Published: 13/06/2002, Volume II2, No.5809 Page 22 23 24 25
The government is not normally keen to hide its light under a bushel when it hits a target.Bizarrely, that is what it seems to be doing over GP appointments.The NHS plan said that patients should be able to get an appointment with a healthcare professional within 24 hours and a GP within 48 hours by the end of 2004.
At the time the plan was issued about half of all practices were thought to be offering access to a GP within 48 hours, based on the 1998 patient survey.
1The Department of Health set interim targets of 60 per cent of practices in England being able to offer a GP appointment within 48 hours by March 2002 and 90 per cent by March 2003. NHS chief executive Nigel Crisp said in April that this 60 per cent target was being reached.
2But the DoH's own data, based on a survey of all practices and personal medical services providers carried out by primary care trusts every three months, suggests that this target is already being exceeded, although the proportion of practices meeting it has significantly declined in the past eight months.The three surveys carried out so far show that in September 2001,79.8 per cent of practices were offering an appointment within 48 hours - but in December this dropped slightly to 78 per cent and in March it dropped again to 74.7 per cent.
All regions of the country showed a decline between September and March, suggesting that problems in primary care may be worsening.The target for access to a primary care professional within 24 hours was also missed in March, if only just - 59.2 per cent of practices against the target of 60 per cent.This is despite the government already having invested money in improving access to primary care through incentive schemes set up in 2001-02.
In March 2001, the government announced£100m to modernise general practice.The first tranche of money - around£5,000 per practice - should have been distributed by the end of 2001 and many PCTs are using this money to work towards 48hour access.
Despite this, access still seems to be becoming harder.
Concerns about the surveys on which the DoH claims are based may be another reason for it downplaying the results.
These surveys involve every PCT telephoning each practice once a quarter, identifying itself and asking when the next available appointment is.There are concerns about how accurate a picture of access this can provide.Certainly, the surveys so far show some rapid rises and falls in individual health authority areas (see box 1).
Another reason why the DoH is cautious may be because of the way it has defined meeting the target, which may not reflect patients'views of what constitutes improved access.
3The practice has to offer an appointment with any GP - not necessarily the GP the patient is registered with, or even one within the same practice.
In theory, practices could arrange with other doctors locally to see patients or even use other primary care services, such as walk-in centres, to meet the target, although there is little evidence that much of this is happening yet.Nor does the appointment have to be at a time the patient can make or which is convenient to them: it is the appointment being offered, not taken up, which is being measured.
This may explain an ICM poll of patients from London and the South East, published in April, which seems at sharp variance with the government figures.
4The poll showed that only 17 per cent of patients had been seen by their GP practice within 24 hours,36 per cent waiting between two and five days and 45 per cent waiting six days or longer for an appointment.Despite these long waits,89 per cent said they were quite or very satisfied with the service.
The DoH figures are based on one-day snapshot surveys by PCTs, which are told by the DoH to exclude urgent and emergency appointments so that the surveys only measure the availability of routine appointments.The DoH argues that this reflects patient experience, but in many cases the first available appointment is likely to be a cancellation and, if this is not convenient for the patient, the next available slot may be some time ahead.
The National Primary Care Development Team, part of the NHS Modernisation Agency, which promotes a system called advanced access, uses a different measure - the third available appointment - specifically to avoid measuring cancellations and other blips. It also measures availability across time, rather than on a single day, and looks at availability of individual GPs rather than the practice as a whole (details on www. npdt. org) There is much criticism within the NHS of the government's preferred measure.One manager describes it as 'pretty meaningless'and 'open to all sorts of other factors'.
Nicola Walsh, a fellow at the health services management centre at Birmingham University, argues that the 48-hour target should not be the sole measure of access.Research with PMS practices suggested that looking at it alone was 'too narrow and meaningless', she says.'We need a broader notion of access.'
College of Health director Marianne Rigge says of the surveys: 'This really does not seem to reflect what proper choice should be about.'
Is there other evidence to back up the department's figures?
East and West Dorset community health councils carried out a survey in September 2001 which showed speedy access to a GP was easier than in September 2000.But this survey - of patients rather than practices - showed a much more complex picture than the national census.Patients were waiting considerably longer than in the late 1990s:42 per cent were waiting for two days or more in 2001, compared with just 20 per cent in 1998.
And patients were unlikely to see the GP they were registered with quickly.Only 20 per cent could see them on the same or next day, with 35 per cent having to wait more than four days.
Overall, the CHCs'survey was at odds with DoH figures which showed that 92 per cent of practices in Dorset HA were meeting the 48-hour target in September 2001.
Pontefract and District CHC, which carried out telephone surveys of practices in 2001 and 2002, found waiting times for routine appointments had worsened significantly.Only eight practices out of 20 in Pontefract were able to offer routine appointments within 48 hours in 2002, compared with 15 out of 20 in 2001.
Emergency appointments for patients with severe symptoms were available quickly, but waiting times for routine appointments were as long as 12 days.According to the department's data, in the old Wakefield HA, which covers Pontefract,72 per cent of practices were meeting the 48-hour target in March.
Where patients are getting to see a GP more quickly than in the late 1990s, how is this being achieved? The answer is partly through the promotion of 'advanced access' in some practices and partly through other surgeries choosing to change the way they work.
Dr John Oldham, head of the National Primary Care Development Team and a GP in Glossop, says that well over 90 per cent of the 1,000 practices in the advanced access schemes, run through primary care collaboratives, have succeeded in hitting the 48-hour access target.Practices which have not achieved it are mainly those which have joined only recently, he says.On average, waiting times for a routine appointment have been cut by more than half and in some cases even more dramatically.
'I think by making alterations to their systems, far from being overwhelmed, they have found in some places that demand is starting to drop and There is a dramatic fall in do-not-attends.'
The advanced access system tries to match the supply of appointments with demand - described as 'doing today's work today'so that surgeries are not booked up weeks or days in advance. It also tries to control demand by offering patients selfhelp guidance, telephone and e-mail consultations, and encouragement to use other members of the primary care workforce such as practice nurses to relieve the pressure on GPs.
Approaches include ensuring as many GPs and nurses as possible are available on a Monday morning, traditionally a time of high demand, and scheduling follow-up appointments for other days of the week.
But it is not only practices involved in advanced access which are hitting the targets.NHS Alliance chair Dr Michael Dixon says his Devon practice is now usually meeting the 48-hour target and has done this by dealing with more patients by telephone and increasing access to nurses.Also, two days a week one GP just sees patients who want to be seen on that day.The practice has taken on a nurse practitioner who offers same-day appointments on the remaining three days of the week.
Even so, there can be problems at times of particularly high demand.'To be frank we do not meet the target in times of a flu epidemic in winter, 'says Dr Dixon.'I think access is important, but It is not the only important thing.A lot of people across the country are now complaining they can't get a really personal service from their doctors.'Other methods used by practices include 'open access'surgeries, where patients are certain to be seen when they turn up, even if they have to wait a long time.
But how can GPs be motivated to meet these targets? In the long run, the department has said it wants them included as part of the new contract, probably within the quality framework as it is for PMS GPs.But it is likely the British Medical Association's GP committee will oppose this, claiming there is no evidence that it improves outcomes. It wants to see stress on demand management as a way of ensuring better, quicker access for patients who need it.
'We must not sacrifice quality during the consultation on the altar of expediency and access, 'says GP committee spokesman Dr George Rae.At the moment the 48-hour target is not explicitly within the new contract framework.The results of the GP ballot on the framework will be announced next month.
In the short-term, PCTs are using persuasion and the promise of extra resources to encourage GPs to address access issues.The DoH allocated£168m to the Primary Care Access Fund for 200203, with the 48-hour target a priority.There is also money available for access facilitators.A DoH spokesperson says PCTs should show 'leadership and support' to local GPs.
Offering additional financial and management support, and developing and working with new services such as NHS walk-in centres, NHS Direct and community pharmacists, should mean that patients receive the right response at the right time and have the opportunity of fast face-to-face access to a GP if they want it, 'he says.
The next test will be March 2003, by when 90 per cent of practices should be meeting 48-hour access targets.Even the department views this as challenging, and it may be particularly so for PCTs with large numbers of practices that are short of staff and struggling with their existing workload.
Such PCTs may need to turn more to other methods of providing access, such as using duty doctor schemes to cover a number of practices, or even walk-in centres.
Access privileges: but only in some areas The surveys carried out so far show significant regional variations in how easy it is to see a GP.
London scored consistently lower than other regions - the surveys are classified under the old health authorities and regions - but even within London some areas are achieving far higher levels than others.The London-wide figures were 65.5 per cent in March - down from 71.8 per cent in September.
East London and City had 53 per cent of practices providing 48-hour access in the March survey, and Camden and Islington had just 49 per cent.
In contrast, a number of HAs in the north of the country were achieving close to 100 per cent - Morecambe Bay hit 100 per cent in December and North Cumbria was on 96 per cent.The Wirral was 100 per cent in September - but did not submit data in December and slipped to 81 per cent in March.Some HAs showed an almost unbelievably rapid improvement - Southampton and South West Hampshire went from 45 per cent in September to 84 per cent in December.
There is no easy correlation between whether areas have a high percentage of practices hitting the 48-hour access to GP target and also the access to a primary care professional within 24 hours.
Some areas scored well on both; others were high on one, low on another.But in London, a number of HAs scored badly on both counts.Camden and Islington achieved 62 per cent on GP access in December and 38 per cent on primary care professional access.
Overall, it was easier to see a GP within 48 hours than another member of the practice team within 24 hours - 74.7 per cent to 59.2 per cent in March across the country.Access to another primary care professional (likely to be practice nurses) improved initially and then slipped back. It is hard to avoid the conclusion that both GPs and practice nurses are increasingly under strain.
Monday, Monday: how one PCT hit the target
Phone any of the 13 practices within North Bradford PCT and they should be able to offer an appointment within two days, compared with none in July 2001.
How can North Bradford achieve this when others can't? The official figure for the whole of Bradford area shows that 83 per cent have met the target.Part of the reason may be that 12 out of 13 practices are personal medical services schemes: so the PCT holds their contracts and has specified access times within them.Six practices were involved in the first part of the primary care collaborative, and looked at the supply and demand for consultations at their surgeries.
PCT director of planning and commissioning Lesley Hill says: 'They did things like making sure all GPs were working on a Monday morning.They have all developed their telephone consultations and in some of them you can order repeat prescriptions by e-mail.'
The PCT's role has been to facilitate these shifts: providing protected time for practices to learn about improving access and organising a conference on the subject.Government money for improving access has been passed down to the practices, which have chosen to spend in a variety of ways, such as Saturday morning surgeries or extra clinics in the evening.
Practices now monitor their own access, looking at the third available appointment on a few days each month at the same time of day and then averaging the figures out.These are then sent to the PCT each month.The PCT's aim is to offer patients appointments within 24 hours, but occasionally it does increase to as long as 48, says Lesley Hill.'Most practices now operate a system where if there are more patients to be seen, they just work longer, ' she adds.
Waiting game: what do patients want?
Access to primary care matters to patients, but the issue may not be as simple as the target of seeing a GP within two working days suggests.Research suggests that patients want it all: quick access to GPs, convenient appointment times and an old-fashioned personal GP service which offers continuity.The government's emphasis on access comes from the consultation exercise carried out with patients and professionals before the NHS plan was issued.This identified cutting waiting as one of their top three priorities.
A Consumers Association survey last year showed that 60 per cent of respondents viewed the ability to get a GP appointment at short notice as a priority in providing healthcare.There was no distinction made in the survey between urgent and routine needs.
The National Patient Survey in 1998 revealed that up to 20 per cent of working patients put off going to the GP because of inconvenient surgery times: around a quarter of patients had to wait four days or more for an appointment.
But research by a group of Oxford GPs suggests that convenience was less highly rated than personal care by a known GP, especially for more serious illnesses.They concluded: 'The current political emphasis on fast access and convenience may be more of a priority for patients in full-time employment and for the management of minor illness only.'
5Research by the College of Health over a period of years has highlighted how patients are not homogeneous.Some value continuity, others want quick access, and their preferences may change.The college's director, Marianne Rigge, says: 'People are prepared to make trade-offs depending on what they want out of the consultation.'Unfortunately, GPs are unlikely to ever be able to satisfy every patient all of the time; and patients' conflicting demands will make it more difficult to satisfy all of them even some of the time.
Conflicting evidence On the face of it, Croydon health authority's access figures show a steady decline, down from 84 per cent in the government's September survey to 75 per cent in December, and with a further decline to 68 per cent in March.But behind that is a story of hard work to address specific problems in the area's 68 practices.
Jacqueline Goodchild, the PCT's national primary care collaborative manager, says individual solutions have to be put together painstakingly.Eleven of the PCT's practices have been formally within the collaborative and their knowledge and experience is helping others to tackle their own issues.Ms Goodchild says: 'One practice has undertaken triage on same-day appointments.They decided they would get a GP to talk to a patient before they would give them an appointment.
'They found they could manage at least 50 per cent of the requests through that.But children can't be dealt with in that way, so they set up a health visitor-led minor ailments clinic.They really felt the difference in that practice.'
But despite initiatives like this, on the government's measurements access is getting worse. It is possible that the March measurements coincided with people using up their annual leave.
1Department of Health.The National Survey of NHS Patients . DoH, 2002 [online, cited 22 May 2002] http: //220.127.116.11/public/nhssurv ey. htm
2Take risks now to hit targets - Crisp.HSJ 112(5800):4-5.
3Department of Health.Achieving and sustaining improved access to primary care, 2002 [online, cited 22 May 2002] www. doh. gov. uk/pricare/ improvedaccess. htm) 4NHS/Evening Standard ICM Poll.
April 2002 [online, cited 22 May 2002] www. icmresearch. co. uk/ reviews/2002/es-nhs-poll-april2002. htm
5Kearley K, Freeman GK, Heath A.
An exploration of the value of the personal doctor-patient relationship in general practice.Br J Gen Pract 2001; 51:712-718.