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6 June 2019
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With extended hours access now rolled out across England, Rachel Carter explores how practice managers really feel about the initiative
It’s been six years since the then Prime Minister David Cameron announced a £50m funding boost for improving access to general practice, placing extended hours schemes firmly on the agenda.
The Prime Minister’s Challenge Fund comprised 57 pilot projects – covering 2,500 practices and 18 million patients – which tested new ways of working to offer more convenient access to GP appointments.
In 2016, the General Practice Forward View reaffirmed this by promising to support CCGs to fund the provision of extended hours and setting a target for all patients to have access to GP services during evenings and weekends by 2020.
However, in February 2018, the programme was accelerated when NHS England issued new guidance requiring all CCGs to provide these services for 100% of their population by that October.
At the end of 2018, it was announced that primary care had hit the deadline – all patients now had access to a GP in the evenings and at weekends, providing an estimated nine million extra appointments per year. But what has been the experience of practice managers in delivering this?
Primary Concerns 2018 – The State of Primary Care, a report released in March by Management in Practice publisher Cogora, surveyed more than 400 practice managers and found that almost two-thirds, 61%, were in favour of the introduction of extended hours.
Perhaps unsurprisingly, given that the deadline to provide this service had been moved up considerably, just over half of practice managers, 52%, also said they had experienced pressure from their CCG to adopt extended hours in the 12 months leading up to the survey.
We spoke to three practice managers about what the process has been like for their GP surgery.
Birley Health Centre, Sheffield
‘It can reduce the waiting time for patients wanting a routine appointment’
The extended access scheme in Sheffield was set up four years ago using money from the Challenge Fund and is delivered by the GP confederation, Primary Care Sheffield.
The city-wide service is based in six practices which offer appointments from 6pm-10pm on weekdays, and between 10am and 6pm at weekends.
Approximately 55% of the appointments are with GPs, while the remaining 45% are with practice nurses, healthcare assistants and physiotherapists.
Birley Health Centre practice manager Kiz Haigh says one of the challenges has been workforce. The hub sessions are staffed by local GPs, with 77 of the city’s 81 practices signed up to the scheme.
Ms Haigh is allocated a number of slots to fill with GPs from her practice. ‘I’m using my GPs, but they work long hours already, so sometimes we are just taking clinicians from one place and using them elsewhere,’ she says. ‘What we really need are new clinicians coming into primary care.’
However, she adds that staffing the service with the practice’s own doctors has also helped encourage patients who were initially reluctant to go to a hub appointment.
‘I guess it’s the fear of the unknown. After they’ve been once they are happy to go again, and it helps when they know that one of our doctors is at the hub.’
‘Bringing back learning’
Ms Haigh is also in charge of keeping staff up to date with changes to the service and ensuring the reception team is fully trained, as they are responsible for helping patients navigate the hub.
Patients have to consent to having their record shared so it can be seen by clinicians at the hub, so receptionists have to tick a box on the system, which Ms Haigh says ‘is easy to miss when you’re on the phone, but crucial to the whole system’.
She adds that for patients, the main benefit of the service is the choice it offers, both in terms of appointments outside the working day, and where patients can be seen.
‘Most of our patients want to go to a hub that is close to our practice, but some want to be seen somewhere else if they are travelling from work, for example.
‘For patients wanting a routine appointment, it can also reduce the waiting time. At the practice it might be a week or two, whereas they could be seen that weekend at the hub.’
Although Primary Care Sheffield is responsible for staffing appointments with nurses and healthcare assistants at the hubs, Ms Haigh says two practice nurses from Birley also attend regularly.
‘They come to me and say, “This is what we do at the hub, why don’t we do that here?”
So they are learning and bringing it back to the practice. That’s been really good.’ Ms Haigh finds that being able to offer patients an appointment on the same day has increased her job satisfaction. ‘I would be devastated if we lost it,’ she adds.
Freshford Practice, Essex
‘The service has been running since October – but we haven’t sent a single patient there yet’
The Freshford Practice in Braintree, Essex, has two options for extended hours access, says practice manager Linda de Silva. A directed enhanced service (DES) has been running for around six years and a new scheme, for mid-Essex, was launched in September 2018.
Under the DES, local practices have received funding from NHS England to open outside of core hours. At Freshford this means a few hours on Saturday mornings.
Ms de Silva says the practice used to open on Saturday mornings in the 1990s, as this was the best use of the clinicians’ time when they were on call on a Friday evening.
Instead of ‘making different house calls, they would say, “pop down to the surgery in the morning”.’
She adds that when the funding came in for the DES it was ‘a bonus’ because the practice was now paid for opening at that time – but this has decreased over the years.
‘The funding no longer covers the cost of it, but it’s still beneficial to patients, so we still do it.’ The Saturday morning clinic offers a mixture of routine appointments, nursing appointments and the opportunity for patients ‘who get up and are far more unwell than they thought’ to come in.
‘It suits us very well because we are a rural practice and it’s a long way to A&E,’ Ms de Silva says.
‘Not a good use of public money’
The new extended access scheme has been rolled out across Mid-Essex CCG, and Freshford can book patients into appointments at the four hubs: Braintree, Maldon, Chelmsford and Halstead. However, Ms de Silva says they ‘haven’t sent a single patient yet’.
‘Our patients don’t want to go there – public transport to those locations isn’t good and they would rather be seen here in a familiar setting, by one of our clinicians.
We’ve also often got an appointment available sooner than the hub has.’ The practice had to sign an agreement for clinicians at the hubs to access its patient records and also carried out staff training to book patients into the appointments.
Aside from this, ‘there wasn’t a massive amount of work involved’ in joining the scheme, Ms de Silva says. She adds that a proportion of the evening, weekend and bank holiday appointments at the hubs are not being filled.
This has led her to question whether funnelling resources into a new service ‘at a time when every GP practice is at full capacity and does not waste appointments’, has been the best use of funding.
‘To me it demonstrates that the money could have been better spent directly in practices to get more clinicians: we would fill the appointments and improve the number of patient contacts,’ she says.
Mid-Essex CCG says appointment uptake had risen to nearly 60% by the end of March but de Silva is not convinced the service is a wise investment. ‘The NHS should think about what patients need,’ she says.
Hall Green Health, Birmingham
‘It’s really positive for primary care to be working this way’
The extended access scheme in Birmingham was launched by GP collaboration Our Health Partnership in October 2018 and involved the creation of seven hubs across the city.
John Hood, practice manager at Hall Green Health, which is part of a network of nine practices covered
by one of the extended access hubs, says the two main reasons for setting up the service were to improve access and flexibility for patients, and to offer 15-minute appointments for more complex problems, such as long-term conditions or mental health issues.
The combined patient list for the nine practices is 89,000 and Hall Green Health is the base for the hub, chosen for ease of access for the whole patient population.
The seven hubs all offer appointments from 6.30pm until 8pm on weekdays, but opening times on Saturdays and Sundays vary depending on local patient demand, Mr Hood says.
‘We sent out surveys to see when patients would most likely attend. For our hub the hours have ended up being 9am to 1pm on a Saturday and 10am to 2pm on a Sunday,’ he says.
There are huge benefits in working at scale’
Mr Hood was practice manager lead for the hub in his locality and his initial role included writing a standard operating procedure. This is used across the other hubs to ensure patients receive a consistent service.
The hubs are staffed by practitioners from the member practices and through an agreement with a locum provider, which advertises shifts to GPs, nurses, advanced nurse practitioners and healthcare assistants who have signed up to work at the hubs.
‘My ideal would be the GPs from the nine practices taking the shifts, but because of the lack of GPs, that would never be possible,’ says Mr Hood.
‘But anyone working in those practices is given priority and can book directly into the shifts – everyone else has to apply and it’s my role to approve them.’
Mr Hood says there were a lot of ‘teething issues’ with IT and data sharing when the service launched. Another challenge was the time it took to set up and develop the project.
Now, his day-to-day input and responsibilities include creating rotas, approving shifts and dealing with anything ‘that needs fixing’.
My previous experience was working in secondary care and A&E, so it hasn’t been unusual for me to deal with these issues and isn’t as difficult to bridge some of the gaps,’ he says. ‘As long as you’re proactive, these things eventually become more manageable.’
Mr Hood adds that the service has helped take pressure off the practice team, because there are now an extra 45 hours’ worth of appointments available each week.
‘It is a really positive step for primary care to be working in this way. Having come from a secondary care background, it’s nice to see that things like this are starting to happen,’ he says.
‘There are huge benefits in working at scale – not just economies but the learning you get from the networks you build. The peer support I’ve gained from setting up this hub has been great.’