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Professor Martin Roland: GPs need continuity to provide safe care

The Government’s ‘fixation’ with longer GP opening sees it investing money in the wrong place, argues Professor Martin Roland.

So £50m is going to be spent on extending GP opening hours. Inevitably this means that patients will find it harder to see their own doctor (even if they know who he or she is). This flies in the face of what we increasingly know to be important about continuity of care.

NHS England recently produced analyses that show that emergency admissions for ambulatory care sensitive conditions are most impacted by responses to the GP Patient Survey in terms of:

  • Ability to see your preferred GP (for patients who say they have one)
  • Ability to speak to someone at the surgery on the phone

We have a forthcoming publication (in Emergency Medical Journal), also looking at GP Patient Survey scores, which shows that out-of-hours attendance relates to:

  • Convenience of opening hours (the strongest predictor among a range of access variables)
  • Ability to see your preferred GP (for patients who say they have one)

Surprisingly the relationship with convenience of opening hours was strongest for those not in work, suggesting that extended hours isn’t necessarily the answer. This also fits work recently done for the Department of Health evaluating the GP Choice pilots, which showed that weekend opening (Saturday and Sunday) was not an important factor in determining patients’ choice of practice.

Professor Richard Baker, professor of quality in healthcare at Leicester University, has also done research which shows that attendance at A&E is related to the ability to see a doctor of your choice in your practice.

Taken together this provides support for Jeremy Hunt’s focus on having an identifiable doctor responsible for patient’s care (in both hospital and general practice). Yet what’s the money being spent on? Longer opening hours.

Getting to see any old doctor is at times important for patients, but many people want to see a doctor they know and doctors find it very hard to deliver high quality care to patients (especially complex ones) who they don’t know. Practices need to be organised to provide this, and not just be open for longer hours. This is fully in line with the ‘responsible doctor’ agenda that the Secretary of State is already promoting, but seems to be at odds with the £50m Prime Minister’s Challenge which is all about opening hours.

The DH often looks to the US (perhaps surprisingly) for models of care. When I talk to American colleagues, they’re amazed that English patients can’t identify ‘my doctor’. 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?

Professor Martin Roland (@ProfRoland) is professor of health services research at the University of Cambridge and a part-time GP in Cambridge.

This article first featured as a blog for the Cambridge Centre for Health Services Research (CCHSR)

 

 

Readers' comments (9)

  • Ivan Benett

    Continuity is important for people most of the time, especially the elderly, and those with multiple or complex problems. But when people feel ill and perceive that they need to be seen urgently they would rather be seen quickly. The GP survey clearly shows an inverse association between GP access and attendance at ED.
    In our extended surgery pilot in Central Manchester we are starting to show changes. Compared with the same time last year A&E attendance overall has levelled out. There is a reduction in people attending the 'Primary care stream' by about 27%. The proportion of people attending because 'they can't get an appointment with the GP' has fallen by 50%. Of those attending the extended hours surgeries one in five said they would have gone to A&E if that appointment wasn't available.
    I wouldn't dream of picking a fight with Martin, but there's more to help seeking behaviour than continuity, or else why would so many choose to wait 4 hours at a noisy crowded and often smelly A&E department?

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  • martin is right and has a good evidence base and his ethos is of principled patient centred evidence based care..not a weak willed giving in to an ignorant consumerist .me,me, agenda supported by a mendacious government and its useful idiots hangers on that will divert more scarce resources from genuine patient care.
    no,gp shpuld touch with a bargepole this government responsible for such pathetic utterly disgraceful farces as nhs 111 and many other lunacies....................

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  • Dear Ivan, here we go again.
    You have noted that patients attending A and E because they cannot get appointment in with their GP has fallen by 50%. Do you not think that if more money is invested in the GP surgeries and there are more practitioners hence more appointments, will this not be money spent in the right direction.
    Secondly,you stated that 'Of those attending the extended hours surgeries one in five said they would have gone to A&E if that appointment wasn't available'. Is this because the appointment was convenient or because the appointment was necessary?
    Yet out of hours doctors are supposed to start seeing patients from 18:30hrs. (Money is also spent on this)
    Your statistics are exactly as erroneous as the DH's statistics of co-relating rise in A and E attendance to the 2004 GP contract. They show weak 'co-relations', not cause and effect.
    This £50million is money spent in the wrong direction and is just propaganda.

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  • Ivan Benett

    I think annon 12.06 has missed the point. Money IS being spent in those surgeries to expand capacity in Primary Care. This is exactly what he is asking for. Seeing more urgent care in the extended hours means more time to see people with longterm conditions who can access the GP they want to - so better continuity.
    It's not either/or its both availability for those who want it, and continuity for those who need it, by investment in GP practices. I don't see your problem.
    As for Annon 1.06am I don't know what point you're trying to make but see previous answer.

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  • Its simple - You can either have continuity of care or Extended opening hours..You simply cannot have both unless you are willing to provide a long term substantial financial commitment to funding General practice.

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  • Ivan Benett

    Well done, that's exactly the point. We want long term extra funding for both. We wont get it unless we can show it can be delivered. We will get it if we can show it reduces hospital activity. It IS simple, but rather than complain, we need to get on and do it. Then we can show why we need those extra GPs and that we can provide the care necessary to take activity out of hospital. It's reallly not that difficult to understand

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  • Ivan Benett

    No one has ever suggested, certainly not me, that this all happens within existing resources. There has to be a substantial shift out of hospital and into Primary care. I have said 12% shift from in hospital to out of hospital....but that's a guestimate, don't quote me, but it's that order of magnitude we need. In Greater Manchester that's £72M. That's a lot of money and we need to get on with it quickly without destabilisaing the rest of the system too much. So lets stop arguing whether it's continuity or extended hours. It's both, so we can manage urgent care and panned care out of hospital

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  • and ivan what is your response to martin rolands article.and hard evidence....i see you have no substantive response..seems naive to think that if your scheme reduces aed admissions that more resources would go into primary care..this has never happened before ...esp as kings fund report has debunked the notion that lack of access has increased aed attendances.
    please explain why seeing more people in extended hours provides more time for routine issues when there is no increase in gp numbers or time..clearly it will reduce dr appts. in standard hours.i don't think you have answered any of the points made yet

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  • We need nominal charges to see GPs, and higher charges to be seen in A&E unless sent by a GP. A subscription service will not work as that will encourage people to make use of the payment and get their money's worth.

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