Should general practices open for longer?

Demise of out of hours care

The model of delivering primary care in England has been evolving since the inception of the NHS in 1948. A pivotal moment in this evolution was the renegotiation of the general practice contract implemented in April 2004. This allowed general practitioners to opt out of out of hours care and determined core contract hours for delivery to be from 8 am to 6.30 pm, weekdays only.3 Since then, urgent care provision has incrementally come under extreme pressure in all sectors of the NHS and access to routine appointments remains a national concern.

A central focus of the current NHS reorganisation is to find a remedy for the increasing demand on urgent care systems. Patients are increasingly using emergency departments for non-emergency care; more and more people are presenting for routine ambulatory care and sometimes with simple self limiting illnesses.

Some patients refer themselves to emergency departments when unable to see a GP within two weekdays,4 and recent research has shown that more accessible general practices in England have fewer emergency department visits per registered patient.5

Other solutions have been ineffective

Walk-in centres and NHS Direct have not had the expected effect on reducing inappropriate or unnecessary contacts with emergency departments or out of hours primary care services. The solution to the NHS’s current fiscal challenges, and potential compromises in productivity and quality, should focus therefore on improving access to primary care services, both in terms of availability and the range of services provided. Indeed, a 1% increase in the proportion of patients able to access their doctor in general practice is associated with a £20 000 (€24 000; $32 000) annual cost saving for the average practice.6

Waiting for access to NHS care has always been the public’s main concern about our most loved public service.7 The last Labour government acknowledged this concern by making shorter waiting times and improved responsiveness throughout the service a key target. Specifically, the NHS plan of July 2000 stated that by 2004 all patients should be able to see a general practitioner within 48 hours of their request.8

However, the main endeavour was delivery of an 18 week target in secondary care from referral to treatment, and no longer than a four hour wait in emergency departments. Access to general practice did not receive such detailed attention.

The “advanced access” programme designed in the United States and implemented in the NHS aimed to tackle unacceptable waiting times for GP appointments by increasing the proportion of same day appointments. However, it led to only slightly faster access to appointments and made it harder to book appointments in advance. It failed to tackle more availability through longer opening hours.9

Too often access has been regarded as a single activity, focusing on the time to see a healthcare professional from the moment of request. Equally important is the type, range, and quality of care as well as the availability of services throughout the week. There seems little point in expanding the capacity of the primary care system with longer opening hours without increasing its capability to complete more episodes of care out of hospital. The US Agency for Healthcare Research and Quality “primary care medical home” is a model for transforming the organisation and delivery of primary care to provide high quality, accessible, and efficient healthcare for all citizens.10 It has already been incorporated into many English general practices. In addition to longer opening hours, we need to upgrade the provision of care.

New ways of working

On 1 October, the Department of Health in England and the Prime Minister’s Office announced proposals for improving access to general practice. The aim is to create a £50m fund for a pilot programme to make it easier for people to see their family doctor from 8 am to 8 pm, seven days a week. These pioneer sites will also test several virtual consultation methods using existing information technology, and form part of a wider plan to strengthen out of hospital care. It is expected that this programme will roll out across the country from April 2014.

With extra funding from our clinical commissioning group at £30 per head of registered population, my practice has devised new ways of working, facilitating same day, urgent, and prebookable appointments within extended hours to meet the needs of our registered population. We call this the “never full practice.” We have also focused on delivering a good work-life balance, with staff involved in the design and choice of new working hours, rewards for innovative services, and encouraging high personal esteem among the team.

I was lecturing recently at a college that trains allied healthcare professionals. Its maxim is “training tomorrow’s health carers today.” It made me wonder for how much longer we can tolerate some general practices continuing to treat today’s illnesses tomorrow.

Unsustainable demand for care

Our demographics mean that the present system may become unaffordable within the next decade, yet politicians still promise a gold plated service run on a tight financial base. The proportion of UK gross domestic product spent on healthcare is lower than in most of the Western world.

Media pressure persuades patients that they should demand attention for many minor conditions and self limiting conditions that in the past would not have been medicalised. This demand is fuelled by politicians, who find it hard to tell their voters—our patients—that there is a limit to what can be provided by an NHS funded from general taxation.

The average consultation rate in general practice has risen substantially and seems to be rising exponentially. The rate for 1981 was an average 3.1 consultations a year for each registered patient; in 1995 it was 3.88; and in 2008, the latest year for which government statistics are available, it was 5.45.11 Anecdotal evidence from member practices of the Family Doctor Association suggests that this rate is now nearer to 8.

Between 1999 and 2009, the average consultation rate for patients aged 85-89 rose by 95%. This vast rise in demand has not been balanced by a rise in the number of whole time equivalent GPs, and although the government will say that there are more GPs, it is strangely quiet on numbers of whole time equivalents. What is clear is that the number of consultants working in emergency departments has risen more in line with the demand than has the number of GPs (a 140% increase in consultants compared with 25% increase in GPs from 2000 to 2012).12 13

The continuing pressure of increased workload not matched with increased resources is leading to a crisis of morale in ordinary, frontline general practice, additionally fuelled by imposed changes to pensions and contracts. The imposition of this year’s contract changes has caused time, workload, and morale constraints in practices.

Evidence indicates that continuity of personal care in general practice reduces whole system costs.6 This is at risk from longer opening hours. Doctors can only work so many hours, so longer opening makes it more likely that a patient’s usual doctor will be unavailable at a the time convenient to the patient.

Evidence does not support 8 to 8 opening

We have a clear model of the cost and benefit of 8 am to 8 pm, seven days a week opening from Darzi centres. These 8-8 centres were imposed on every English primary care trust, whether or not there was local need. The first opened on 1 November 2008. The £250m equitable access fund was nearly completely swallowed by these centres and ordinary practices could not bid for this money for service provision.

The economics of these centres must be called into question.14 According to Practice Business magazine15 in a 2011 survey of 95 primary care trusts (out of 150), 12% had no registered patients, one had one registered patient, 28% had fewer than 500 registered patients, and 35% had fewer than 1000. Those centres are extremely well funded by comparison with ordinary general practices. For example, the Adelaide Surgery in Southampton in 2011-12 had 1200 registered patients and funding of £907 000, or £743 a patient a year. Comparable figures for general practice range from £58-£120 a patient a year. Some primary care trusts decommissioned their Darzi centres, the first being Stockport, whose trust branded the centre an “unaffordable luxury.”16

The widely quoted paper by Cowling and colleagues,5 which makes a case for the rise in attendances at emergency departments being linked to accessibility of GPs, bases a large part of its argument on the annual Ipsos MORI GP patient survey.7 By its very nature, this survey tends to be filled in more by the worried well and much less by those whose first language is not English and by hard to reach populations. Cowling and colleagues also quote as one of the main sources for the reason that patients choose to go to emergency departments rather than calling on their GP, a study by Agarwal and colleagues of patients who attended an emergency department in Leicester.4 The paper was based on interviews with only 23 patients and they were not only those who had self selected but included ambulance admissions and patients attending the urgent care centre, not just the major trauma centre.

The way forward

We need honesty about what level of service the NHS should provide. Is it there to satisfy health needs or health wants? We increasingly have a system funded for needs and charged to deliver wants. Some practices provide hand-outs for patients advising how and when to access healthcare. Although some Darzi centres provide excellent care, the evidence is that the 8-8, 7/7 model is extremely expensive and requires funds considerably beyond the reach of ordinary general practices, whether working alone or in groups. Were the funding now spent on Darzi centres and walk-in centres given back to practices, the excellent service demanded by our patients would be nearer to our grasp.