Is extended hours working?

After intense DoH pressure, most GPs now offer extended hours. Tom Ireland looks at the legacy of option A.

Last February, GPC chairman Dr Laurence Buckman accused prime minister Gordon Brown of holding a gun to the profession's head over extended hours.

The DoH left GPs with a stark choice - accept a deal in which £158 million of funding from access, choice and booking directed enhanced services (DES) was diverted into an extended hours DES, or ministers would impose swingeing QOF cuts and probably deny the profession a pay rise.

Left with little choice, GPs accepted the 'least worse' option, but many looked likely to stand firm in their opposition to longer hours.

Fast-forward 18 months, and 77 per cent of practices provide extended hours, according to DoH figures for July. But has GPs' antipathy to extended opening mellowed, and how will the initiative evolve?

Local deals

GPC negotiator Dr Chaand Nagpaul believes many practices open extended hours because local deals were worked out with primary care organisations that were 'workable and meaningful'.

'The uptake has been a reflec-tion of flexible local arrange-ments, which provide the flexibilities that the GPC originally asked for in the DES.'

Dr Grant Ingrams, secretary of GPC West Midlands, adds: 'Many practices are doing it because there is a genuine need, and many were doing it before the government decided to do it. For many, where they do not have much space, re-organising the day into three sessions has been helpful.'

But the legacy of the govern-ment's imposition is that many practices run the service where there is little or no demand - just to recoup funding cuts from the 2007/8 contract.

This week's GP poll shows that at one in 10 practices, less than a quarter of extended hours appointments are used. Nearly four-fifths report that a normal mix of patients attends, rather than those who cannot attend during the day.

Dr Jeremy Phipps, a GP in Lincolnshire, says his rural practice has little demand for the service, but he does it anyway 'because we would lose more money by not doing it'.

Dr Ingrams describes a colleague who loves his Saturday surgery: 'He can get his paperwork done because there are no patients.'

But more than 22 per cent of practices do not provide extended hours, including Dr Ingrams' practice. His population is elderly and asked for more daytime appointments.

But Dr Ingrams said practices should be cautious about deciding not to open extended hours. 'Practices that do not offer it will lose the mobile, young patients, who they might not see very often, and retain more patients they will need to see more often.'

The effect on staff should not be underestimated, either. Dr Raj Thakkar, a partner in Buckinghamshire, describes extended hours as 'costly and exhausting'. A quarter of GPs say extended hours have strained relationships between staff, according to GP's poll.

Future funding

With more practices open longer, and Darzi centres open from 8am until 8pm, seven days a week, some fear the extra hours will become standard.

The prime minister this year revealed plans to explore giving patients a 'right' to see a GP in the evening, and NHS chief executive David Nicholson described a range of improvements, including opening hours, as new 'minimum standards' in his annual report.

The Conservatives have threatened to scrap the national DES, but warned that patients would leave practices that did not offer extended hours.

Dr Nagpaul reassures GPs that core opening hours for GMS services will remain 8.30 until 6pm and the GPC has 'no intention of incorporating extended hours into that'.

But some GPs have lost confi-dence in the government and the BMA. Dr Thakkar fears the government 'will force GPs to keep practices open for even longer', and feels 'blackmailed' due to falling income.

'Why the BMA has not inter-vened, with more effective out-comes, who knows,' he says.

For all the uncertainty, extended hours is surely here to stay - no party would shut practices that currently open at weekends.

To make the service worthwhile, says Dr Nagpaul, other primary care services, like labs and pharmacies, need to be open alongside the GPs.

But numbers opening longer hours will remain high; the DoH has its soundbite and many GPs simply cannot afford not to.

If the DoH can learn only one lesson to avoid the protracted, confrontational negotiations of 2008, it should be that local needs require local solutions.


September 2007: Alan Johnson tells Radio 4 GPs have too much of a 'nine-to-five attitude'

December 2007: Laurence Buckman says Gordon Brown is holding a gun to GPs' heads over demand for three extra hours per average practice

March 2008: GPs vote for 'least worse' option A - which leaves practices losing £18,000 unless they open extended hours

October 2008: Then health minister Ben Bradshaw says DoH target of 50% of practices extending hours has been met

August 2009: 77% of practices now open extended hours - uptake rising fractionally over last few months

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