Access to GP services in England
January 2008
Introduction
The BMA acknowledges that access to primary care services is a real concern for some patients and that it needs to be improved in some parts of the country. This briefing paper discusses patients’ current access to GPs and proposals from both the Government and the BMA to improve access to GP services.
Background information on the GP contract
A new contract for GPs was introduced in 2004 and was endorsed by the General Practitioners Committee (GPC) of the BMA, NHS Employers and the Government. It was signed off by the Chancellor of the Exchequer at the time – Gordon Brown. The contract was designed to address a number of problems faced by the profession which included the increasing difficulty of recruiting and retaining GPs, low morale and a previous contract that penalised practices financially if they offered high quality care.
The new GMS contract places far greater emphasis on rewarding the quality that is being delivered by GPs. For the first time, GPs are being rewarded for delivering improvements in the care of their patients through the Quality and Outcomes Framework (QOF). The QOF resulted in significant increases in GP income but also considerable investment in their practices in terms of additional GPs and nurses and increases in practice productivity.
Opening hours
GPs are currently contracted to offer routine services from 8am to 6.30pm, Monday to Friday. Most GPs will also do work to run their practices outside the hours set aside for seeing patients.
Out of hours services
At the end of December 2004, GP 24-hour responsibility for patient care ended and responsibility for providing out-of-hours urgent care cover in most areas was transferred to Primary Care Organisations. Relieving GPs of the obligation to provide 24-hour care was necessary to ensure that general practice remained an attractive option to doctors and that GPs had an acceptable work/life balance. It is important to recognise, however, that many GPs still choose to provide out-of-hours services to their patients either directly or by working for an out-of-hours organisation.
Dual registration
The BMA has explored the idea of ‘dual registration’ with NHS Employers, where patients can register with both a home practice and one near their workplace. However the practicalities of this are complex and consideration would need to be given to funding arrangements and access to patients records by both practices, which depends on the progress of the development of NHS Care Records Service (NCRS). In addition, any dual registration arrangement must not be allowed to diminish the registered list system. This protects continuity of care that is an essential feature of the personal care given by family doctors – especially important to people with long term conditions.
The political debate on access & extended hours for GPs’ surgeries
The Prime Minister has given an undertaking that GP surgeries in England will be open in the evenings and on Saturday mornings. This commitment has been reinforced by the detail of the Darzi interim report on the NHS, which stated, ‘our aim is that at least half of all GP practices will open each weekend or on one or more evenings each week’. It is clear that this issue has become a major political imperative and the top NHS priority for the governments in England and in Scotland (following the publication of Better Health Better Care).
The BMA’s General Practitioners Committee (GPC) has questioned whether demand for extended hours actually exists: the Government’s own survey of 2 million patients in 2007 found that nationally, 84 per cent of patients are happy with the opening hours of their GP surgery. The survey also found that only four out of every 100 patients wanted practices open on a weekday evening and only seven out of every 100 patients on weekends.
Despite the high patient satisfaction rates in the Patient Experience Survey, the GPC was willing to engage in discussions with NHS Employers on proposals to extend the opening hours of GP practices outside the existing practice hours of 8am to 6.30pm, Monday to Friday.
Government proposals to extend GPs’ surgery hours
In late 2007, the BMA’s General Practitioners Committee (GPC) and NHS Employers (on behalf of the Government) were involved in negotiations to deliver further changes to the GP contract. This resulted in a package of proposals, which included a sensible balance between offering additional appointments to be flexibly based on patient needs and local circumstances, and further encouraging improvements in the quality of care offered to patients with long term serious illnesses, such as osteoporosis and heart failure. This was all to be done within existing resources.
The Government rejected these proposals. The Government is insisting that practices offer significantly more routine surgery appointments late in the evening (after 6.30pm) or on Saturday mornings irrespective of whether or not demand for such a service exists locally. The GPC is concerned about the inflexibility inherent in the Government’s proposals because there is no scope for extended hours to be determined according to local circumstances or patient needs. Furthermore, the Government did not want any of the quality care changes being recommended.
GP pay and resources
There is a perception amongst some sections of the media, the public and politicians that GPs should agree to improve access without any increase in their resources because of the high salaries many GPs are believed to earn. The General Practitioners Committee (GPC) of the BMA would like to clarify that reports of GPs earning £110,000 a year are misleading and out of date: this figure relates to 2005/6 and only includes GP principals. It excludes the one-third of GPs who are salaried GPs. Practice funding has been cut back in real terms for two years running and average GP pay (including all GPs) is now estimated to be approximately £88,000. The GPC offered to provide extended hours and improvements in clinical care within existing resources but this was rejected by the Government.
Will the Government’s proposals improve patients’ access to GPs?
The GPC is concerned that in some instances, patient access to GPs and other health professionals could be diminished, rather than improved if the Government imposes extended hours on practices.
For example, forcing practices to extend their hours may mean that GPs have to reduce the number of appointments they provide during the day, a time that currently suits the vast majority of patients. Other services may also be affected which would have an impact on those patients who use GP services the most - the elderly, children and people with chronic illnesses. It is quite possible that patients who prefer to consult their GP during the day may in the future have to opt for a less convenient appointment at night. Undoubtedly this will lead to complaints from patients that their GP is not as available as they once were.
GPs are aware that a number of patients, such as working women, would like greater access to nurse appointments. There is minimal scope within the Government’s proposals for extended hours to increase access to appointments with the practice nurse- indeed the arrangements positively discourage this. While patient access to GPs could in some instances be improved, access to practices nurses will remain unchanged despite their being a clear demand from patients for this service.
The Government gave notice that if their proposals for extended hours were rejected by GPs, they would instead impose even more draconian changes on GP practices. Essentially, the Government is threatening to remove large amounts of funding from practices (up to £36,000 in resources for the average three-doctor practice of six thousand patients) if they do not carry out extended hours and do not meet the requirements demanded by the Government's revised access scheme. The loss of such significant sums could have a major impact upon GPs’ ability to deliver clinical care and in some instances, could have a significant impact on the ability of some practices to maintain their current level of services to their patients.
Polyclinics and access to GP services
The Darzi interim report on the NHS includes proposals to open 100 new practices in the 25% of PCTs with the poorest provision of GPs as well as 150 new health centres (or polyclinics), which will be open seven days a week from 8am to 8pm. The GPC welcomes the expansion of GP services in areas where, historically and relatively, there have been fewer GPs per head of population, leading to inequalities in access to primary care services. The creation of 100 new practices in the 25% of PCTs with the poorest provision will therefore help ease any difficulty patients have faced in registering with a GP practice in these areas.
The GPC has a number of concerns however, about the Government’s polyclinic model. While polyclinics will undoubtedly improve access to GP services for the small minority of patients who want it, the resource and quality of care issues for patients raised by polyclinics need to be addressed.
For some patients, polyclinics will actually be further away from their home than their existing, local GP surgery.
Secondly, the GPC believes that the Government’s insistence upon on an 8am to 8pm model for polyclinics constitutes an irresponsible use of scarce NHS resources since the demand for evening and weekend surgeries appears to be limited. The Government in Westminster is requiring each of the 150 PCTs in England to open a health centre/ polyclinic regardless of whether or not local demand for such a facility exists.
Although the Darzi interim report says the new practices can be either traditional general practice or new private providers (under Alternative Provider of Medical Services contracts) the GPC is concerned that PCTs will only be able to use APMS contracts to run the health centres. If these health centres are to be run by private companies, questions ought to be raised about whether it is appropriate for the Government to remove significant sums of money from well-established, local GP practices to fund practices run by multinational corporations. These APMS practices use employed GPs and locums and are reported to have a higher turnover of GPs and higher running costs than 'traditional' models of general practice. These practices may also have a destabilising effect on well-established, local practices.
In comparison, the ‘traditional’ model of general practice, which is based on a registered list of patients, offers continuity of care, a personal doctor and advocate, and value for money. GPC is arguing that some of the new money that the Government has earmarked for access should go towards developing existing local, GP premises, which would allow them to expand and offer more patient services. This could deliver significant improvements in access to primary care sooner than the alternative APMS health centre route. At the very least, the GPC wants to see the option of using traditional GP models for the new practices and health centres.
Therefore, while patients’ access to GP services may increase with the introduction of polyclinics/ health centres and extended hours, the GPC is concerned that the imposition of health centres will lead to patients’ overall satisfaction diminishing.
Impact on GPs and their practice staff
The GPC is concerned about the impact of extended hours on both GPs and their practice staff, who may also be required to work late into the evening or on Saturday mornings if the Government imposes extended hours on GP practices. The Government does not appear to have adequately considered the personal safety of GPs and their practice staff as the current proposals specify that a GP should work alone in the vast majority of practices. This would certainly discourage female GPs from doing extended hours surgeries in evenings. Furthermore, the Government also needs to consider that younger GPs are predominately female and they and their staff may have having caring commitments of their own towards children and/ or elderly parents or relatives, which could be jeopardised if they are forced to work extended hours.
For further information:
Please contact the parliamentary unit:
Email: parliamentaryunit@bma.org.uk