The first wave of the Prime Minister’s ‘Challenge Fund’ pilots across England have tested seven day access to GP practices, with some surprising results. Seven day access to general practice from 8am to 8pm was the first pledge in the Conservative manifesto, and it’s been in the media spotlight ever since. The key question is: do patients really need or want a seven day service?
Access to general practice needs to improve, as outlined in Improving General Practice – A Call to Action, a quarter of patients do not rate the experience of making an appointment as “good”. Without sufficient change, primary care will not be able to reduce the avoidable pressures on hospital resource.
In October 2013, David Cameron announced a new £50 million Challenge Fund to help improve access to general practice and stimulate innovative ways of providing primary care services. 20 pilot sites were selected covering 1,100 general practices and 7.5 million patients.
Were the wave one pilots a success?
The wave one pilots had unquestionable successes. As the first evaluation report on the wave one pilots published in October 2015 outlines, approximately 520,000 additional appointments have been provided in core hours to patients across the pilot schemes, and approximately 400,000 additional appointments have been provided in extended hours.
As a result, after more than a year of the pilots there was a 15% reduction in minor, self-presenting A&E attendances compared with 7% nationally.
The report estimates that the savings for the pilot areas would be £3.2m, but acknowledged that this figure was “dwarfed” by the upfront capital required for the pilot schemes (which should be considered as a broader investment given the lessons that can be shared from the pilot schemes).
The rub - patients don't get sick on Sundays
The somewhat surprising results are that, in many cases, the uptake on Sundays was low.
The evaluation report recommends that given reported low utilisation on Sundays “…it would be more sensible to allocate additional hours to weekday slots or possibly Saturday, rather than trying to establish a Sunday service.”
Can this be true? Can we herald Sunday as a day where patients don’t get sick?
If we examine A&E attendances on a Sunday it seems that, of course, patients do get sick on Sundays. The A&E Statistics briefing paper to the House of Commons in July 2015 outlined that most A&E attendances occur between 9am and 6pm, and that Monday and Sunday are the two busiest days in terms of attendance levels - with Monday experiencing 17% more attendances than a Friday.
How do we solve the pattern of low demand?
The Challenge Fund evaluation report highlights a pattern of low demand on Sundays nationally, citing only Slough, Bury, Morecambe, and South Kent Coast as not reporting any utilisation problems at weekends.
In defence of the pilots who did experience low utilisation the reports states “…the lack of success with certain weekend extended hours slots is not necessarily attributable to the delivery and design of projects or an ineffective communications strategy; rather it as a result of entrenched patient behaviours”.
So how can commissioners shift entrenched patient behaviours? Clearly there is patient demand as, despite ardently rejecting the 8-8 access scheme, the Royal College of General Practitioners cite in their letter to the House of Commons Health Committee’s primary care inquiry, “the percentage of patients reporting that they have to wait more than a week for a GP or practice nurse appointment…now stands at 18%, up from 13% in June 2012.”
Perhaps these are patients who make Sunday and Monday in A&E particularly busy…
Taking the time to make the change
It may be that the answer lies in one of the report’s conclusions: shifts in working culture take time. It is understandable that if the practices are taking time to adapt and to build confidence in the scheme, then patients will also need time to adapt.
A YouGov poll in June suggested that 61% of those surveyed wanted seven day access to general practice. With significant public support, we should be cautious of dismissing Sunday’s low utilisation as mostly due to low patient demand.
The report summarises that “one year is considered insufficient to fully instil (or measure) permanent behaviour and mind-set change amongst both patients and GPs, especially given the process barriers that were faced in the first few months.”
With the precedent of reducing A&E by up to 15% within months of implementation and the potential to make significant savings, commissioners should consider taking the time to make the change.
Fundamentally, patients need to be taken on the journey to make it a success, as this may be an opportunity to make a real difference to the whole health care system.
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