20 May 2005
Dissenting NHS voices claim the drive to improve access times to GPs has compromised other areas of patient choice. Seamus Ward asks if primary care can deliver flexibility as well as speed
One of the defining moments of the general election campaign was a clearly taken-aback Tony Blair on BBC1's Question Time, surprised by complaints that patients were unable to make an appointment to see the GP they wanted, when they wanted. His officials and colleagues from the Department of Health would have briefed him on the progress general practice has made to ensure all patients are offered a GP appointment within 48 hours, but this was something entirely different.
The source of patients' anger is that many practices allow appointments to be booked only on the same day or a day before. Patients who wish to book, say, a week in advance are told to call back nearer to their desired time, meaning they cannot plan time off work or childcare. This also affects patients with long-term conditions who need regular, repeat appointments, together with those who wish to see a specific doctor and cannot be accommodated that day.
Patients believe this does not tally with the government's commitment to patient choice and a patient-centred NHS, where opening times suit the public – the sort of health service evoked by Bupa's 'The patient will see you now, doctor' poster campaign last year. For many, the row over pre-booked appointments demonstrated that the patient-centred NHS is a long way off.
On the face of it, the problem has been caused by a clash between government targets and what patients want. In 2000, the government decided patients wanted faster access to GPs during surgery hours. This was true. At the time, they were lucky to be offered an appointment in two or three days.
In 2000's NHS Plan, the government set a target that by 2004 patients would be seen by a GP within 48 hours and a qualified professional (such as a practice nurse) within 24 hours. But to meet this target, gain an annual bonus averaging £3,875 per practice (due to increase to £6,200 in 2006) and abide by the DoH's maxim that they 'do today's work today', some GPs abandoned advance booking.
The department claims all patients can now expect to see a GP within two working days, compared with just half of patients in 1997. However, patients report a different scenario. In a Healthcare Commission survey published in August 2004, only 54% said they had been seen within the target limit of two working days. Of those who waited a day or more, 41% waited to see their choice of doctor, the same proportion waited as they could not see any doctor sooner, while 11% said an earlier appointment was inconvenient.
This is reflected in patient experiences passed on to pressure group Patient Concern. A spokeswoman says: 'We hear complaints from all over the country from patients who have had to give up all hope of seeing the GP they have known and trusted for years. They now have the choice of ringing first thing in the morning and accepting any doctor on offer or ringing back day after day in the hope of getting lucky. It also means that working people have to be ready to take a half day off work, rather than arranging appointments around other commitments.'
Some doctors and managers blame the 48-hour target, arguing that while it might have improved access times it stands in the way of the flexible service demanded by many patients.
The NHS Alliance, which represents primary care trusts, believes the target is too simplistic. 'It is over-simplification to reduce access to general practice to one, simple, tangible target, and it has had a knock-on effect on book-ahead appointments,' says its general practice spokesman, David Jenner.
'The alliance believes there is a clear need to have quality standards for access to a GP. Access is the key issue. Patients are worried about waiting times, about the time spent in waiting rooms and the ability to talk to a doctor or a nurse on the telephone. Patients are also concerned about the ability to see the clinician of their choice.'
Jenner adds that the real problem is that demand is outstripping supply. There are not enough GPs, nor are there likely to be for some time. Despite the work of the department's agencies, such as primary care collaboratives, which spread good practice in booking systems, there is much work still to be done.
'A lot of GPs would say patients still have to wait a long time and the survey evidence shows that nothing much has improved. In some practices, a lot of patients will say they can't get through because so many people are trying as they need to book an appointment on the same day,' Jenner adds.
However, Jo Webber, the NHS Confederation's primary care policy manager, is not sure there is a widespread problem with advance booking. 'The one thing you can point to is the improvement in the 48-hour access target. It is different in each area as it's down to individual discretion in the local area how the target is achieved,' she says.
Indeed, her view appears to be borne out by the department's own figures, which show that the number of GP surgeries that do not allow any advance booking fell from 7.7% last December to 3.6% in March. The provisional figure for April is 2%. However, this could still mean several hundred practices do not offer advance booking.
'People need to have the ability to have a long-term appointment, particularly those with long-term conditions,' Webber adds. 'You need that flexibility but you also need to be able to see people quickly. For now I think we should recognise that practices have done amazingly well and some have not quite got there yet. But within 300-odd PCTs, you are going to see some variation.'
To be fair to the department, it did not tell practices to abandon advance booking. Former Health Secretary John Reid told the NHS Alliance conference in October 2003: 'I want patients to be able to pre-book appointments if it suits them. I also want everyone to be able to see a GP within 48 hours if they want to. One does not exclude the other. We have never, are not and will not order doctors to stop giving patients pre-booked appointments.'
And NHS chief executive Nigel Crisp wrote to PCTs at the end of last year telling family doctors it was unacceptable to abandon forward appointments to leave time free for patients who needed to see them urgently.
During the election campaign, Labour acknowledged that NHS targets could have perverse effects and vowed to ease the standards regime. In some quarters it has been suggested that the target should apply to 80% of patients being seen within 48 hours in order to leave time for pre-booked appointments.
Webber rejects notions that the 48-hour target should be abandoned. 'I don't think anyone would want to go back to a time when it was difficult to get an urgent appointment. People are more surprised now if they can't get to see a GP within 48 hours.'
She believes the NHS has to become more sophisticated in how it offers patients unscheduled care, rather than develop more sophisticated targets. Patients and people in primary care should be looking at the next stage of reform as the NHS begins to offer different forms of care. This will free time for pre-booking appointments.
Both the NHS and patients need to change their attitudes, says Webber. 'The direction of travel is towards more self care. That means the NHS has to give patients more information and put them more in control so they make the choice about how they use the NHS. We are still halfway through the process of changing the way people access the NHS.'
This is happening in long-term illnesses, where patients and their carers are encouraged to get to know their conditions, preventative measures and warning signs. In the future, walk-in clinics and pharmacy consultations are likely to replace many appointments with GPs for minor ailments.
'From our point of view, the debate needs to focus on how people access primary care so they get the right care in the right setting, whether that be face to face with a GP, over the phone or with a nurse specialist or pharmacist.'
This plurality of provision will be important in serving patients outside normal surgery hours, too. Since October, PCTs, rather than family doctors, have been responsible for out-of-hours care. But this has not been free from controversy, with patients complaining they cannot get a GP to visit them at night and doctors complaining the service is underfunded by 10%.
In North Yorkshire, one company set up by doctors to provide services to a number of PCTs folded this year, claiming financial difficulties.
In March, the BBC Radio 4 File on 4 programme published a survey of 21 PCTs and found that one in four was failing to meet the target of seeing their patients within an hour. Areas in London and the Midlands were worst affected.
The BMA believes that though there are problems in some areas, the handover of out-of-hours care went well. But a spokeswoman adds: 'The new arrangements have been underfunded. This reflects the fact that GPs have been providing out-of-hours cover on the cheap since the NHS began. A greater use of skill mix outside normal surgery times should help with this problem, and many areas are using nurses and paramedics alongside GPs. The BMA believes there must always be GPs available out of hours for those patients who need to see a doctor.'
Dr Jenner, a GP in Devon, agrees services can be patchy. 'It's like a curate's egg – good in parts. In my own area we have received maybe one adverse comment from a patient. The biggest problem is the ability to recruit GPs or other suitably qualified professionals to do the work. Funding is an ongoing concern because you need to pay premium rates to attract doctors. With practice profits up by 15% to 20% anyway, maybe not so many GPs need to work these unsocial hours.'
Out-of-hours services might be a problem in some areas but appointments during normal surgery hours now top the political agenda following the prime minister's embarrassment during the hustings. New Health Secretary Patricia Hewitt will be asked to investigate the extent of the problem and fix it. Jenner asks that she does not act hastily before amending the target, and that she involves patients and doctors in a debate over what needs to be done.
Whether a more sophisticated standard is adopted or the department finds another means of providing both fast access and pre-booked appointments, it seems inevitable that something will be done.