The Prime Minister has put up £50m for innovative schemes to improve access in general practice for half a million people. The logic goes like this:
- It’s hard to get an appointment with your GP.
- More opening hours would make it easier.
- Let’s provide 12 hours 8-8, 7 days a week.
- We’ll have to pay a lot but just do it.
The premise is true for many people, much of the time. The second point is not necessarily true because easy access within normal hours is perfectly possible, demonstrated by many practices we work with. The third point aims to make a decisive difference, but has been criticised for leading to reduced continuity of care by spreading doctors more thinly, and for the cost to family life for GPs and their staff.
However, the funding which roughly doubles the capitation global sum for GPs who offer the scheme is interesting. To get this off the ground the government has decided to pay top rates (compared for example to the cost of out of hours providers doing something similar, and all night). This suggests it cannot be sustained at that level for the remaining 99% of the population, but means it represents a very valuable opportunity for the successful early movers.
The key question is whether 84 hours per week can be offered economically versus the standard 52.5 hours. Other innovative elements are expected, such as phone consultations, but at its heart 60% more time for 100% more money sounds good.
The offer is potentially far better.
The reason lies in the flaw which assumes perceived higher demand needs more supply. What we have found repeatedly is that when supply is unrestricted, and the thinking changes to predicting and matching demand, the workload falls even as service improves. Ample case studies across diverse practices have shown this to be true. Many practices have told us that they cannot fill their extended hours slots on even one evening per week, as there simply isn’t the demand when patients have easy access to their GP during normal hours. Demand typically starts quite high at 8am but tails off through the day and by 6 pm is very light. We have seen exactly the same effect in commuter towns and inner cities.
What this means is that providing additional hours will incur very little extra demand. How much? An important indicator comes from our research on clinical urgency. GPs were asked to determine whether the presenting condition was routine (not time critical), urgent (see within 24 hours) or emergency (see within the hour). So far we have n = 4348, and the results are 76% routine, 23% urgent, 0.7% emergency. Let us suppose that a weekend service saw only urgent cases – we could expect demand to be just 23% of a weekday. Granted, patients’ judgment of what is urgent may differ from a clinician’s view, but there’s more evidence from general practice that patients get their assessment of “routine” largely right. Monday is the busiest day, typically 40% busier than the average day. If Monday needed to cover all of Saturday, Sunday and Monday’s demand, it would be 200% busier than the average day, which it clearly isn’t.
We therefore predict that evening load would be very low, and at weekends perhaps 20-25% of a weekday. Even this would be an overestimate if patients simply didn’t bother to call the doctor at the weekend. The demand could be managed to a degree, by offering a service aimed to help urgent need: no choice of doctor, no prebooking and face to face consultations locally but not necessarily the home surgery. What this means is that a much smaller workforce could cover weekends, so GPs would seldom have weekend duties or could opt out of them altogether if enough of their colleagues volunteered (say those with fewer family commitments). The recommended combined list covering at least 40,000 ensures that such a rota would be viable.
How would the service benefit patients? There is some urgent need at weekends, often from the most vulnerable, young children and elderly, which can best be met in primary care. The benefits of rapid and local care by GPs with full access to medical records are clear.Understanding demand precisely is crucial both to an economic design and to rapid response. Safety and efficiency considerations show that a GP phoning first but with the opportunity to see the patient very soon works well. Detailed evaluation of performance will be critical for bidders (initial response times, wait to be seen, effects on secondary urgent care and much more).
Our conclusion is that the offer represents outstanding value for GP providers, provided certain conditions are met:
- rapid response and continuity are offered in hours , so demand doesn’t spill into OOH
- demand and capacity at weekends are thoroughly understood
- the service is designed and monitored to achieve both clinically and operationally excellent service.
Yet perhaps the hardest thing will be none of the above, but getting agreement between GPs and their practices on how to bid for the work as a coherent entity. Will only large scale corporates be sufficiently organised? Now there’s the real challenge.