The government's guidance on extended hours is not the only way for GP practices to answer the pleas for better access. Ingrid Torjesen looks at some local solutions

Improving patient access to routine general practice is a government obsession. First the focus was on cutting waiting times by promising access to a GP within 48 hours. The agenda then moved on to improving GP provision in under-doctored areas, and introducing initiatives to bring in private providers to achieve this and ramp up quality in underperforming areas.

Since Gordon Brown took over the premiership last year, the focus has been on centralising GP services in new-build polyclinics and his fixation on making GPs more available for routine appointments outside of core hours.

Such has been the government's vehemence on this in recent months, it prompted a virtual war between it and the British Medical Association.

The argument was not over whether patients should have better routine access to GPs, but on how much of a priority it should be and how it should be achieved. Outside of government, the view is that a rigid approach to effecting it is the wrong path, but that is exactly the route that has been taken.

The Department of Health published guidance on the directed enhanced service on extended opening hours in April, which most primary care trusts will use to help meet the NHS 2008-09 operating framework target to commission 50 per cent of practices to provide extended hours.

The directed enhanced service is worth£2.95 per patient to practices in return for providing 30 minutes of extra hours per 1,000 patients in minimum one-and-a-half hour slots. A single GP is meant to provide the extra clinical sessions. The BMA had wanted a more flexible approach on timings, GPs to be able to work in tandem and for some appointments to be with nurses.

National Primary Care Research and Development Centre director Martin Roland says: "The DES is the end of a tortuous political negotiation, so to expect the conclusion to be logical is expecting more of human nature than is realistic. It is a compromise, as are all political negotiations. The needs of different population groups are very different, so to address these things in a national contract isn't necessarily the most sensible way to do it, because it doesn't give you maximal flexibility."

He says people who need speedy access at convenient times, and if possible close to their work, tend to be fit and healthy employed people with minor illness. However, the main users of the NHS - the elderly who have multiple illnesses - need a different kind of access: continuity of care from people who know them and their multiple problems.

He adds that a lot of research shows patients value being able to see the same doctor more highly than they value speedy access.

Professor Roland is also a GP at a surgery in central Manchester where most patients do not commute and many are unemployed. The practice is piloting extended hours but Professor Roland says the evening surgeries do not meet the patients' needs. "In the winter and autumn, people don't want to come out at night because it isn't very safe round here."

Imperial College London professor of health policy Nick Bosanquet says: "We need to be moving to a situation where there is local responsibility and local power to develop services that fit local needs. How far away we are from this, when there has to be a national agreement on something which may not be necessary in a lot of areas, yet in other areas we might need longer opening times.

"The danger of this national agreement is that it will turn out to be the maximum rather than people thinking creatively and flexibly about what fits local needs."

He praises the approaches taken by PCTs such as Barking and Dagenham and Kensington and Chelsea, which have set up their own local enhanced service. The Barking and Dagenham PCT scheme began last year and was one of the first.

Barking and Dagenham PCT assistant primary care contracting director Jemma Gilbert says it restricted the local enhanced service to practices that were providing good access in hours and meeting a series of other quality measures, such as scoring well on the quality and outcomes framework.

Now the directed enhanced service is available, the PCT will operate a three-tier system. The directed enhanced service will be available to all practices.

Those that meet the PCT's quality measures will be eligible for the local enhanced service, which is worth slightly more at£225 per one-and-a-half hour clinical session. All but six of the PCT's 42 practices have qualified for the LES.

Ms Gilbert says the PCT considers the difference a "quality premium". She warns: "If a practice isn't achieving the criteria or doesn't maintain them, that could be removed and reclawed."

Four practices that have scored very well will be allowed to open between 8am and 8pm at weekends and paid the same rate for doing this as the local enhanced service.

"We have got three who are champing at the bit out of the four that are eligible," Ms Gilbert says.

BMA GPs committee chair Dr Laurence Buckman says many PCTs will be forced to consider a local enhanced service because they are worried about hitting the target of 50 per cent of practices providing extended hours, as the inflexibility of the directed service makes it unattractive to practices.

Dr Buckman emphasises that the stalemate with the government over extended hours was not, as the media presented it, about the government wanting more hours than GPs were prepared to deliver, but about flexibility.

He says the BMA had been keen to reach an agreement because it did not see extended hours as a main issue. "I have made it quite clear what I regard is a key matter and it isn't extended access. The government see that as the only thing that matters. There are bigger issues to talk out."

The issue that concerns Dr Buckman most is the movement of large private sector companies into primary care aided by initiatives such as polyclinics, which the government again argues are needed to improve patient access to GPs.

The interim report of health minister Lord Darzi's next stage review published last October committed the NHS to establishing at least 150 of these GP-led centres, which will provide walk-in services from 8am to 8pm, seven days a week to both registered and non-registered patients. The aim is for the centres to also house some community-based services, outpatient clinics and diagnostics, to promote integration. The NHS 2008-09 operating framework sets PCTs a target to complete procurement of at least the GP services this year.

Dr Buckman says that, like other vacant practices, polyclinics have to be put out to tender. "NHS GPs can bid but there are some spectacular examples recently where quite good GP tenders have ended up being given to the private tender instead."

It is not surprising the GPs have concerns about polyclinics because they will be competing against them. But they are not alone. Patients and health policy experts also have serious concerns about the initiative.

Patients Association vice-chair Michael Summers says he finds the concept of a national health service manned by NHS GPs contracted out to private companies "rather strange".

"GPs are independent and run small businesses," he admits, "but they are not trying to make massive profits out of their patients. Private companies would inevitably be thinking to themselves, 'We are a company with shareholders which we have to satisfy; we have to show that we are making a profit.'"

He suspects that the polyclinic initiative could be more about saving money than improving access. "Perhaps the government thought, 'One way we could save money on having independent GPs dotted all over the country is to have them dotted around in fewer places and larger practices.'

"That might be all right in London, but what about in rural areas? How can we have polyclinics miles away from anyone? It isn't practical."

Integrating general practices with community and some secondary care services in one building might be a good idea for some areas, but imposing rigid models on communities is the wrong way to go about it, says NHS Alliance chair Dr Michael Dixon.

"These things need to be grown on the basis of the services currently available and involving the frontline professionals and patients in organically developing a better integrated service," he says.

NHS Confederation PCT network director David Stout thinks the polyclinic is one way of improving patient access to a range of services and their integration but not the only way. "I don't think they are the answer to life, the universe and everything."

"I think that it is unlikely that the current model of general practice will all be ensconced somehow into a polyclinic model in the sense of a series of single buildings encompassing all general practice," he says.

Professor Bosanquet is a vehement critic of polyclinics, arguing that the concept, which was first raised by Lord Darzi's report Healthcare for London last July as a solution for the capital, is not evidence-based.

"What was striking about the original Darzi report on London was that it has no analysis of primary care in London at all, yet it makes the most sweeping recommendations about it," he says. "They can see the weaknesses but they don't understand the strengths and the need to empower local people to do more within the range of resources that are there."

He adds that while everyone agrees there should be more integration of services, setting up lots of capita projects side to side with existing GP services was just "going to cause a turf war world for a couple of decades".

Professor Roland says: "There is a view that small practices dotted around the place is somehow old-fashioned and it would be better if they were all put into a spanking new building, but there is very little evidence that that is a good idea."

He admits that there are some circumstances when centralising GPs in new buildings is sensible, such as when they are in shabby premises or are unsalvageable single-handed practices. But this was only likely in some areas of London and other metropolitan areas.

Elsewhere, he supports the Royal College of General Practitioner's federated model of general practice in which general practices are able to access community services, diagnostics and community matrons housed in a central building but are not based there themselves.

But Professor Roland cautions against moving specialist services out of hospitals into the community, arguing that it would not be an efficient use of NHS resources. "Specialists work more efficiently in big hospitals where they have access to teams of junior staff and sophisticated investigations," he says.

Community-based specialist services would, however, improve access for patients, even if the clinics were further away than the local hospital, he admits. "They may be more accessible because hospitals are incredibly difficult to park in. Although that sounds a trivial issue, it is quite a big issue for patients."

Conversely, polyclinics would actually reduce access to GP services and patient satisfaction with them, Professor Roland warns.

"There is quite good evidence that patients don't like big practices and satisfaction is higher in smaller practices. Plus, if you do concentrate all practices in large facilities you reduce access for patients and you potentially reduce choice. People have further to go and that is a particular problem for the old and disabled."

Kensington and Chelsea PCT pilots its own way to add hours

Kensington and Chelsea primary care trust began a four-month pilot of extended GP hours at the end of March. It is evaluating patients' experience with the aim of turning the pilot into a local enhanced service and offering that instead of the directed enhanced service.

The scheme is funded at a similar rate to the directed service, at£180 for each 1½ hours. However, practices are being encouraged to provide more extra time, as they can apply to offer an extra 1½ hours per week per 1,000 patients. They are also being allowed to do this more flexibly than the directed service in both time and workforce.

The service must be GP led, but practices can decide to offer a combination of GP and nurse appointments and other nurse services.

The trust's primary care commissioning director Frankie Lynch says this allows the full portfolio of patients' needs to be catered for, because some patients will want health promotion and screening services provided by nurses at more convenient times as well as GP appointments. The trust will also pay for more than one health professional to provide extended hours at the same time.

Ms Lynch says: "I suspect that we will go down the road of an LES. Having spoken to practices, they really welcome the fact we have got it as a mixture of nurses and doctors and not just doctors.

"What we've picked up is that the DES is really quite restrictive and practices will probably not do it."

So far, 16 of Kensington and Chelsea's 43 practices have signed up to the pilot.

Larger capacity

Ms Lynch is frustrated that the NHS 2008-09 operating framework target is for half of practices to provide extended hours. "If they had said half our registered population, we would have hit it, because it is larger practices that are doing it. Inevitably, larger practices have the capacity: they can manage their reception staff and capacity better."

But she is keen to point out a couple of single-handed practices are also involved.

One thing about the pilot that has not gone so down well with local practices is that the PCT only allows those that can demonstrate a high level of quality care in core hours to provide extended surgeries.

To be eligible, practices must have an open list, be open 40 hours per week, provide clinical hours for 70 per cent of opening hours or a minimum of 16 clinical hours per 1,000 patients, hit 24- and 48-hour access targets, offer telephone consultations and, most controversially, have scored at least 900 points on the quality and outcomes framework.

Ms Lynch says: "Barking and Dagenham did a very detailed bit of research on extended hours and who could extend it and they said you have got to allow the practices who have genuinely got the capacity to deliver this."