Investing in extended patient access to GPs is a key government objective, but which patients will benefit, and will it have its intended consequences?
Despite little evidence that it is demanded by patients, extended access to GPs, providing care outside normal office hours, has been a key plank of Government NHS policy since 2015. For example, the NHS Five Year Forward View states that 100% of the country will benefit from extended access to GP appointments by March 2019. It is viewed as part of the transformation of the NHS, described as moving it from a reactive, secondary care service towards to a more anticipatory primary and community-based model. It is claimed it does this by managing demand in primary rather than secondary care..
In considering extended access from the perspective of potential users, a number of issues arise. Firstly, is it what patients want? Asking people if they want more of a public service invariably produces a positive response. If the question is clarified, though, patients want quick – ideally same-day – access to GP appointments, but they do not express a strong preference for seven-day services. A 2014 GP Patient Survey, run by Ipsos Mori on behalf of NHS England, showed that extending GP surgery opening hours and weekend opening were not a high priority for many patients. Indeed, long waits for appointments and failure to see a preferred, named doctor were more pressing issues. So the question arises: if patients do not want it, will they use it? Changing patient behaviour is notoriously difficult.
As extended access is rolled-out, the second question to be asked is which patients will benefit, i.e. will it benefit all patients equally?
Projects funded by Prime Minister’s GP Access Fund (2013), were aimed at those patients who would otherwise present at hospital A&E Departments, but evaluations demonstrated little impact on this group. Moreover, recent research suggests that, rather than extending access in general, it is continuity of care with the same GP which could be a key defence against rising hospital admissions. A further concern is that extended access will simply supply a level of service that will meet demand that is currently unexpressed, i.e. increased opening hours will mean that more people go to GP surgeries in these times, not that GP surgeries will have more availability. Evaluation of pilots in Greater Manchester demonstrated take-up of services but it was not clear that, if these services had not been established, whether those patients would otherwise have presented. Elsewhere, research by the Nuffield Trust has highlighted the risk of additional supply fuelling demand for care.
Increased access applied equally across England also has the potential to exacerbate existing inequalities – the inverse-care law. The highest demand for extended care is in less deprived areas: for example, a survey of patient views found that in Ascot, Windsor, and Maidenhead 28% wanted extended opening, whereas in Wigan it was 14%. Without recognition of these (in)equity issues in the planning of extended access, it is possible that the less socially-deprived will benefit at the expense of those who are more deprived.
The Five Year Forward View explicitly targets extended access services at particular groups, i.e. those who, because they work similar hours to GPs, find it difficult to access their services. However, a recent Nottingham University evaluation states:
“The biggest users of primary care GP services are the elderly and the very young. These groups do not have problems accessing services during the working week. The expectation seems to be that people in full-time employment have a strong demand for weekend services, but the evidence indicates this is not the case.”
There is an argument that those in work, especially in the dominant service sector, and the “gig economy” have increasingly varied, erratic, and unconventional working hours and that for these people, access during “normal hours” is not an issue.
Finally, the economic case for extended access is unproven, with the available evidence so far indicating that the cost to deliver the service outweighs the return on investment. In Greater Manchester, where extended access is being pioneered, £41m is to be invested over 4 years: replicated across the NHS in England this may require upwards of £300m recurrently.
Why then, when the evidence is stacked against it, is extended access being pursued? Politically, a seven-day service is attractive, and may play well amongst certain voters, it is certainly part of wider agenda across government. However, there may be a more calculated, strategic reason why it is being pursued. The NHS struggles to implement change successfully, being a victim of competing interests and priorities, managerial and organisational instability, and inconsistent political direction. It is ripe for a disruptive intervention to break the dominant acute-based, reactive model of care. Extending GP access could provide important symbolic and practical momentum to the NHS as it seeks to achieve the ambitions of the Five Year Forward View. Given the extent of this investment, and the lack of any supporting evidence base, perhaps this intervention is designed to disrupt the pattern of NHS conventional service delivery, and to provoke the NHS to generate and deliver new models of care? If this is the case, the implications of these new models in terms of equity of provision and access need to be worked through, if the NHS is to remain a free universal service, based on need.
About the Author: Adrian Mercer Ph.d, is a former primary care trust chief executive, NHS policy researcher, and occasional lecturer in health and social care policy. Based in Devon, he is currently researching and writing about NHS developments, including privatisation, democracy in the NHS, and digital politics.