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Blurred lines (where Improving Access and Out of Hours meet)

Caffeine and contemplation

Dominique Thompson

Tuesday, 19 June 2018

AdobeStock_187621641_bl_crop.jpgOne in four people have never heard of ‘out of hours (OOH) GP services’, according to a nationally representative survey by the National Audit Office (May 2014).

At a time when NHS England (NHSE) is aiming for 100% population access to ‘extended’ GP services by 1st October 2018 (a staggering increase in target coverage from 40% last year), in response to patient feedback, this lack of awareness of OOH caused me to ponder. If many patients are not even aware of the existence of urgent GP care provision, how can we expect them to triage themselves appropriately to the multitude of primary care options currently on offer; ‘core’ GP services between 8am and 6.30pm, ‘Improving Access’ (IA) routine pre-bookable or same day appointments after 6.30pm, weekends and holidays, or urgent (OOH) GP care? Or might they just cut their losses and go to A&E?

And yet triage themselves appropriately is what we need them to do (or expect NHS111 to do for them) if these multiple primary care schemes are to function without fatally undermining each other. Otherwise, the Improving Access scheme might hoover up workforce resources from OOH, ‘core’ GP will be stretched ever thinner, and an already ‘fragile’ (in some areas) urgent care service may collapse.

NHSE’s solution is that in order to successfully provide these various GP services there will need to be ‘better integration’ between NHS111, OOH, IA and ‘core’ GP teams, but this ignores the fact that it will all come down to correctly triaging patients at whichever point they contact primary care. Receptionists, pharmacists, or NHS111 operators, all will need to know the options, and who should use which service.

There is no single point of access anymore, so the potential for inappropriate use of resources is multiplied. Urgent angina cases turning up for ‘same day’ Saturday morning surgery instead of OOH, or routine pill reviews in OOH clinics are equally likely to cause frustration, fragmented care, and potentially poorer outcomes and satisfaction.

And with NHSE’s insistence that evening and weekend appointments for Improving Access schemes are offered ‘on an equal footing’ with core GP appointments, there will be potentially inefficient use of ‘non-core’ slots which might be more usefully offered for example to commuters or those of working age. Receptionists ‘guiding’ patients to sensible and relevant appointment times will be frowned upon.

The real challenge in all of this will be staffing, of course. How can general practice, which is haemorrhaging GPs and seeing practices close at an unprecedented rate, be expected to safely staff such a variety of primary care schemes, even where non-GP primary care colleagues such as nurses, pharmacists and physios (all of whom can be included in IA provision) are deployed?

There seems little logic in NHSE currently pushing for 100% coverage of a scheme to provide a wider choice of GP appointment times (when OOH already covers the urgent stuff) in response to complaints about poor access, when it will simply mean stretching the same clinical staff out over more of the week. By ‘improving access’ at weekends/evenings, we will make ‘core’ access poorer. By asking our clinicians to work additionally at weekends and evenings we may push them to leave the profession, the UK or to be off sick. By stretching appointment availability for routine care, we will potentially fragment continuity of care, despite this being shown to improve health outcomes. The blurring of boundaries with Improving Access could deal the fatal blow to English OOH services.

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Dominique Thompson

Dominique has been a student health GP since 2000, developing innovative new services to treat eating disorders and personality disorder in primary care. She was the GP member of the NICE Eating Disorders Committee 2017. She was a Pulse ‘GP hero’, in 2014, and a ‘Rising Star’ in 2016. Dominique writes about young adult wellbeing and mental health, in both the medical and non-medical press. Her latest adventure is as an independent consultant in student health and wellbeing www.buzzconsulting.co.uk. She is fuelled by caffeinated drinks.
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