Changing the way GP surgeries are managed could help improve access for patients who are excluded by the current system, argues Jim Ford

When I left general practice in 1991, I vowed not to comment on what I had left behind. So why do I risk the ire of former colleagues by commenting on the government's fight with GPs over extended hours? It is because of the patients.

My patients are working people. In recent years, many have seen their employers become more assertive and have accepted a tightening of their working conditions and a reduction in benefits such as sick pay and pensions.

One area that has been tightened up is time off to see GPs and dentists. Employees are now expected to book leave if they need an appointment. If they commute to work, this may require a full day because of short surgery opening hours. They cannot get an appointment on Saturdays or even collect prescriptions.

NHS rationing

The NHS has traditionally rationed care by time rather than by charges, so we have become used to queuing for appointments. But New Labour has changed that and many working people no longer have to wait months for an MRI scan or common surgery, although less commonplace interventions such as hand surgery or nerve conduction studies may be more difficult.

But working people are disadvantaged by GP appointment systems and other forms of time rationing in the NHS, such as hospital phlebotomy clinics and accident and emergency.

Being told you have to ring up on the day to get an appointment means that someone who works, has a non-urgent complaint and is unfamiliar with the surgery will be competing with a young parent with a sick child who knows the receptionist from regular clinic attendances. Difficult access is an equity issue for people of working age.

Managing extra hours

Before my GP colleagues call foul, maybe they should talk to their local occupational physician about how industry copes with extended hours and 24/7 working in general. Many factories run two day shifts, one starting very early and another starting in the afternoon and finishing late evening, sometimes with a night shift as well. Staff frequently have preferences for one shift or another, which can be accommodated. Other organisations, such as the nuclear industry, have 12-hour shifts. Staff are able to finish their full working week in three days.

GPs will need to structure their work to provide for continuity of care, but computers do facilitate this. They may also incur greater staff and facility expenses by opening for longer hours, which their leaders will need to convince the Department of Health about. However, the prospect of a long midweek weekend might prove as popular to the profession as the extra income of recent years has.

To achieve this, practices would have to be well organised. The best negotiating successes are win-wins, so the challenge to the prime minister is to convince GPs of the silver linings in his cloud.

By moving to longer hours, more appointment space becomes available to those who are excluded at present, with less time for the fat-file professional patients who dominate some surgeries. GPs with family commitments will have more flexibility than the current 9-5 straitjacket permits. And for GPs without commitments, think of the three and a half day weekend starting at 9am Monday.