Bill Jamieson: Getting GPs out of that 9-to-5 routine is right prescription

Published on Thursday 31 December 2009 21:42

IT WAS the left-wing Labour firebrand Aneurin Bevan who famously said of Britain's doctors that he had to "stuff their mouths with gold" to secure their agreement to work with the new National Health Service.

Cynics might well apply the same crude phrase to GPs in Scotland over the provision of services in the evenings and at weekends – only this time, the gold-stuffing doesn't seem to be working in the manner intended.

A Scottish Government scheme to give doctors extra money in return for an extension of opening hours has been shunned by more than 300 GPs' practices, or almost one-third of the total.

It seems little short of astonishing that some GP access hours should be little changed from the 1950s era. Even high street banks, which persisted for decades with a small access window for retail customers, were finally forced to give way on branch opening times.

With the explosion of social change and the rise in husband-and-wife working, retailers, led by the supermarkets, were obliged years ago to leave the nine-till-five model behind. For millions of households, the weekly shop is now done on Friday evenings, with some stores open round the clock for a service-sector economy that has changed mightily from the ordered world of 50 years ago.

Why should access to GPs be that different? Evening and weekend surgeries would only bring doctors into the world as we now know it. Consumers, not providers alone, should have a say in how and when services are available. It would provide greater flexibility for patients, many of whom are looking after children or providing for elderly relatives and who cannot get to a doctor's surgery in the hours allotted. There is every good reason why there should be an extension in GP hours to accommodate those who cannot get to see a doctor in "normal" working hours. So long as GPs are compensated for this extra service, what should be the problem?

For some GPs, problems there are – and they have legitimate concerns about the extra service they are being asked to provide. But let's keep in mind the bigger and more positive picture. This shows that a substantial majority of GPs have agreed to extended hours. In Dumfries and Galloway, 94 per cent of surgeries have agreed to offer extra appointments outside typical working hours. In Glasgow, 69 per cent are taking part, and in the Lothians the figure is 64 per cent. But for the Borders area, participation falls to as low as 44 per cent.

For some, the scheme poses security problems, both for doctors and for their patients being in surgeries alone late at night. This is a problem all too manifest in Scotland, where some 20 per cent of the population lives in rural or remote areas.

For others, the extra money isn't worth it, by the time extra nursing and administrative costs are taken into account. The cash inducement is 19,000 for the "average" practice prepared to offer an additional 30 minutes of appointments each week for every 1,000 patients – equivalent to three hours for a "typical" surgery. But few GPs would see themselves working in a practice that could be described as "average" or "typical". Each one has its own idiosyncrasies and problems. Some may be located in areas where the local population is in decline, or in rural areas with problems of transport and access.

And the British Medical Association (BMA) disputes the apparent generosity of that "average" 19,000. It says doctors who adopt the scheme receive just 2.95 per patient, less than it would cost to ensure the additional service was properly staffed and administration costs allowed for. Other GPs chafe at the government's refusal to allow them to prioritise working patients for "extended hours" appointments, with the result that they are taken up by patients who could be seen during normal surgery hours.

A more searching objection is the charge that there is little by way of improved outcomes. Dr Dean Marshall, chairman of the BMA's Scottish GPs' committee, says: "There remains little evidence that extended hours are improving outcomes for patients, or if they are being used by patients who would otherwise find it difficult to access GP services during traditional opening hours. The Scottish Government should review this to ensure that taxpayers' money is not being wasted on a policy which does not make best use of valuable NHS resources."

However, measuring "outcomes" is difficult, where the benefit may be more in the form of patient reassurance than in specific diagnosis and cure.

The extended hours proposal grew out of an Audit Scotland report in 2007. This found there were more than a million contacts with primary care out-of-hours services across Scotland. The cost to NHS boards of providing these services in 2005-6 was 67.7 million – a figure that has almost certainly risen since. The main users of out-of-hours services are children, older people and those with long-term conditions, or patients with palliative care needs or mental health problems.

A key finding of the report was that out-of-hours services were under continuing pressure, as fewer GPs were providing services.

"New ways of working are required," it concluded, "as there is a significant risk that current models of service delivery are not sustainable in the long term."

As a general principle, the extension of GP hours to enable patients to gain access to a doctor on a weekday evening and at weekends should be strongly encouraged. Health provision must be responsive to the needs of service users. In any event, the way we live now has changed greatly since the 1950s, and doctors need to adapt to that. Most have willingly done so. But there are areas where take-up of the new scheme has been weak and the Scottish Government should appraise itself as to why this is so, and seek solutions that would encourage higher take-up.

Equally, it should allow GPs more flexibility in the allocation of patient visits, so that the extended hours are available for those who, through household situation or disability, are unable to attend during normal working hours.

That the majority of GP surgeries have taken up the new scheme is encouraging. This is the platform on which to build in the new year.