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3 August 2015

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The Prime Minister’s Challenge Fund has received a mixed response across the country.  Here we look at several practices that have taken on the task

Making it easier for people to see a GP has been a key part of successive governments’ plans for the NHS for many years. The last Labour government’s pledge that patients would be seen by a healthcare professional within 48 hours has been replaced by an emphasis on extended opening
hours and, eventually, seven-day access to a GP.
Part of this has been through the pump priming of the Prime Minister’s Challenge Fund (PMCF). This was set up to improve access and to stimulate innovative ways of providing primary care, with £50 million allocated for the first wave schemes in April 2014 and an additional £125 million for the second wave in 2015-16.
David Cameron told the Conservative Party conference before the scheme was launched: “We want to support GPs, to modernise their services so they can see patients from 8am to 8pm, seven days a week. We also want greater flexibility, so people can speak to their family doctor on the phone, send them an email or even speak to them on Skype.”
For many of the first wave schemes, extended hours have been only one part of a wider approach. On the south coast of Kent, for example, a scheme covering 120,000 patients in Dover and Folkestone has offered eight-eight access to a GP co-located with minor injury units but also a paramedic practitioner who can do urgent visits, a nurse practitioner and a primary care mental health specialist.   
Altogether the PMCF’s two waves cover 18 million people – a third of the English population – and 2,500 practices. The amounts awarded have ranged from a few hundred thousand to more than £5 million for services covering large areas such as Manchester.   
The British Medical Association (BMA) last year attacked the fund as an “unsustainable programme” that would cost £1 billion a year if rolled out nationally. It said there was a need for a long-term plan to provide enough GPs, practice staff and resources. The Royal College of General Practitioners has also been lukewarm about extended opening hours, suggesting that it may not be the best way to improve care in all areas.

The findings
There have been mixed outcomes from some of the pilots established so far. A Department of Health commissioned evaluation of four improved access schemes in Greater Manchester showed there had been a 3% reduction in A&E attendances as a result of the pilots. However, there was little impact on patient satisfaction and some decrease in some areas in out of hours and walk in centre use. There are now plans to extend the services across the Manchester region.
However, in some other areas GPs have found little demand for extended services. A pilot in North Yorkshire decided to drop opening at weekends after only a few months of full operation as the appointment slots were not being taken up – possibly because patients preferred to wait to go to their own practice rather than seeing someone at a central hub. Other schemes have found that demand for appointments on a Sunday has been low – which may mean clinical commissioning groups (CCGs) will be reluctant to fund that element when they take on funding responsibility.
With many areas struggling to recruit GPs and other staff, there is also concern that putting on extra sessions makes it harder to cover the rest of the week. A scheme set up in West Sussex has concentrated on getting existing GPs to work additional hours. Sue Parton, managing partner at the Worthing Medical Group, says: “We are really keen that we don’t destabilise the local market so we have not targeted locums.”
The first clinics in this second wave scheme have already opened with three more minor injury, assessment and minor illness clinics to follow. These will offer urgent appointments eight-eight on weekdays and 10am-2pm at weekends, with some aditional routine appointments available at the weekends as well.

Positive steps
The 19 practices in the £1.6 million West Sussex scheme will be able to offer patients urgent appointments at the clinics as their own fill up. The clinics – set up using spare space in existing surgeries – will be able to share information with the referring practices electronically and will have access to patient records.
Parton says that GPs in practices will be able to concentrate on patients with longer term problems. “The main issue is to reduce the pressure in primary care. At the moment we are putting more resources into urgent appointments and then find people can’t prebook appointments,” she says.
Each of the four clinics being set up in the West Sussex scheme will also test a new element – the first one to open will have walk in facilities for children, aimed at reducing the number going to A&E each year. Other plans include one with a pharmacist and one hosting joint visiting teams that will react quickly to patients who need home visits.
In Oxfordshire, money has been awarded on a countywide basis but schemes are being developed locally. A practice manager, who did not want to be named, at a PMCF practice near Witney, says that the GP federation in his area wants to set up a hub where patients can see a duty GP for urgent appointments during weekdays to enable existing GPs to offer 20-minute consultations for patients with ongoing conditions.
“All doctors will still be seeing people in their practices but will be able to spend 20 minutes with patients with chronic conditions,”
he says.
Like the West Sussex scheme, the federation wants to use existing GPs. It is trying to attract those doing four sessions a week or less with the aim of covering an additional 20 sessions, and also using a minor illnesses nurse. Emergency care practitioners may also be used for home visits.
The scheme is helped by all the nine practices in the federation Weir’s practice is involved in using a single software package that allows for transfer of information.

In some areas the Challenge Fund has built on existing close relationships between practices. In Brent, North West London, for example, practices were already working together to improve access.
The PMCF money has enabled more to be done including some innovative thinking on managing demand through offering more social and community support. But Caroline Kerby, managing partner at Brentfield Medical Centre and director of strategic developments for Harness Healthcare, says: “People don’t want to come on Sunday. We are trying to convince people that they do want to see a GP on a Sunday because otherwise we have GPs doing nothing.” Monday remained the busiest day for practices, she said, suggesting that patients may delay seeking help. Nor are patients
willing to travel very far to access services as many don’t have their own transport: in Brent, three hubs are now offering extended hours. Kerby says that nurses can be hard and expensive to recruit – and come at more of a premium than doctors. As GPs can usually see more patients, it can be cheaper to have a GP than a nurse.

The next step
While the second wave of schemes are just beginning, the first ones are coming to the end of their central funding – which raises questions about their long-term future.
Much of the funding will need to be met by CCGs from this September and it is by no means certain that all elements of all schemes will be kept.
Where uptake of appointments is low, such as on Sundays, will cash-strapped CCGs want to see cuts? And will they look for evidence of money being saved in other areas, for example, through reduced A&E attendances – before they agree to mainstream funding? The future of the schemes seems far from certain and may depend on the financial health of the wider NHS.

Alison Moore is a freelance journalist and writer specialising in healthcare.