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GPs vote against increased access in general practice

Introducing weekend and evening opening hours in general practice will be harmful to patients, GPs at the Pulse Live event in Manchester said today.

Following the Big Debate at the conference this morning, headlined ‘Access: is it harmful?’, the majority of delegates concluded that the funding for extending access could be better spent on other services, while local leaders expressed concern that pilots will not be able to reduce demand on secondary care.

The Government has made moves towards extended access, including providing £50m central funding to GP practices across England.

But this vote follows similar expressions of disapproval from the profession, including a Pulse survey earlier this year - which found that 58% of GPs said it will harm patient care - and the LMCs conference, which voted against extending access, even if it were properly resourced.

Speaking against increased access, Manchester LMC honorary secretary Dr Tracey Vell argued that the Greater Manchester seven-day access scheme - previously reported on by Pulse - was not a good use of resource.

She said: ‘In Manchester there is extended access 6pm-8pm every night at a remote practice, it is not held at your own practice and it is with a GP who is not your GP. It also occurs three hours on the weekend on Saturday and Sunday. This costs almost £500,000 for six months.’

‘The access is for a pre-booked, routine appointment with a GP. This means they don’t have access to any investigation, but they do have access to your notes, which you give consent to merely by arriving there at your pre-booked appointment.’

She said there were already services that are aimed at reducing admissions.

Dr Vell added: ‘If GP access on remote sites away from the hospital could reduce visitors to A&E departments then walk-in centres and out-of-hours services surely would already have achieved it.’

‘In Manchester we spend on all three things at the same time: we spend on out of hours, we spend on extended access, and we also nationally spend on NHS 111. A waste of money and resource when we are not looking at the questions of why people are visiting A&E.’

In favour, John Boyington, a lay non-executive director at a GP federation in Bury, which has provided seven-day access under the Greater Manchester scheme, said that there was already 6% fewer attendances with minor illness at the local A&E, according to figures for the first few months of the scheme.

He said that access should not be ‘designed to fit one-size-fits-all’.

Mr Boyington added: ‘At the moment, people access a range of services when they can’t access their GP in what they consider to be a timely manner. There is a debate about need versus want but we should put such a clear delineation because at the end of the day it is always the patient who develops the first view about whether they need a service.’

‘All that happens if you [restrict access] is people take their demand elsewhere.’

Meanwhile, Londonwide LMCs chief executive Dr Michelle Drage said she was ‘on the fence’, but added: ‘If you did have the resources and you were able to provide a service where patients have coordinated care as they go through the service, then of course access to that level of service would be great - [but] the reality is we don’t have them.’

Readers' comments (7)

  • Vinci Ho

    I think the word 'demand' should be rephrased as 'false expectation ':
    Clearly, we are talking about having 'A GP ' available 7 days a week for that time period. But the false expectation created in the public(facilitated by the media) can be easily ' your GP available for 7 days' .
    After all , what is the bl**dy hell difference between this and a modified/improved version of currently existing out of hour service with the appropriate funding.
    Don't give me that crap that we need to try different 'model' to meet the local needs!!!

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  • Ivan Benett

    Not for the first time Dr Vell hasn't quite understood the extended hours scheme in Central Manchester, nor portrayed it accurately. It is part of a system wide range of changes to reduce hospital activity and get people to attend for urgent care problems in Primary care rather than go to A&E. It also provides extra capacity to manage long term conditions.
    She is right to say that at the moment there isn't access to the full range of Primary Care, including diagnostics, but that will come as the service becomes embedded. Soon A&E will be able to book in, and ultimately the patient themselves.
    She also chooses to ignore the evidence that increasingly suggests that quality outcomes are associated with better access (1). Poor outcomes are also associated with less good access including attendance at A&E (2) and acute presentations of cancer (3). She will know from our own experience in Manchester that better pro-active management of long term conditions also reduces unnecessary admissions. This requires better access to expert advice within the practice, both in terms of holistic care and medicines optimisation, but also prompt access to advice and intervention before people become so ill as to need admission.
    The system wide changes, including extended hours, in Central Manchester has been associated with a reduction in urgent care demand which bucks the trend elsewhere. Compared to the same time last year we have seen a 27% ↓ in Primary Care stream at weekends; 38% ↓ in Primary care stream Mon-Friday; 50% reduction in people attending ‘because they couldn’t get an appointment with the GP’. 95% of population is covered by practices agreeing to be measured by the responsiveness standards, 99% of people in those practices receiving care according to clinically assessed need. There has been a >20% reduction in costs and activity for those managed through integrated care teams. Whole population has access to 8-8 during the week and 3hrs on Saturday & Sunday, well except patients at her own practice. It seems to me strange that she would prefer her patients to be seen by a junior doctor in A&E who does not have the benefit of viewing the patient’s notes, than be seen locally by a local GP who can view the patient records and enter the consultation within those records.
    Now, the extended hours service isn’t perfect, and there are many adjustments being made to improve cost effectiveness and better match demand to capacity. It has only been going for 6 months and there has been an uptake phase. I don’t believe we will see the full benefit until it has been going for at least a year, and after it begins to provide full Primary care. Meanwhile, has anyone got any better ideas?
    1. Raleigh V, Frosini F Improving GP services in England: exploring the association between quality of¬ care and the experience of patients. The Kings Fund, November 2012
    2. Cowling TE, Cecil EV, Soljak MA, Lee JT, Millett C, et al. (2013) Access to Primary Care and Visits to Emergency Departments in England: A Cross-Sectional, Population-Based Study. PLoS ONE 8(6): e66699. doi:10.1371/journal.pone.0066699
    3. Bottle A, Tsang C, Parsons C, Majeed A, Soljak M, Aylin P (2012). ‘Association between patient and general practice characteristics and unplanned first-time admissions for cancer: observational study’. British Journal of Cancer, advance online publication, 24 July. doi:10.1038/bjc.2012.320.

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  • Harry Longman

    Yes, there is some emergency demand best dealt with in primary care, but no, spending huge sums on prebooked routine appts out of hours is a waste of scarce resources. Access to notes is one thing, but it is NOT relationship continuity and the literature shows that this is the driver of better quality and lower resource use, elective and emergency.

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  • Ivan Benett

    I think it's about getting the balance right and getting the planned and urgent care capacity to fit the demand. The literature is a bit equivocal, actually, on the benefit of relationship continuity, but on balance it is obviously a good thing. However, some trade access for continuity depending on the situation. Timelness is often chosen over continuity for urgent problems, especially for children. Continuity is preferred for the elderly, people with longterm or emotional issues, and women.
    Continuity however, risks collusion with the patient e.g. sickness behaviour and other pathological relationships (see Eric Berne 'Games people play')
    On the whole I don't think it's a choice between access or relationship continuity, it's having both for the right occasion. Besides, you can't have continuity without access!

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  • Almost all patients seen in OOH settings never needed to be seen or could easily have been dealt with in own practices - in normal working hours.

    There needs to be a convenience charge to stop people just popping in after work as they see it as a 24hr market culture.

    Banks don't open usually outside 9-5 though online resources and call centres may help - just like OOH advice lines and NHS direct website for guiding those in real need what they should do.

    GP surgeries are small businesses as well as care providers, and primary care needs resources if you are going to push boundaries.

    However this needs to be costed in a shrinking financial environment and is this really cost effective use of resources and manpower.

    Only Accidents and Emergencies should be going to A&E - redirect all else to Primary care in/out hours.

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  • Without funding you just thin out the numbers over more hours. this just makes life more miserable unless there are enough GPs out there to fill in. Build another lane on the M25 traffic congestion eases for a few months, more people use the service and it backs up again. Same in GP land. Extending hours did not lessen in hours demand, just made me increase hours to 50 or so and be exceptionally grumpy when consulting on extended hours days and missing my kids sports on Saturday morning and not getting a lay-in.
    All part of recover from a tough working week!

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  • Without funding you just thin out the numbers over more hours. this just makes life more miserable unless there are enough GPs out there to fill in. Build another lane on the M25 traffic congestion eases for a few months, more people use the service and it backs up again. Same in GP land. Extending hours did not lessen in hours demand, just made me increase hours to 50 or so and be exceptionally grumpy when consulting on extended hours days and missing my kids sports on Saturday morning and not getting a lay-in.
    All part of recover from a tough working week!

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