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Surviving the extended hours funding squeeze

Practices need to think creatively about how to manage their extended opening times in light of recent reductions in funding, says Dr Helen Clark

With the rude reality of a cut in funding for extended hours this year, GPs could not be blamed for feeling as betrayed as they initially did when the DES was foisted on the profession in 2008.

The service was always of dubious clinical benefit, and with a cut in 2011/12 from £3.01 per registered patient to £1.90, you may be wondering if it is worth running these surgeries at all.

For some practices the loss in funding may be a push too far. But others will opt for some smart thinking to retain much-needed practice funds and give their public relations a boost. In this article, I will look at the key aspects of the new deal you should consider and provide tips on how to make extended hours worth the money.

Review carefully what has changed

Although the cut in funding has been the most visible change, there are other new flexibilities in the DES that will benefit practices (see below).

Discuss the impact on your patients

Providing extended hours is a challenge, but it is worth taking a sober look in your practice at what these surgeries provide.

A surprise outcome for many GPs was the discovery that these surgeries – if managed well – could enhance the consultation experience and personalise care. GPs running these surgeries were freed from the interruptions of a typical busy and unpredictable day in general practice and had protected time to focus on the patient in front of them.

Often GPs have received hard-won acknowledgement and thanks from patients for what was recognised to be an extra service for them – and before you go any further, it is worth considering as a practice what the worth of this is.

Do a calculation of the popularity of extended-hours surgeries, and if necessary, a straw poll of patient opinion of them.

Do your sums

The reduction in funding will require a rethink even for those GPs who enjoyed running extended hours. It will simply not be cost-effective to provide doctor-led surgeries at the new rate on offer.

The DES directions published in April 2011 advise the formula for calculating the required time commitment of a practice offering the DES (see below).

This figure can be rounded up or down to the nearest quarter of an hour and the calculated time must be provided in full, but can be in one or more sessions of at least 30 minutes.

For a practice of 6,500 patients this will amount to three hours and 15 minutes. With remuneration at £1.90 per registered patient, such a practice will receive £73 per hour.

While this is not adequate to provide reception cover, overheads and payment for a GP, the figure might allow you to offer these services by employing other healthcare professionals instead.

Consider alternative staffing models

One of the welcome changes to extended hours is that appointments may be offered by any healthcare professional rather than GPs only, although practices will have to think smart.

Affordability of nursing staff will vary with the seniority of the practice nurse. You also need to consider any pay for what will, in effect, be extra work at unsociable times.

With nursing staff and healthcare assistants, it is clear that availability must be in addition to hours worked during core surgery times.

Where a practice has adequate reception staff to allow internal cover, receptionists may be given time in lieu for working extended hours and this could prove more cost-effective.

A practice must be sure, however, that its reception team has the capacity to deal with this on a regular basis as patient

safety and needs must come first at all times.

Reduce clinical risk

The greatest opportunity for practices with the new DES is apparent when considering what type of clinical work could best be achieved under the new regulations.

Certain activities may be too high-risk for health professionals working practically alone, particularly in smaller practices.

For example, immunisations and other injections, though generally safe, can sometimes result in emergency situations and a practice may prefer not to put its staff and patients in a position where they would be without support.

Providing a chaperone would be

a problem if a practice decided to provide extended-hours clinics for cervical cytology. But a practice may find it gets a competitive edge from offering a healthcare assistant-led registration clinic that could be publicised on their website and wherever else services are marketed.

For larger practices, concurrent working may be the solution. Consider cutting your GP’s time to half an hour and running another clinic alongside staffed by nurses and healthcare assistants, with the GP providing the required medical presence in the practice.

Communicate any changes

The cut in funding is likely to mean that patients lose the additional access they had to GPs in many practices, but patients often have a clear understanding of funding issues and rarely expect their GP to work for nothing.

Practices would be wise to explain the cut in funding to patients through patient participation groups. The majority of our patients value us highly, and they can be our allies if we use the new opportunities we have to educate them.

We need to tell them what we are doing and the difficulties we face. With effective public relations strategies such as patient meetings plus posters and leaflets that inform them of the reasons behind changes, patients have the potential to become the champions for a properly funded primary care service.

Ironically, this public relations work is now potentially funded by the Patient Participation DES, carved from the reduction in remuneration for extended hours.

Negotiate a local deal

Finally, we must not forget the possibility of negotiating a local enhanced service. With pressure on primary care organisations to maintain financial balance, there may not be the same scope to negotiate as there was in 2008, but access remains a focus in the new DES on patient participation and, as such, may warrant local solutions.

For these to become a reality, practices will need to be united in giving the message to their PCOs that the funding for the DES

is set too low to maintain the delivery model previously pursued. Creative thinking will be the name of the game and practices need to be very careful with the new extended hours DES that they do not end up working for nothing – or even working at a loss.

Most importantly, I think we should all be giving thought now to how we raise our profiles, market our wares and ensure that we exploit the new DES on patient participation to help us do it.

Dr Helen Clark is a GP in north-west London and a medical director of Londonwide LMCs

Changes to the extended hours DES 2011/12

• Funding reduced from £3.01 to £1.90 per registered patient
• Appointments may be offered by any healthcare professional, rather than GPs only
• No stipulation that one hour of extended opening must be delivered by a single GP working for an hour. Now it can be delivered by two GPs working in tandem for half an hour
• Surgeries may provide urgent as well as routine appointments
• Overall additional hours that have to be provided to qualify for the DES remain the same
• Additional hours may now be provided in blocks of 30 minutes or more rather than the minimum of blocks of one and a half hours required previously

DES formula

Contractor’s registered patients x 30 minutes

Surviving the extended hours funding squeeze