With the disappointing results from last month's primary care access survey, the government is expecting a fast response from PCTs. David Stout suggests competition between practices could be the answer

The GP patient survey results on primary care access were published with some fanfare at the end of July. The expectation from the Department of Health is that primary care trusts will develop local action plans by the end of September to improve access, responsiveness and choice.

At first glance, national primary care satisfaction rates are outstanding compared with any other public service and would be the envy of most private-sector organisations. So you might wonder what all the fuss is about.

What the national figures hide, however, are wide variations in the results between PCTs. For example the rates of patients reporting they were able to book appointments in advance ranged from 62-88 per cent. And there was even wider variation between individual practices within PCTs. Size of practice also appears to be a factor, with larger practices generally less popular than smaller ones.

There are also worrying differences between satisfaction levels in different ethnic and age groups. Although these are similar to findings from previous Healthcare Commission patient surveys of satisfaction with other parts of the health service, it will be important to identify the underlying causes of this variation, particularly in relation to ethnicity. The work commissioned by the DoH from Royal College of GPs chair Dr Mayur Lakhani on this is very welcome.

Patient feedback is an important part of the commissioning process for any service. Where satisfaction rates are relatively low, PCTs will want to improve local performance.

But what actions are PCTs already taking to improve services? And what will they be looking to do in the future?

First, they want to see performance in the round. Satisfaction with access to care is only one of the elements PCTs are taking into account in relation to quality of services. A number of PCTs have been developing balanced scorecards to measure primary care quality, including clinical quality indicators as well as satisfaction rates. PCTs are also starting to use contractual devices - locally enhanced services, personal medical services and alternative provider medical services - to drive performance improvements across a range of quality measures.

Neighbourly competition

The next step is for PCTs to publicise the results at practice level - to the practices themselves and local people. Simply knowing that they are doing worse than the neighbouring practice might be enough to motivate some to find ways to improve. Most are following this up with discussions with their local practices about performance and how they intend to respond.

Beyond this, local solutions will vary depending on the local issue. For example, where patients are dissatisfied with practice opening hours - and it is worth pointing out that 84 per cent of patients say they are happy - what they say they are unhappy with varies. For example, patients in rural areas are more likely to want their surgery open on a Saturday, while patients in urban areas are more likely to want evening opening.

It is also worth noting that the patient survey shows nationally that the greatest levels of dissatisfaction are not about opening hours, but about being able to book ahead for appointments. Overall national satisfaction with this is 75 per cent, suggesting this is the aspect of access which may be of most concern in many places.

In urban areas patient choice might be a powerful lever for change. A PCT might commission one or two practices to run extended hours in the part of the patch where dissatisfaction is highest. This need not be particularly expensive, if limited to a few practices.

Money talks

And if this leads to patients choosing to register with the local practice with longer hours, neighbouring practices might be forced to take note.

The financial incentive for extending hours would need to be thought through carefully.

Experience from Waltham Forest PCT, which piloted this approach a few years ago, is that delivering changes works. But the PCT also found that some of the original planning assumptions needed adjusting in light of experience. Having initially commissioned 8am-8pm services, seven days a week, there was not sufficient demand for services on Sundays and in the late evenings for it to be cost-efficient.

An alternative to using patient choice to drive change in primary care is for local practices to work together to provide extended hours. This approach is being developed in Oldham PCT, for example.

Some trusts have gone further and commissioned extended hours from the majority of practices. Tower Hamlets PCT, which has a particular challenge with patient access and a very diverse community, has commissioned extended hours from 30 of its 36 practices. This is a rather more costly approach and unlikely to be seen as value for money unless access is a top local priority.

Policy options

On top of the local solutions, are there also national policy options that could be considered?

The DoH has already indicated that the quality and outcomes framework will be reviewed to incentivise further improvements in responsiveness to patients and allow PCTs to determine some priorities locally. It makes sense to refocus existing incentive mechanisms rather than inventing new ones. But we know the negotiation process with the British Medical Association GPs committee is likely to be long and arduous.

What else could be done? We could give working patients the option to register with practices close to their workplace rather than their home. The idea of dual registration has previously been rejected as it leads to risks of poorly co-ordinated care. But what is stopping patients registering with a practice close to work?

The main barrier is that practices will be very reluctant to take on patients who live far away because of the duty to provide home visits. A potential solution would be for GPs to be released from the duty of home visits for this particular group of patients.

There would need to be a reduced payment to practices in these circumstances to release funding for PCTs to commission home visits from alternative providers. Many patients would not be happy with losing continuity of care so this option might only be attractive to commuters who are infrequent users of primary care services.

Another approach would be to recognise many patients are already voting with their feet by choosing to use alternative providers such as accident and emergency departments as their main source of primary care.

Rather than assuming patients are wrong and trying to find ways of dissuading them from 'misusing' A&E, maybe we should turn this on its head and see this as an example of patient choice.

Double trouble

The problem is that PCTs end up paying twice for the same service, as we continue to pay practices for patient registration through the 'global sum' in the general medical services contract and pay trusts for each A&E attendance.

Instead, we could give patients the right to register with walk-in centres, urgent care centres and A&E departments for their primary care services as an alternative to general practice.

The primary care funding would go to the provider of the A&E service. This would build on the approach many health economies are already pursuing of developing a primary care 'front end' to A&E, but would take this much further by recognising A&E as a legitimate provider of primary care for patients who would prefer this to general practice.

An alternative approach would be to include all primary care use, including A&E and walk-in centres, in the GMS contract. For example, practices rather than the PCT would be charged for the costs of patients on their list using A&E services.

This would give much stronger incentives to practices to manage the whole urgent care system more effectively. It would require the global sum in GMS to be increased to cover the costs of A&E services through a capitation-based calculation. It would also require more timely and accurate practice-level data on patient usage in A&E.

These ideas are much longer term and would need thinking through in detail, in negotiation with GPs. But they do show there are alternative policy levers which might strengthen primary care responsiveness if there is the political will to take this on.

Is it worth the effort and upheaval? That depends on your judgement of how serious the problem is, compared with all the other pressures facing the NHS.

It is the same dilemma at national level that is facing PCTs at local level when faced with requirements to improve patient access - all the while dealing with every other local priority.