One of the few highlights of Britain's recent lacklustre election campaign was the television ambush of Tony Blair by a woman complaining about her difficulty in booking an appointment with her GP more than 2 days ahead. It clearly came as a shock to the prime minister to discover that one of the unintended consequences of his government's major primary care policy initiative — to guarantee patients an appointment with their GP within 48 hours — was that, in some cases, they could not get an appointment more than 48 hours in the future. The anticipated backlash over this humiliation has now arrived, in the form of a further government initiative to ensure that doctors provide both immediate and long-term appointments.
Health minister Lord Warner proposes action to ‘tackle restrictive booking and tighten tests on the 2-day GP target’.1 Although, before the election, the government acclaimed GPs' successes in achieving targets for 48-hour access, Lord Warner now sternly declares that ‘there is absolutely no justification for this target being used as an excuse for an inflexible appointment system’. He threatens ‘more robust checks’ to ensure that there will be no further embarrassments for the prime minister on this issue. It does not seem to have occurred to the government that its ill-advised interference in GPs' appointment systems has itself fostered inflexibility.
The government's preoccupation with the problem of ‘access’ to GPs' surgeries goes back to the 1997 election campaign, when one of the focus groups so influential in New Labour strategy reported that concerns about getting urgent appointments were running high among key sections of voters. The drive to reorganise primary care to ensure that all patients could expect to see a GP within 48 hours (or another primary care professional within 24 hours) was backed with substantial resources and dedicated personnel. By 2004, the targets were being met, but the perverse consequences were also becoming apparent.
The biggest problem resulting from the fetish of 48-hour access is that it has put the demands of the ‘worried well’ before the needs of the ‘seriously ill’. Focus groups are attended by middle class professionals in good health, not by patients suffering acute or chronic illness or physical or mental disability. Rapid access to any health professional may suit those who only occasionally attend the surgery; for those who are more frequent attenders, continuity of care with a familiar doctor is more important — yet this is now accorded a much lower priority. New Labour's pandering to swing voters has reinforced the ‘inverse care law’ (those whose need for health service resources is least receive the most, and vice versa) which Old Labour once identified as one of the defects of the NHS under the Tories, to be remedied when the party returned to power.2
The imposition of targets on every GP surgery by central government destroys local autonomy and flexibility. Doctors' surgeries provide services in a very wide variety of communities with different requirements and their appointment systems have evolved over the years in response to these needs. No doubt some GPs are more flexible than others in meeting demands for appointments. But it is not surprising to find that an attempt to impose a uniform national incentive scheme on access to GP surgeries has made the system more rather than less inflexible. This is particularly the case at a time when the major constraint on the provision of appointments is not the inadequacy of appointment systems but the shortage of GPs and other primary care professionals. Indeed one of the factors exacerbating the shortfall in the supply of appointments is the trend towards early retirement in general practice, in part a result of the relentless stream of interfering initiatives from government.
It seems that the government we elected to run the country is more concerned with running our surgeries. This is certainly proving detrimental to the interests of patients in primary health care. Can it be good for the country?
- © British Journal of General Practice, 2005.