Accessibility of primary care in the UK has been promoted through a pay for performance scheme since 2004. It has a short but complicated history with many changes in monitoring and financial incentives.1-4 Payments were made through the Quality and Outcomes Framework (QOF) and depended on patient satisfaction in the General Practice Patient Survey (GPPS)) between 2008 and 2011. The GPPS is a national postal survey of patient opinion, which has been conducted annually since 2006.5
A separate scheme for extended hours commenced in 2008. This enables practices to earn additional income by offering appointments outside the core contracted hours of 8 am to 6.30 pm on weekdays. ‘The intended outcome is an increase in patients’ access to GPs at times outside current contracted hours, while standards of access and availability during contracted hours are at least maintained.'6 The payments for the extended hours scheme do not depend on patient satisfaction.
An annual payment of £2.95 per registered patient was available for offering extended hours. This equated to approximately £5600 of gross annual income per primary care physician.6-9 To qualify for the national scheme, practices had to comply with several conditions, listed in Box 1.
Local primary care trusts (PCTs) were given flexibility on how to adopt the national requirements. Uniformity of terms and conditions was also affected by a delay in the issuing of national specifications and many practices agreed a Local Enhanced Service (LES) instead of the national Designated Enhanced Service (DES). The national guidance stated that ‘PCTs should particularly assess whether their scheme delivers the same or a broadly similar outcome to that expected from the DES’, but there is no report on how closely this has been followed.6
Normally a DES obliges PCTs to ensure the service is available to all patients, as is the case with vaccinations and minor surgery. However, for the extended hours DES the minimum target was to engage 50% of the practices in each PCT. The uptake per PCT is monitored and published by the Department of Health.10,11
The hypothesis behind the study was that practices with capacity problems might be more likely to sign up to extended hours, possibly prompted by lower satisfaction survey results. The benefits of the extended hours scheme could be threefold. First, increasing capacity through extended hours generates additional income, where doing so within the core hours does not. Second, survey results for access might improve, generating additional income through the Quality and Outcomes Framework. Third, pressure on core-hours appointments would decrease and this would help the efficiency of the front office.
This report examines how the introduction of the extended hours scheme affected patient opinion and satisfaction in the GP Patient Survey.
How this fits in
There is high satisfaction with opening hours in the UK GP Patient Surveys despite perceived difficulties with access to primary care. Financial incentives to improve access and convenience were introduced in 2004. Offering additional capacity has led to a small relative improvement in patient satisfaction with opening hours. However, only capacity in the form of Saturday appointments reduces patient demand for appointments outside office hours. The extended hours scheme provides a financial incentive to make more appointments available. The scheme rewards practices irrespective of whether patient demand is met. Offering additional appointments does not generate additional income from the Quality and Outcomes Framework, despite Saturday appointments having a small effect on the income generating questions.
