The doctor will see you now

GP access has long been a controversial issue, with concerns over whether primary care in its current state can meet patient demand in a country with a growing population. Many patients complain that appointments can be difficult to arrange at times they are able to attend, and practice staff have spoken of a loss of continuity of service, as well as an increase in the number of instances of abuse towards receptionists. Alarms were raised by recent reports of Gloucestershire’s A&E departments being flooded by patients unable to secure a timely GP appointment.

Commenting on recent research into this topic from Imperial College London, Dr Richard Vautrey, deputy chairman of the BMA’s GP committee, said: “General practice is under intense pressure from a combination of rising patient demand, especially from an ageing population, and funding cuts.
“There are not enough GPs and other staff available to treat the sheer number of people coming through the surgery door. However, given the unsustainable strain on GP services, it is understandable that patients are becoming frustrated at the number of appointments available, something that GPs are just as concerned about.”

Greater investment
Some claim that the answer is to provide longer opening hours, extending to early mornings, evenings and weekends, though as this is expensive to carry out and could place more pressure on medical staff already stretched to their limits there is reluctance in some quarters. However, as general practice handles 90 per cent of the NHS’s patient contacts with 8.39 per cent of the overall budget, greater investment may be called for. Recent years have seen various solutions proposed, and a major initiative that has been running since April of this year is trialling a number of these ideas.

Challenge fund
It is hoped that the recently launched Prime Minister’s Challenge Fund could help to bring about significant changes in how GP practices provide out of hours services. The funding project, worth about £50 million in total, involves a number of trial projects testing ideas for improving patient access over 12 months, with individual schemes awarded sums ranging from £400,000 to £5 million.

The ideas being trialled include having practices open from 8am to 8pm, making greater use of telecare and health apps, carrying out consultations through email and video calls, and greater flexibility with in-person access. Pilot projects were selected based on a set of criteria including: sustainability; scale and ambition; leadership and commitment; and links to local strategy.
When the successful bids were announced in April, NHS England deputy medical director Mike Bewick said that the initiative aimed to help people manage their health needs more easily: “This fund is about helping those people who struggle to find a GP appointment to fit in with family and work life and making the most of new technologies. We need to create an environment that enables GPs to play a much stronger role, as part of a more integrated system of out-of-hospital care.”

Projects by region
Of the twenty successful bids, three bursaries were granted to projects in the London area. For example, Transforming Access to General Practice links 365 North West London surgeries to better serve residents in the area, with 39 networks offering appointments from 8am to 8pm and for six hours on weekends. Southwark’s scheme, Extending Access to Primary Care, supports 45 practices to improve urgent care and general access for 300,000 patients through ‘access clinics’ which are manned by existing practice staff.
The North of England has seven schemes catering to diverse needs in the region. Morecambe’s Opening Doors - Aligning and Integrating Health and Care Services (awarded £1,137,132) features an out of hours X-ray service and apps to inform people about local services and to help people with long term illnesses manage their condition. Bury’s Easy GP Project focuses on working people and school pupils who find it difficult to make it to daytime appointments. It will see more flexible practice hours offered in addition to a mobile app which enables patients to order prescriptions and book consultations directly. Another scheme in Darlington will give additional support to frail and elderly patients, preventing unnecessary hospital visits.
Schemes in the South include Steps to the Future in Slough, which allows patients to subscribe to free texts containing wellbeing tips, and pre-booked and drop-in appointments for out of hours GP visits. The Midlands and East England will see integrated health and social care services in Watford, in addition to a pilot scheme in Herefordshire which will help roll out an additional 90,000 appointments carried out in person, over the phone or over Skype. A cross regional pilot involves nine practices across England offering improved telephone services through a single contact point, whereby patients will be able to access key information on treatment and arrange prescriptions.
NHS England’s Charles Alessi has said that these schemes could have wide ranging long-term impact: “The GP Challenge Fund will give colleagues the time and ability to work innovatively to ensure better patient outcomes in an out-of-hospital environment.”

Some figures in the medical community have urged cautious optimism around the scheme. The British Medical Association’s chair, Chaand Nagpaul, has said: “These pilots will give some GPs the opportunity and resources to test ways of improving access, use of technology, and extend their opening times in areas where it is felt there is demand from local patients. However, as pilots, it is important that these are independently evaluated to ensure they are a responsible use of stretched NHS funds.”
Pointing out that there are no guarantees in place to continue the pilots beyond 12 months, and that around 7,000 practices are not benefiting from the Prime Minister’s Fund, Nagpaul continued: “It is vital that we have a long-term plan in place to help support all GP practices to deliver appropriate care to their patients. We must also make sure that finite NHS resources are directed to where they are truly needed.”

Focus on care
The Prime Minister’s Challenge Fund is not the only project in place dealing with patient provision in primary care. The Care Quality Commission (CQC) is in the process of updating how it regulates and inspects out of hours GP services, with a statement due late this summer on how practices are managing. The CQC aims to apply more systematic measures of how successful out of hours services are, with particular focus on the main ‘five questions’: are practices safe, effective, caring, responsive and well-led? As reports come in from the Challenge Fund and the CQC’s inspections, we will hopefully have a more detailed view of whether the NHS is delivering the care patients need.

Further information