Enhanced access: Not enough hours in a day

With the countdown to enhanced access well under way, PCNs discuss how they will find the capacity to provide the extra evening and weekend appointments for patients. Emma Wilkinson reports

A choppy start to the new PCN DES has left clinical directors (CDs) trying to navigate the new enhanced access service at a time of change and uncertainty.

General practice remains under huge pressure. Recent data show that GP appointments increased so sharply in May that they boosted national GDP. At the BMA Annual Representatives Meeting at the end of June, frustrated GPs voted to withdraw practices from PCNs by next year.

Clinical commissioning groups (CCGs) have given way to integrated care systems (ICSs). Looking to this new future, the Fuller stocktake described urgent same-day appointments being delivered by ‘single, urgent care teams’ across larger populations.

Against this backdrop, PCN CDs say they are taking a pragmatic approach to enhanced access. For those hours, 6.30 to 8pm on weekdays and all day on Saturdays, the overriding message is that they will not just do more of the same.

Blended model

Dr Simone Yule, CD at The Vale (BVP) Network in Dorset, said her PCN’s aim is to deliver something that addresses wellbeing, prevention, and supporting ‘high intensity’ patients who may have low-level but unaddressed mental health needs.

Historically she notes when funding has come into primary care for additional capacity it’s been swallowed up by urgent care. ‘We’re stuck on a hamster wheel of activity, and it could be that some of this capacity supports moving to a more proactive approach.’

Her PCN is opting for a blended model. For the evening hours it will look to the community trust, which already does some urgent care, to provide some phone triage and GP appointments. This will be under the oversight of the PCN rather than the CCG or integrated care board (ICB) so the PCN can influence the service.

‘We don’t just want to be an extension of the urgent care service; we are trying to think about wellbeing too. We have done some patient questionnaires and had a real mix of responses so we’re trying to accommodate as much of that as we can.’

That includes a physiotherapist doing a clinic once a month and some social prescribers. The PCN is also considering a yoga group. Some of these decisions are driven by the shortage of GPs. They can’t work 16-hour days and a Saturday as well. Dr Yule’s own practice has been trying to recruit a partner for over a year.

One slight worry is that the PCN had built a good relationship with the CCG. Colleagues there understood what general practice was up against. But the move to an ICS has produced some uncertainty. ‘I am slightly anxious there might be pressure to morph it into urgent care but this shouldn’t be about propping up emergency services.

‘I really hope we can maintain this as a wellbeing offer, and doing vaccinations and managing long-term conditions,’ she says. ‘It’s about ensuring there’s flexibility to meet patient needs but it will be dependent on the workforce we have to deliver it.’

Building on vaccination service

In North Hampshire, staff shortages plus the soaring success of their collaborative vaccination service have formed the basis of the enhanced access plan, explains Tim Cooper, CD for Whitewater Loddon PCN.

‘We’re aiming to build on our shared Covid vaccination service to deliver the Saturday element. This would be six PCNs collaborating in a single space, with vaccinations, health checks and group consultations,’ he says.

The PCN had already had discussions about how to make good use of the keen and engaged staff that were trained to deliver Covid jabs. ‘We still vaccinate but we’re also trying to do a bit more with staff who work for us, such as health checks, health promotion, all these things we couldn’t do for a lot of the pandemic and don’t have time for in day-to-day practice.’

The PCNs see the value of collaboration in minimising the impact of other changes as and when they come in. They would rather do that work now, he adds. A key part of that will be rigorous data collection to show what works. The problem is ‘you won’t see the value of much of this for another five or six years’.

Despite all the talk of modernising general practice and using new roles, this still looks like the contract from 15 years ago, he adds. ‘It’s time for general practice to be braver and bolder’ in changing the way it operates, he says, really looking at population health management. Individual PCNs don’t have the workforce to offer this, but there is power in collaboration across the 15 PCN practices, he believes.

One group session his PCN is hosting is for new parents. They were coming to the GP with feeding and nutrition questions after the decline of local health visiting services and Sure Start schemes. 

‘We looked at what consultations we were having and thought we should pick up people who have had a baby in the past 10 months and invite them in [for a group consultation]. The most effective aspect is the relationships that people build with each other.’

The biggest challenge is trying to create capacity in general practice, he says. ‘We have staff working in the vaccination site who are new and really want to help, then there are the people in the practice who say they can’t tolerate taking on any more work. We’re trying to match up those two things.’

If he went to his staff and said ‘congratulations you’re on a rota for one in four evenings and weekends’ they would all say, ‘okay, we’re off to work elsewhere’, he says. ‘We’re trying to take the contractual requirement and make it work.’

Hybrid approach

In Warrington, Cheshire, there has been a difference in approach between the PCNs, says Dr Laura Mount, CD at Central and West Warrington PCN. The other four PCNs are outsourcing the enhanced access hours but hers has opted for a hybrid model in its six practices.

‘There’s a lead practice that has been selected because it already had a contract to provide evenings and weekend care in the CCG and it didn’t want to lose those staff. It has taken responsibility for weekends and Fridays and the other practices are doing a night each during the week,’ she says.

As per the specifications, her PCN has to keep a GP on site but it is also trying to offer a range of other appointments, including access to a phlebotomy nurse, nurse associate and a mental health nurse. Any patient at any practice can book. 

Some of the logistics have not been easy, such as the need to have a central phone number patients can call to cancel an appointment, a logistical hurdle that was surprisingly hard to solve. Dr Mount’s practice also had to move from EMIS to SystmOne after realising all the practices needed to be on the same system. ‘That was a huge amount of work. We had a two-week blackout where we could record things on EMIS but they wouldn’t transfer over so we had to do it all manually.’

But the biggest headache has been the insistence by the CCG that they conduct a 12-week patient consultation because the plan involved changing location from the current extended access provider that operates from a building in the centre of town. It had to be signed off by the health scrutiny committee, which only meets every three months.

For Dr Mount, this didn’t seem a proportional response because the contract was ending anyway and the aim was to bring the service closer to patients. ‘This is a national direction, PCNs have been asked to do this but the CCG insisted it went out to consultation.’

She makes the point that demand is so huge, however many other appointments they offer, they are barely scratching the surface. 

Pre-bookable slots

This sentiment is shared by Dr Tom Rustom, CD at Healthy Horley PCN in Surrey, who says it is like opening up an extra lane on the motorway, which will always get filled.

His PCN began doing Saturday clinics a few months ago to try to ease the massive on-the-day urgent demand. It involves a nurse-led smear clinic and a healthcare assistant doing health checks. They use weekends when it’s quieter to do learning disability health checks, which can be quite important for people with anxiety, he says.

‘We’ve usually got one or two allied health professionals, a physician associate (PA) or paramedic, and a GP as well,’ he explains. ‘We initially started using it as an overflow, so three or four days beforehand we would open those appointments but we’ve now made it pre-bookable much further in advance.’

It has been very popular, he says, not least because patients are not seeing locums, but members of the practice team they know. The PCN was lucky in having staff who were keen to work those hours – an area he knows other PCNs are really struggling with. 

‘The whole governance structure is subcontracted through our GP federation, so although it’s delivered by the usual people, the risk is taken away, which is reassuring.’

For weekday evenings, the plan is to have a remote GP service either managing e-consultations or doing video consultations. ‘It will be a pilot scheme by a local pool of remote GPs.’

He adds there is potential down the line for other approaches, such as group consultations. ‘I think at this point, with the pressures on general practice, it is really important to have extra appointments that patients can book into because we get hammered during the week.’ 

But it was clear that whatever the PCN offered, it had to be a planned service, rather than more urgent on-the-day appointments, not least because the digital infrastructure to allow enhanced access is ‘woefully inadequate’, he says. It is an issue that frequently pops up in PCN leader discussions on WhatsApp.

‘Because we’ve controlled it and made it very clear what the type of appointments are, staff go in knowing what they’re going to do and are comfortable with that.’

Dr Rustom was concerned when the DES first came out that it was far too prescriptive but in reality it  asked what was needed, what the PCN wanted to do ‘because there’s no point in telling us what to do if we haven’t got anyone to do it’.

Gathering the right data

In Gateshead, Tyne and Wear, the PCN looked at what practices were already dealing with. As a result, it is putting on the brakes a little. As in Surrey, the practices were already doing the required number of extra hours, though not necessarily at the specified times because previous surveys had told them their patients wanted early mornings. The practices already offer minor surgery and smears on a Saturday as a way to make best use of their limited estate.

But the data could not tell the PCN what services were needed, because nothing is operating ‘as usual’ at the moment.

Sheinaz Stansfield, director of transformation for Birtley Oxford Terrace PCN in Gateshead, explains that the current period of ‘special cause variation’ with high waiting lists, GPs dealing with the overflow from secondary care, pressures on emergency services and rising Covid cases mean they cannot work out the real patient need.

‘It’s all contributing to failure demand. Our patients are being bounced around the system and are not getting what they need first time round. All that contributes to us not having real data to make decisions about a service.’

The PCN also had to contend with the fact that that provision through the federation was funded for another year and if it pulled out everything would be destabilised. Instead the PCN has worked to find
a different solution.

‘We’ve been talking to the CCG  and federation about a pilot that will tell us what the real need is in general practice. From October to March we’re going to measure demand, so from April we can have conversations.’

It ties in neatly with the Fuller stocktake, she says, and the model that is being proposed in localities. ‘If 40% of people are coming with mental health problems, we will look at a mental health practitioner; if the patients are really complex we will need a complex case management approach,’ she says. 

‘We didn’t just want to do a finger-in-the-air exercise. We are already providing the hours but not all the opening times. We’re going to maintain the status quo with the current providers [and also] conduct a pilot to work out what the model should be.’

She says the enhanced access service seems to be a precursor to Fuller and as such it’s worth taking a step back. ‘This is our opportunity to get data. Everyone is signed up to working like this.

‘Nobody knows what the real demand is. We don’t have the data so we’re taking a pragmatic approach. It’s a precursor to scaled-up general practice.’