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Lead GPs disagree on opening hours

Would longer hours save money and cut A&E pressure, or be unaffordable?

Louise Prime

Wednesday, 20 November 2013

Leading GPs have clashed over whether or not general practice opening hours should be extended. Their debate, published today on bmj.com, centres on whether longer opening hours would reduce pressure on emergency services and improve patient outcomes, or reduce continuity of care – and be simply unaffordable.

Merseyside GP and president of the National Association of Primary Care, Dr James Kingsland, argues that there is still far too much variation in opening hours across the country. He points out that since GPs were allowed to opt out of out-of-hours care when the contract was updated in April 2004, “urgent care provision has incrementally come under extreme pressure in all sectors of the NHS and access to routine appointments remains a national concern” – a situation that was not resolved by either walk-in centres or NHS Direct.

He refers to international evidence that comprehensive primary care, rather than more specialised services, is key to improving patient outcomes and experience, as well as improving value, and writes: “A 1% increase in the proportion of patients able to access their doctor in a GP surgery is associated with a £20,000 annual cost saving for the average practice”.

Dr Kingsland calls for new ways of working in general practice, to improve access, and writes that his practice, with extra funding of £30/head from the clinical commissioning group, was able to facilitate same-day, urgent and prebookable appointments within extended hours to meet patient need – what they call “the never-full practice”.

He concludes: “We have also focused on delivering a good work-life balance, with staff involved in the design and choice of new working hours, rewards for innovative services, and encouraging high personal esteem among the team.”

But Swindon GP Dr Peter Swinyard, who chairs the Family Doctor Association, points to the politician-fuelled demand for medical attention for “many minor conditions and self-limiting conditions that in the past would not have been medicalised”. He says this has led to a huge rise in the annual consultation rate from 3.1 per patient in 1981 to 5.45 in 2008 (and according to the FDA’s own figures, to nearer 8 currently) without a corresponding rise in the number of whole-time GPs.

Dr Swinyard writes that as opening hours become longer, patients are less likely to be able to see their own GP, and he points to evidence that “continuity of personal care in general practice reduces whole system costs”.

He calls for an honest look at whether the NHS is there to serve patient needs, or patient wants – and argues that currently it is funded to meet needs while being expected to meet wants.

He concludes: “Although some Darzi centres provide excellent care, the evidence is that the [8am to 8pm, 7 days a week] model is extremely expensive and requires funds considerably beyond the reach of ordinary general practices, whether working alone or in groups. Were the funding now spent on Darzi centres and walk-in centres given back to practices, the excellent service demanded by our patients would be nearer to our grasp.”

James P Kingsland and Peter W Swinyard. Head to head - Should general practices open for longer? BMJ 2013;347:f6832 doi: 10.1136/bmj.f6832

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