Analysis: PM pushes GP access to its limits
As the Government announces details of its seven-day access pilots, Jaimie Kaffash looks at the prospect of practices working 84-hour weeks
Seven-day GP opening is classic soundbite policy. A popular idea, trumpeted personally by the Prime Minister, that looks a lot less straightforward when analysed in detail.
Just last month, David Cameron announced the winners of £50m of additional funding to trial 84-hour working weeks, 24-hour telephone access and greater use of online services.
The national newspapers heralded the scheme, which will see 1,000 GP practices trial various ‘forward-thinking services to suit busy lifestyles’, in the Department of Health’s words.
But the reality of Mr Cameron’s pilots is far more complicated. The funding is only for one year and, in some cases, pays participating practices less than £3 a patient.
Pulse has learned that cash-strapped CCGs are likely to have to pick up the bill after the scheme runs out next spring and primary care academics are warning that the Government’s ‘populist fixation’ with extending opening hours could compromise care.
A Pulse survey shows that nearly two-thirds of GPs think the move to seven-day GP access will harm patient safety, and support for the policy among the profession is low.
But insiders say the idea is not going to go away. Dr Paul Charlson, vice-chair of Conservative Health and a GP in Brough, East Yorkshire, says it is an area the Government is determined to pursue.
He says: ‘It is such a hot issue with the public and one that the Government is understandably keen to pick up and encourage.
‘Access needs to be improved and the Government wants to do so. Whether that is by carrot or stick depends on a number of factors – one being GP recruitment. As with most people, carrots tend to be more effective
Mr Cameron made seven-day access one of the big announcements at the Conservative Party conference last autumn, promising to ‘support GPs to modernise their services’.
He said the £50m ‘Challenge Fund’ would be set up to help the ‘millions of people [who] find it hard to get an appointment to see their GP at a time that fits in with their work and family life’, and he suggested that it could help relieve pressure on A&E departments.
The winners of that fund were announced last month, with 20 successful bids – instead of the planned nine – from 1,147 practices.
Dr Tracey Vell: ‘Our patients do not want evening appointments’
Our practice decided not to opt in when our local CCG set up a scheme for practices to open at evenings and weekends.
We prefer less fragmentation of the care of our patients and to look after them ourselves. Also, our patient survey did not indicate that our practice population particularly wanted appointments later in the evening.
We also feel it is a duplication of current GP out-of-hours services that are closer to our surgery than the hub that the CCG has allocated to provide extended hours surgeries.
We do not feel that routine appointments at these times are fully supported with pathology and other investigations.
Politically, we feel that access for our patients is already great and that money could be spent on other projects.
I don’t see how a ‘routine’ extension of hours for patients finding it difficult to consult in-hours would relieve any pressure on A&E departments, as the two scenarios are entirely different.
I know it is not popular to have views opposed to those of the Government but there are more important problems in primary care, and patients can appreciate this when they are given all the available information to make a valued decision on funding.
Dr Tracey Vell is honorary secretary at Manchester LMC and a GP in Manchester
The DH said the area covered by the scheme had been expanded to cover 7.5m patients, because of an ‘enthusiastic response’ from GPs.
Successful bids included one worth almost £11m from private provider Care UK to run an England-wide ‘super-practice’ available by telephone 24 hours a day. Under the scheme, patients will be able to talk to a GP or nurse who can handle routine queries, arrange prescriptions, or signpost them to appropriate treatment.
A £1m Birmingham scheme will offer 8am-8pm GP appointments, seven days a week, but the largest scheme sees GPs in north-west London working together to create 39 ‘networks’, covering 365 surgeries, to improve access for 1.8 million residents. Each network will offer appointments from 8am to 8pm on weekdays and for six hours at weekends, with same-day appointments within four hours for patients who need them. It has been awarded £5m – or around £2.77 per patient.
Dr Mark Grealy, a GP in Morecambe, Lancashire, led a successful £1.1m bid for four practices to open between 8am and 8pm, seven days a week, to make routine appointments and home visits more accessible for 61,000 patients.
He says: ‘What we are trying to do is avoid this influx of elderly patients to A&E, especially at weekends. We will be measuring and evaluating the scheme over the next year, perhaps at the six- and 12-month marks, to see if there has been a decrease in A&E attendances and admission rates in particular among this elderly population.’
But not all GPs are so positive about the scheme. A Pulse survey of 431 GPs reveals that 68% would not support moves to extend access, even if it was properly resourced. Some 58% of GPs surveyed think seven-day access will negatively affect the safety of patient care, as opposed to 17% who did not.
Dr James Kingsland, president of the National Association of Primary Care, submitted an unsuccessful £1.6m bid to the Challenge Fund to roll out his ‘never-full’ practice idea covering 40,000 patients. He says funding per patient has been dramatically reduced from when the Government first announced the scheme, which was supposed to benefit 500,000 patients at around £100 a head.
He says: ‘I don’t think there was one GP who was not interested in increasing access at that level. But they have ended up with schemes that are worth an average of £7 a head. You are not going to do transformational change on £7 a head.’
NHS England says the scheme’s funding is limited to one year and Pulse has learned that managers are expecting GPs to find alternative sources of funding from CCGs after the pilot ends.
An NHS England spokesperson says: ‘The successful pilots have had to demonstrate that they have clear, credible plans for delivering benefits to patients on an ongoing basis, beyond the lifetime of the pilots. The programme will produce evidence-based models of innovative practice and actionable learning about how best to implement them.’
‘From what I’ve seen they won’t be making any savings…’
Dr James Kingsland on what reduced QOF payments will do to CCG accounts
But the prospect of relying on funding from CCGs comes as they face deficits next year. A recent King’s Fund report warned that only a third of CCG financial leads are confident that they will have balanced their books by 2015/16.
Dr Kingsland says he believes funding of £40 per head of population is needed to fund extended access in general, but that CCGs are unlikely to have this level of spare cash, particularly as savings from the schemes are likely to be modest.
He says: ‘From what I’ve seen they won’t be making any savings. I don’t see that a Skype consultation will necessarily save the NHS money. The pilots are about meeting the needs of hardworking families, but I have no feeling that they will even help meet efficiency targets.’
Many GPs will remember the extended hours DES that was forced on the profession in the last few years of the previous Labour Government. In some PCT areas, utilisation of extended hours services reached barely half of the expected level – meaning GPs found themselves providing additional surgeries without being sufficiently reimbursed.
NHS England has said it will carry out an independent evaluation of the pilot schemes after they finish, and the GPC has warned that any extension of GP access must be based on evidence.
Dr Chaand Nagpaul, chair of the GPC, says: ‘Let’s not forget that we have already been down this road with the seven-day GP Darzi clinics and these were decommissioned because they did not provide value for money.
‘These pilots are not addressing the bottom line: GPs have inadequate resources and a lack of capacity to meet extra demand. They are overloaded and overstretched and we do not have the workforce to meet future demand and this is not going to be addressed through a short-term, one-year scheme like this.’
He calls for a commitment from Government on ‘extra sustained funding for GPs to meet future demand’.
Experts are also warning the two strategies of extending access for working people and providing continuity of care to avoid hospital admissions may work against each other.
Professor Martin Roland, professor of health services research at the University of Cambridge and a part-time GP in Cambridge, warns that the Government’s ‘populist fixation with opening hours’ will compromise care.
He says: ‘This flies in the face of what we increasingly know to be important about continuity of care.
‘Doctors need continuity to provide safe care, and our increasingly complex elderly patients need it too. When will the Government drop this populist fixation with opening hours?’
Meanwhile, Professor Richard Baker, a professor of healthcare quality at the University of Leicester, who has studied the relationship between continuity of care and A&E admissions, warns GPs are ‘overstretched’, and that asking practices to focus on extending access may have unintended consequences.
He says: ‘I think continuity of care is likely to decline in some of these schemes, and reduced continuity is associated with more admissions – particularly among patients with complex conditions. So there are likely to be unintended consequences because asking general practice to do something extra without new capacity will almost certainly mean other elements of care will not occur.’
Reducing A&E activity
But there are some positive signs. Seven-day access to GP services has been rolled out in several areas. In central Manchester, the CCG’s scheme to boost access to GPs was cited last year by the DH as a ‘successful’ blueprint for GPs.
That claim looked somewhat empty when Pulse discovered it was made before the scheme began, but GP leaders in the city now claim the scheme, which gives 50,000 local residents access to GP services between 8am and 8pm on weekdays and for three hours on Saturdays and Sundays for routine and emergency appointments, has already begun to reduce emergency activity.
Dr Ivan Benett, clinical director of Central Manchester CCG, says: ‘We estimate this has led to a 27% reduction in primary care attendance at Central Manchester University Hospitals NHS Foundation Trust A&E compared with last year.
‘There has also been a reduction of 50% of people turning up to A&E saying they are there because they could not get an appointment with their GP.’
Dr Benett says the scheme has already seen 3,000 people and will pay for itself: ‘I’m confident the extended hours will provide a better service and reduce urgent care activity so it will be self-funding.’
Elsewhere, 30 practices across NHS North Durham CCG have also been providing services at weekends to ease pressures on A&E during the winter months, after a £1m CCG cash injection.
A CCG spokesperson said 18,500 appointments were provided during the six-month period, adding: ‘There has been a reduction in urgent care activity for the duration of the scheme.’
Whether or not the national pilots prove successful, GP leaders say the political momentum has now shifted towards longer contracted hours for GPs.
Dr Robert Morley, chair of the GPC contracts and regulations subcommittee, says: ‘It seems to be the direction Number 10 is headed. We have these pilot projects and I am sure what the Government will do is look for whatever evidence they can that this pump-priming has been beneficial. They will try to roll it out but they have no intention of recurrent funding, he adds. ‘There is no way that the current levels of funding of the core GP contract allows general practice to be provided safely in the core hours, let alone extended hours.’
Dr George Rae, chief executive officer of Newcastle LMC and a member of GPC, says: ‘There is a concern the Government will try to put this in the contract. As a contractual requirement, this would not be possible with the current state of general practice.’
But with patients already asking their practices in some areas for evening and weekend appointments, GPs are facing rising pressure to open their doors 84 hours a week.