient, personal and popular with patients. It can be quick (not always) but allows me to routinely have 15-20 min appts with those who need them.
    It takes energy and a dedicated team. Both of these are diminishing currently in the world of GP. Poor morale is what I pick up in most of the anonymous entries and this is a real concern.
    We remain (currently) independent contractors so I guess we have to be proactive about finding the solutions. More money is not likely to come flooding in. Creative solutions are needed. This is just one example.

    Unsuitable or offensive? Report this comment

  • I have just read the comments regarding tis article and cannot believe it. It appears very clear that Dr Ashley is one of these people who seems to genuinely believe that there is a sensible solution to more demand. Probably wants to SKYPE patients and be available constantly for e mail consults.
    Down to basics, list size ? number of partners? number of nurses ? number of admin staff? and total number of phone contacts/day and face2 face contacts daily....... I trust this heavnely practice is in a city and not a leafy suburb/country . I wonder just who you are actually kidding.
    Increasing patient demand and expectation by outside forces for their own agenda (politicians) .Increasingly decreasing effect of secondary care. Decreasing budgets- decreasing GP workforce- do the sums !!!

    Unsuitable or offensive? Report this comment

  • Lots of practices have tried various telephone / triage schemes. Whilst it works for some practices if you speak to most (or read their patient surveys) patients frequently see this as 1) for the Doctor's benefit 2) restricting access even if this isn't the case and 3) unnecessary steps in achieving what they want. They adapt over time to the flaws in the new system and it goes round and around.

    Surely a better solution is to understand that access cannot be unlimited, that patients need to take some responsibility for their own health and that GP is already OVER capacity and can't take any work from secondary care without an expansion in funding and GP numbers...

    Unsuitable or offensive? Report this comment

  • Ashley Liston

    Hi anonymous 3.19
    I kid you not! Average list size/GP in relatively deprived urban setting. I am definitely NOT interested in Skype or e-mail consulting --far too risky. Not a heavenly practice but certainly hard working--and willing to think outside the box.
    Here's something we have learnt and needs to be believed if you open the floodgates to rapid response telephone consulting. Demand is finite and is predictable. Once you realise that you might have the nerve to venture into a new way of working like RRTC.
    Is it possible that by reducing A+E and unplanned admissions we might release resources for primary care development? That will need some constructive dialogue with our CCG--which we are actively persuing.

    Unsuitable or offensive? Report this comment

  • Has anyone thought of asking the GP's what they want?
    It does appear that everyone else knows best but nobody has consulted GP's!

    I ti is a fact of life that we cannot have everything we want, when we want it! Folk don't die waiting for GP appointments, they die waiting to see consultants who work office hours, or whilst they use the NHS theatres fro private work so the general public have to have their surgery cancelled.
    Why all the GP bashing, they are the foundation of the NHS whilst all the services needed urgently van work part time whatever hours suit them.
    I am sick to death of GP bashing and feel more time / money should be concentrated on paying them a decent wage to to a decent job, minus all the rubbish paperwork. they should be trusted care for their patients without having to overload their books just to make ends meet.

    A&E is there to deal with accidents and emergencies so why don't they do that? Stop belly aching about the work load and extend the services instead of expecting GP's to be the 'be all , end all' of the NHS.

    Unsuitable or offensive? Report this comment

  • I've never seen such a load of old tosh as monitor's proposals, they are completely out of touch with reality. How exactly can we open longer when we are already working 11 hour days?
    I've worked in practices that use both traditional and triage systems and I'd struggle to say that triage has much impact on productivity. It tends to cut through demand but you get a huge amount of work duplication and you have to be prepared to compromise on quality like dishing out antibiotics over the phone and not examining people. You have to be quite relaxed about the risks whilst medico legal problems are heading in the opposite direction. Increasing the use of the estates will just inflate costs as buildings need more heating,lighting and maintenance. The funding gap of £30bn is artificial and just a claim by politicians to shrink the budget whilst GPs are pretty much the most efficient part of the system absorbing risk and doing extras like management routinely for free. Co-ordinating practices into groups of 70,000 will see exponential growth in management costs and hospitals have been trying to dump complex patients onto GPs for years but they refuse to resource the safe management of high risk drugs arrogantly assuming that writing a hopeless 'shared care pathway' delegates responsibility (have a look at drug error litigation to see how that worked out). It currently appears that Monitor is yet another big stick to beat GPs with whilst adding little to patient care. If you want a better model of the way to go, perhaps we should look hat the recent highly successful floatation of the Royal Mail. If the public directly owned a stake in NHS services they would have some say in how they were run.

    Unsuitable or offensive? Report this comment

  • Since we can not define safety levels in numbers seen or hours worked because of our Independent [ ie Imposed !!] Contract, we will have to do as the DOH wishes. Bpth Panorama and Which magazine showed GPs doing 8 hours of face to face consultations [ 42 patients]. This is dangerous enough.
    I wonder why Monitor only said 2 extra appointments. Why not 10 or 20 each day.
    Folks, until we define SAFE workloads, we will have to do more. Either go salaried with EWTD, leave and other benefits or leave the NHS. This Contract is becoming impossible.

    Unsuitable or offensive? Report this comment

  • I would venture a safe number to be seen in a surgery is 12.

    This would allow us longer to sort out all their problems and would actually save money in the long run.

    Unsuitable or offensive? Report this comment

  • How about Monitor working out how many appointments are used up chasing up hospital appointments,results, prescribing meds for secondary care, issuing sick notes post-op etc and finding somebody else to deal with these. That would free up a substantial number of appointments straight away.

    Unsuitable or offensive? Report this comment

  • "The government needs to watch it's step. It may believe that GPs will not strike but it cannot control the action of individual GPs who will retire and emigrate. We are reaching a tipping point. But perhaps this may be what the government wants. Unfortunately they may not be able to control the chaos that ensues and then all the spin and PR in the world will not save it from the wrath of the voters."

    Although I agree with all that has been said here I think we are missing the part where the government blames the "chaos" on the lazy, greedy GPs who don't care about the patients or the NHS. There is already a staff shortage in primary care, a significant number of resignations/retirements could cause a collapse in primary care services. Collapse is ultimately what the government wants. No one party is prepared to take the blame for the desperate situation within the whole NHS but ANY of them would be MORE than happy to have a scapegoat......!!!

    Unsuitable or offensive? Report this comment

  • They may want to scapegoat us GPs but I think the public will not be that stupid. After all if being a GP is so great why are we all lining up to leave ?

    Unsuitable or offensive? Report this comment

  • I am intrigued by the way this thread has run.
    there is no doubt that many primary care colleagues (but far from all) have introduced a telephone triage service.
    I recall my excellent Colleague Dr Chris Peterson of the Elms Health Centre Liverpool talking about this many years ago and presenting evidence of the quality improvement in patient experience and 30% increase in consultation slots required.
    Her Majesties Government then launched a National Telephone Triage service for the NHS called NHS 111.
    Why does this look, like a trick to obtain cost neutral service of a quality that should have been originally specified for 111 for it to actually work for the benefit of patients?

    Unsuitable or offensive? Report this comment

  • out of interest how much does Monitor, NHS England, DOH, NICE, and other support / bureaucratic monitoring services cost the NHS?

    since they are not front line services can we eliminate them first?

    Unsuitable or offensive? Report this comment

  • i think what this shows is we need a proper evaluation of telephone consultations. this thread has one strong advocate. however a good friends whose practice did this 6 months ago found that to begin with they loved it but they are now regretting it as 1. a lot of patients have left them to go to another practice - enough for them to have a cut in their income 2. the number they can divert has gone down 3 they have had some complaints about missed diagnoses. both lung tumours in pts with chronic cough. im prepared to give it a go but need really strong evidence it will work not just anecdotes. Pulse - what about doing a special feature - really analysing it not just reporting an interview with an evangelist.

    Unsuitable or offensive? Report this comment

Have your say