Seven day access to routine care in general practice

Few would disagree that good access to general practice is important. It is a prerequisite for delivering safe, effective, and equitable care and fundamental to reducing pressure on hospitals. But there is little agreement about whether the current level of access is acceptable, what are reasonable public expectations, and how much additional investment is required to increase access.

Current government policy guarantees evening and weekend access to routine general practice services for all patients by 2020. Despite giving some ground in recent policy announcements,1 politicians are unlikely to back away from this commitment; they see improving access as a vote winner.

GPs disagree that improving access is a top priority for patients, and the data seem to support their view. The 2016 annual patient survey2 found that 85% of patients were able to see a GP of their choosing within a few days; 75.9% of patients were satisfied with their practice’s opening hours, and less than half were in favour of Sunday opening. Indeed, some of the pilot schemes shut down because of lack of demand.3 A poll carried out by the Royal College of General Practitioners in 2015 found that 66% of patients who responded thought protecting existing services was a higher priority than introducing seven day access.4

It appears, counterintuitively, that reasonable access is being provided despite an increase in the number, duration, and complexity of consultations over the past decade.56 This has been achieved by practices working both harder and smarter. But professional leaders point out that practice teams are now experiencing unsustainable pressure, and there is some evidence that patient satisfaction with access is starting to decline.7

The Public Accounts Committee, which provides cross party scrutiny of public expenditure in the UK, has now entered the fray with its second report on general practice access in 12 months.8 The main findings are typically hard hitting: the government is rolling out extended hours in the absence of data about need, demand, or resource requirements, with little thought about value for money or the effect on continuity of care, and in particular without a credible plan to develop a sustainable primary care workforce.

The absence of data to support extended opening is particularly remarkable. The Department of Health knows how long practices are open but nothing about appointment times, duration, or who is providing care. This is in marked contrast to the acute sector, where rich data sources enable NHS England to know what is happening in hospitals in near real time.

Good access to services is largely dependent on having an adequate workforce, and the committee’s report is highly critical of government progress in this area too. It highlights that the number of full time equivalent GPs is dropping rather than increasing as planned—there were 97 fewer GPs in September 2016 than in 2015. The proportion of GP training schemes filled was slightly higher in 2017 than 2016 but remains below target. The same is true for the expansion of the non-medical primary care workforce, where much is promised but implementation has been slow.9 Few doubt the commitment of workforce planners, but GPs remain sceptical that the plans are deliverable.

The Public Accounts Committee highlights other challenges. It reports that 46% of practices were closed to patients during “core hours” (8 am to 6.30 pm, Monday to Friday) and 18% of practices closed their doors by 3 pm at least once a week. The profession provided a possible explanation10 but not before the media had gone to town. And the committee has a point because practices that are open for less than 45 hours a week seem to have more attendances at hospital emergency departments than practices open for longer (an extra 22 attendances per 1000 registered patients on average).7 In addition, the report describes a considerable overlap between the various extended and out-of-hours initiatives, and how the new programmes cost on average 50% more than care during core hours. The tax payer seems to be paying a high premium for better access, and where initiatives overlap, they are paying twice.

The committee’s report yet again exposes the scale of the crisis in general practice and the need for action other than demanding more effort from current staff and new ways of working. If seven day access to high quality routine general practice is desirable, it will be achieved only by expanding the primary care workforce. Without more clinicians the pressures in general practice will increase still further, with serious implications for patients in primary care and other parts of the NHS. Since a year’s worth of care in general practice costs less than two visits to an emergency department,8 the economic arguments for tackling the problem at source are convincing.

In 2014 the then prime minister, David Cameron, claimed that his plans for seven day access to general practice were “not some fairy tale announcement.”11 In the absence of a coherent delivery plan based on good evidence and robust data, and without additional resources, a fairy tale is exactly what it looks like.