Tim Gardner on setting new GP waiting time targets, and the pitfalls of applying a narrowly-focussed solution to ‘fix’ a complex issue
The outgoing chair of the Royal College of General Practitioners has warned politicians against repeating mistakes by setting new GP waiting time targets – so what lessons should manifesto authors learn from past policies?
No major party has announced such a target, at least not yet. But with an election in the offing, all parties will be looking for eye-catching policies that talk about issues beyond Brexit. And there are clear signs that tackling waits for GP appointments is on the to do list.
The prime minister promised to make sure ”you don’t have to wait three weeks to see your GP” in his first speech from the steps of Number 10. Jon Ashworth, Labour’s shadow health secretary, also talked about problems getting GP appointments at the recent party conference.
Tackling waiting times in general practice directly would be a major departure from the recent past. For nearly 15 years, successive governments have taken a broader approach – pursuing better access by increasing the availability and convenience of primary care services, with practices retaining discretion in how appointments are allocated.
This was the common thread in interventions as varied as building new practices and co-located walk-in services, longer and more convenient opening hours, challenge funds, putting GPs in accident and emergency departments and, most recently, digital-first primary care. All were tried, sometimes more than once.
Complexity of primary care
While a new waiting time target would be a big deal, it’s not without precedent. From 2000, the last Labour government had a comparable target for seeing a primary care professional within 24 hours and a GP within 48 hours. That experience is instructive.
In an era where practically everything had a target attached, 24/48 hour access was a top-tier, must-do backed by financial incentives, an “Advanced Access” model for managing demand and capacity and ”the largest improvement programme in the world”. The impact on performance was dramatic and, by 2005, 99.9 per cent of patients could access appointments within target times.
That was based on data collected from practices, but flaws with the methodology meant the data was unreliable. It certainly wasn’t matched by people’s experiences – only 74 per cent of patients reporting having been seen within 48 hours.
There were problems with booking appointments more than three days ahead too, as some practices reserved advance appointment slots to hit the target. This hit the headlines when Tony Blair was taken to task on live television by an understandably frustrated patient.
GP numbers increased in the early 2000s but are now falling, with the biggest impact in areas of high deprivation. While investment in general practice fell relative to the rest of the NHS between 2004 and 2014, demand continued to grow and the increased pressure exacerbated shortages of GPs and practice nurses
24/48 hour access is arguably the textbook example of unintended consequences of a target probably undermining apparent improvements in performance. Patients at “Advanced Access” practices got slightly faster appointments but were experienced little or no differences in satisfaction, and may have been less likely to see their preferred GP. Overall satisfaction with general practice opening hours actually fell between 1998 and 2004.
The past problems with booking advance appointments might be reduced by balancing the urgent appointment target with one for advanced bookings – as used in Scotland. But that still wouldn’t come close to reflecting the full complexity of primary care and the wider set of factors that shape patient experience.
Patients value speed of access, but also place considerable value to convenience of access, choice of time and location, choice of professional and – with general practice increasingly going digital – mode of access.
These aren’t just “nice to haves”. In particular, continuity of care is linked to reduced hospital admissions for some types of common health condition. For some patients, seeing their preferred GP matters far more than speed of access.
And there are considerable differences in patients’ willingness to trade-off one factor against the others. This is why accommodating patient needs and preferences in a clinically appropriate way is not easy – just ask a practice manager or receptionist.
The 24/48 hour target made that task more difficult and it’s hard to see how a similar target wouldn’t do the same.
Measuring performance is another challenge. Data on what happens in general practice is better than the 2000s, but measures of waiting time are limited to the patient survey. The collection being developed by NHS Digital is becoming a rich source of data on activity, but doesn’t illustrate the scale and nature of patients’ needs.
Fundamentally, there’s the overall state of general practice to consider. GP numbers increased in the early 2000s but are now falling, with the biggest impact in areas of high deprivation. While investment in general practice fell relative to the rest of the NHS between 2004 and 2014, demand continued to grow and the increased pressure exacerbated shortages of GPs and practice nurses.
Meeting a new target would require a substantial increase in appointments, which means confronting the daunting issues with increasing the number of GPs. If that fails to materialise, a target could only be met by cutting appointment lengths or time spent on other essentials that also affect patient care – such as the fledgling Primary Care Networks expected to deliver much of the long-term plan. Not to mention the risks of repeating past mistakes by ramping up the pressure to make rapid progress.
The politicians have alighted on a genuine problem – public satisfaction with general practice has been falling steadily for some time. But a meaningful response needs to go beyond the set of incentives and improvement support likely to accompany any new target, with a wider blend of policies to fill staffing gaps, support new roles and changes to skill-mix and invest in practice premises. Otherwise, there is a serious risk that pursuing a narrowly-focused solution to fix such a complex issue will simply make things worse.