BMJ 2015;350:h1373 doi: 10.1136/bmj.h1373 (Published 17 March 2015)
Page 1 of 2
Views & Reviews
VIEWS & REVIEWS PERSONAL VIEW
Extending opening hours in general practice won’t improve access for patients most in need Seven day opening may be popular with affluent, working age people but may not benefit elderly people, immigrants, homeless people, or others from hard to reach groups, says John A Ford John A Ford NIHR doctoral research fellow, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK Even the best healthcare system can benefit only those who can use it, and many see extending opening hours as an obvious way to improve access to general practice in the United Kingdom.1 In the second wave of the prime minister’s Challenge Fund, £100m (€141m; $151m) was earmarked for schemes aimed at improving access to general practice by extending evening and weekend opening and was open to applications until 16 January 2015.2
Here I discuss the potential benefits of longer opening hours and the likely winners and losers in the context of a shrinking budget for general practice. Extended opening may simply increase the expectations of patients with generally good health while further stretching services for patients who need healthcare the most. Improving access to primary care, where more than 90% of patient contact happens, is arguably more important than improving access to any other part of the healthcare system.3 In an age where banking and shopping can be done 24 hours a day, seven days a week, current opening hours at general practices mean that many patients who are employed during “normal” working hours have to take time off to see their GP. Extended and weekend opening would allow patients to do so at a more convenient time, leading to more preventive and community care and reducing the use of expensive specialist services.4 So far, so good—but what are the potential risks in encouraging general practices to open for extended hours, and what can we learn from previous initiatives?
Meeting need, not creating demand
One key principle of improving access is that any solution should seek to meet need, not create demand. Initiatives to improve access should consider what healthcare the population needs, as well as what services the public would like (the demand). We know who needs healthcare most: older people, those with mental health problems, and those from deprived and vulnerable groups, such as people with learning difficulties, immigrants, travellers, homeless people, and sex workers.5-7
These patients often find it difficult to access healthcare, and reduced access leads to widening health inequalities, marginalisation of communities, and increased pressure on other parts of the system (such as walk-in centres, emergency departments, and out-of-hours and ambulance services).8 9
Various policies to improve access in primary care have been implemented in recent years. Walk-in centres provide access to primary care without the need to book, usually seven days a week. Polyclinics, introduced in 2009, offer a primary care “one stop shop” with many different services, including urgent care services and extended opening. Until recently, general practices were given financial incentives to offer appointments within 48 hours. Improving access is included in the Quality and Outcomes Framework, the pay for performance system where practices are paid incentives to undertake peer review of urgent care data and improve access accordingly. More recently, electronic booking of appointments has been introduced. And in 2013 the first wave of the prime minister’s Challenge Fund was launched, which provided £50m to fund 20 pilot schemes to improve access to primary care.2 These pilot schemes range from hubs to extended opening hours and improved appointment booking systems. Walk-in centres were established to increase access to primary care, and they are popular with the public. However, they are more likely to be accessed by affluent, well educated men; less so by ethnic minorities.10 Furthermore, walk-in centres did not have any marked effect on attendance at emergency departments or out-of-hours services or on GPs’ workload, but attempts to decommission local walk-in centres have been unpopular.11
Opportunity costs As with walk-in centres, seven day working is aimed at improving access to primary care for the whole population, and some lessons may be learnt from this. Extended general practice opening hours are likely to be welcomed by affluent, employed people of working age—which is good, of course, except when
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BMJ 2015;350:h1373 doi: 10.1136/bmj.h1373 (Published 17 March 2015)
Page 2 of 2
VIEWS & REVIEWS
it reduces access elsewhere in primary care for those groups that need healthcare the most. The NHS, especially regarding primary care, is facing the most challenging financial pressures in its history, and general practice is facing a workforce crisis, meaning that the opportunity cost to be borne by the most vulnerable patients may be substantial.12 Improving access involves much more than simply extending opening hours. Targeted approaches should be aimed at those who need healthcare the most: such policies would include: more community resources to allow older people to be safely discharged from hospital at the weekend, extending case management coverage, better translation services for people who don’t speak English, social workers situated in primary care, extended appointments for older people with multimorbidity, regular walk-in clinics for patients with less organised lives, and financial incentives for primary care workers to register patients from vulnerable groups. Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare. I thank Nick Steel, clinical reader, Norwich Medical School, University of East Anglia. Provenance and peer review: Not commissioned; not externally peer reviewed.
For personal use only: See rights and reprints http://www.bmj.com/permissions
1 2 3 4 5 6 7
8 9 10 11 12
Department of Health, Prime Minister’s Office. Seven day, 8am-8pm, GP access for hard working people. 1 October 2013. www.gov.uk/government/news/seven-day-8am-8pmgp-access-for-hard-working-people. NHS England. Prime Minister’s Challenge Fund. www.england.nhs.uk/ourwork/qual-clinlead/calltoaction/pm-ext-access/. Health and Social Care Information Centre. Primary care. www.hscic.gov.uk/primary-care. Harvey S, McMahon L; King’s Fund. Shifting the balance of health care to local settings: the SeeSaw report. 19 June 2008. www.kingsfund.org.uk/publications/shifting-balancehealth-care-local-settings. Goddard M; Centre for Health Economics, University of York. Quality in and equality of access to healthcare services in England (CHE research paper 40). August 2008. www. york.ac.uk/che/pdf/rp40.pdf. Shi L, Stevens GD. Vulnerability and unmet health care needs. The influence of multiple risk factors. J Gen Intern Med 2005;20:148-54. Gill P, Macleod U, Lester H, Hegenbarth A; Royal College of General Practitioners. Improving access to health care for Gypsies and Travellers, homeless people and sex workers. September 2013. www.rcgp.org.uk/news/2013/december/~/media/Files/Policy/ A-Z-policy/RCGP-Social-Inclusion-Commissioning-Guide.ashx. Soljak M, Calderon-Larranaga A, Sharma P, et al. Does higher quality primary health care reduce stroke admissions? A national cross sectional study. Br J Gen Pract 2011;61:e801-7. Cowling TE, Cecil EV, Soljak MA, et al. Access to primary care and visits to emergency departments in England: a cross sectional, population based study. PLoS One 2013;8:e66699. Salisbury C, Chalder MJE, Manku-Scott T, et al; University of Bristol. The national evaluation of NHS walk-in centres: final report. July 2002. www.bristol.ac.uk/media-library/ sites/primaryhealthcare/migrated/documents/wiceval.pdf. The Week. NHS walk-in centres Q&A: why popular services are closing. 11 November 2013. www.theweek.co.uk/health-science/nhs/56021/nhs-walk-centres-qa-why-popularservices-are-closing. Royal College of General Practitioners. Over 500 surgeries at risk of closure as GP workforce crisis deepens. 2 October 2014.
Cite this as: BMJ 2015;350:h1373 © BMJ Publishing Group Ltd 2015
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Views & Reviews
VIEWS & REVIEWS PERSONAL VIEW
Extending opening hours in general practice won’t improve access for patients most in need Seven day opening may be popular with affluent, working age people but may not benefit elderly people, immigrants, homeless people, or others from hard to reach groups, says John A Ford John A Ford NIHR doctoral research fellow, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK Even the best healthcare system can benefit only those who can use it, and many see extending opening hours as an obvious way to improve access to general practice in the United Kingdom.1 In the second wave of the prime minister’s Challenge Fund, £100m (€141m; $151m) was earmarked for schemes aimed at improving access to general practice by extending evening and weekend opening and was open to applications until 16 January 2015.2
Here I discuss the potential benefits of longer opening hours and the likely winners and losers in the context of a shrinking budget for general practice. Extended opening may simply increase the expectations of patients with generally good health while further stretching services for patients who need healthcare the most. Improving access to primary care, where more than 90% of patient contact happens, is arguably more important than improving access to any other part of the healthcare system.3 In an age where banking and shopping can be done 24 hours a day, seven days a week, current opening hours at general practices mean that many patients who are employed during “normal” working hours have to take time off to see their GP. Extended and weekend opening would allow patients to do so at a more convenient time, leading to more preventive and community care and reducing the use of expensive specialist services.4 So far, so good—but what are the potential risks in encouraging general practices to open for extended hours, and what can we learn from previous initiatives?
Meeting need, not creating demand
One key principle of improving access is that any solution should seek to meet need, not create demand. Initiatives to improve access should consider what healthcare the population needs, as well as what services the public would like (the demand). We know who needs healthcare most: older people, those with mental health problems, and those from deprived and vulnerable groups, such as people with learning difficulties, immigrants, travellers, homeless people, and sex workers.5-7
These patients often find it difficult to access healthcare, and reduced access leads to widening health inequalities, marginalisation of communities, and increased pressure on other parts of the system (such as walk-in centres, emergency departments, and out-of-hours and ambulance services).8 9
Various policies to improve access in primary care have been implemented in recent years. Walk-in centres provide access to primary care without the need to book, usually seven days a week. Polyclinics, introduced in 2009, offer a primary care “one stop shop” with many different services, including urgent care services and extended opening. Until recently, general practices were given financial incentives to offer appointments within 48 hours. Improving access is included in the Quality and Outcomes Framework, the pay for performance system where practices are paid incentives to undertake peer review of urgent care data and improve access accordingly. More recently, electronic booking of appointments has been introduced. And in 2013 the first wave of the prime minister’s Challenge Fund was launched, which provided £50m to fund 20 pilot schemes to improve access to primary care.2 These pilot schemes range from hubs to extended opening hours and improved appointment booking systems. Walk-in centres were established to increase access to primary care, and they are popular with the public. However, they are more likely to be accessed by affluent, well educated men; less so by ethnic minorities.10 Furthermore, walk-in centres did not have any marked effect on attendance at emergency departments or out-of-hours services or on GPs’ workload, but attempts to decommission local walk-in centres have been unpopular.11
Opportunity costs As with walk-in centres, seven day working is aimed at improving access to primary care for the whole population, and some lessons may be learnt from this. Extended general practice opening hours are likely to be welcomed by affluent, employed people of working age—which is good, of course, except when
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1373 doi: 10.1136/bmj.h1373 (Published 17 March 2015)
Page 2 of 2
VIEWS & REVIEWS
it reduces access elsewhere in primary care for those groups that need healthcare the most. The NHS, especially regarding primary care, is facing the most challenging financial pressures in its history, and general practice is facing a workforce crisis, meaning that the opportunity cost to be borne by the most vulnerable patients may be substantial.12 Improving access involves much more than simply extending opening hours. Targeted approaches should be aimed at those who need healthcare the most: such policies would include: more community resources to allow older people to be safely discharged from hospital at the weekend, extending case management coverage, better translation services for people who don’t speak English, social workers situated in primary care, extended appointments for older people with multimorbidity, regular walk-in clinics for patients with less organised lives, and financial incentives for primary care workers to register patients from vulnerable groups. Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare. I thank Nick Steel, clinical reader, Norwich Medical School, University of East Anglia. Provenance and peer review: Not commissioned; not externally peer reviewed.
For personal use only: See rights and reprints http://www.bmj.com/permissions
1 2 3 4 5 6 7
8 9 10 11 12
Department of Health, Prime Minister’s Office. Seven day, 8am-8pm, GP access for hard working people. 1 October 2013. www.gov.uk/government/news/seven-day-8am-8pmgp-access-for-hard-working-people. NHS England. Prime Minister’s Challenge Fund. www.england.nhs.uk/ourwork/qual-clinlead/calltoaction/pm-ext-access/. Health and Social Care Information Centre. Primary care. www.hscic.gov.uk/primary-care. Harvey S, McMahon L; King’s Fund. Shifting the balance of health care to local settings: the SeeSaw report. 19 June 2008. www.kingsfund.org.uk/publications/shifting-balancehealth-care-local-settings. Goddard M; Centre for Health Economics, University of York. Quality in and equality of access to healthcare services in England (CHE research paper 40). August 2008. www. york.ac.uk/che/pdf/rp40.pdf. Shi L, Stevens GD. Vulnerability and unmet health care needs. The influence of multiple risk factors. J Gen Intern Med 2005;20:148-54. Gill P, Macleod U, Lester H, Hegenbarth A; Royal College of General Practitioners. Improving access to health care for Gypsies and Travellers, homeless people and sex workers. September 2013. www.rcgp.org.uk/news/2013/december/~/media/Files/Policy/ A-Z-policy/RCGP-Social-Inclusion-Commissioning-Guide.ashx. Soljak M, Calderon-Larranaga A, Sharma P, et al. Does higher quality primary health care reduce stroke admissions? A national cross sectional study. Br J Gen Pract 2011;61:e801-7. Cowling TE, Cecil EV, Soljak MA, et al. Access to primary care and visits to emergency departments in England: a cross sectional, population based study. PLoS One 2013;8:e66699. Salisbury C, Chalder MJE, Manku-Scott T, et al; University of Bristol. The national evaluation of NHS walk-in centres: final report. July 2002. www.bristol.ac.uk/media-library/ sites/primaryhealthcare/migrated/documents/wiceval.pdf. The Week. NHS walk-in centres Q&A: why popular services are closing. 11 November 2013. www.theweek.co.uk/health-science/nhs/56021/nhs-walk-centres-qa-why-popularservices-are-closing. Royal College of General Practitioners. Over 500 surgeries at risk of closure as GP workforce crisis deepens. 2 October 2014.
Cite this as: BMJ 2015;350:h1373 © BMJ Publishing Group Ltd 2015
Subscribe: http://www.bmj.com/subscribe
