Conclusions and recommendations
1.Many GP services are closed to patients at times during supposedly core hours, leading to worse outcomes for patients. Core hours in the GMS contract are defined as 8 am to 6.30 pm, Monday to Friday, although practices can tailor their opening hours as long as they meet the “reasonable needs” of their patients. Some 46% of practices close at some point during these core hours, including 18% that close by 3 pm on at least one afternoon a week. Rather than reflecting patient needs, there are geographical variations in these closures, seemingly based on historical patterns. Patients registered to practices with fewer opening hours attend A&E departments more often on average. Furthermore, three-quarters of practices that close during an afternoon each week receive additional funding to provide appointments outside of core hours. NHS England claims that it is addressing these closures and told us that practices will no longer receive this additional funding if they close during core hours. NHS England is also checking with every practice that closes on an afternoon what services are still available during these closures and what alternative arrangements are in place.
Recommendation: NHS England should report back to the Committee by September 2017 on how it has ensured that practice opening hours are reasonable.
2.Despite being introduced in 2004, the main GP contract does not clearly set out what patients should reasonably expect from their practice during core hours. To date local commissioners have not had a consistent view on how to define the reasonable needs of patients, particularly as this has never been written down and agreed. NHS England accepted that these reasonable needs, such as being able to book an appointment or pick up a prescription, should be written down and has agreed to work on this with the British Medical Association and local medical committees as part of the 2017–18 contract. The Department and NHS England explained that the assurance system in general practice has historically relied on a high level of trust with practices. Commissioners have few tools if practices fail to meet patients’ reasonable needs, and instead must rely on financial incentives and peer review to improve access.
Recommendation: NHS England should report back to the Committee by March 2018 on what practices should provide to patients during core hours, and how it will ensure that commissioners are using this definition in managing contracts.
3.NHS England still does not have the information it needs on the availability of appointments during core hours to help it understand when patients can see a professional and where it needs to seek improvements. To be fully informed, patients need to know not only opening times at their practice but also when appointments with GPs and other staff are available. NHS England does not collect this information; nor does it know when and how long practices spend with patients. Without this information, it cannot know whether practices are offering appointments during core hours to suit working people, such as between 8 and 9 am and between 5.30 and 6.30 pm. Yet it is pressing ahead with plans to extend access in the evenings and at weekends to meet the needs of this working population. NHS England says that by April 2017 it will have introduced a tool to collect data on the availability of appointments and that is committed to publishing these data.
Recommendation: NHS England should set out how it will collect data on the availability of, and waiting times for, appointments during core hours at each practice, and when it plans to publish these data.
4.There is a risk that new extended hours arrangements could prove expensive and duplicate existing out-of-hours services. The cost of providing these new arrangements would be 50% higher than core hours if clinical commissioning groups were to simply provide the minimum requirements set out by NHS England. The funding for extended hours is intended to go beyond just additional appointments, and can cover set-up costs such as developing systems to share access to medical records between practices. However, NHS England has not set out how it will make sure these wider improvements are delivered, and some of them will only require one-off investment rather than the recurring funding provided. As accepted by NHS England, there is also a definite risk of duplication of services, with out-of-hours GP services and an existing enhanced service also providing care at weekends and after 6.30 pm on weeknights. NHS England expects clinical commissioning groups to manage this risk.
Recommendation: NHS England should report back to the Committee by March 2018 on how it is ensuring that clinical commissioning groups are delivering the wider benefits intended from extended hours funding and minimising any duplication of funding.
5.Since our previous report a year ago there has been no progress on increasing the number of GPs. In 2015, the Department mandated NHS England to increase the number of doctors working in general practice by 5,000 by 2020. But the number has fallen in the last year, from 34,592 full-time equivalent doctors in September 2015 to 34,495 in September 2016. Increasing this number relies on both increasing the recruitment of trainees and improving the retention of the existing workforce, but Health Education England still lacks a credible plan for ensuring that there are enough GPs and that they are in the right areas. In 2016–17, Health Education England filled only 93% of the available 3,250 training places, although this was 250 more than in 2015–16. A scheme to attract trainees to hard-to-fill placements filled 105 of 122 posts, although we remain concerned about recruiting trainees to rural areas. Health Education England accepted that more could be done to promote general practice as a career choice, and highlighted work underway to make training options more flexible. NHS England added it has a development programme in place to tackle workload in general practice.
Recommendation: NHS England and Health Education England should keep the Committee updated on progress against the targets to increase the number of GPs, including in rural and historically hard-to-recruit areas, as set out in the GP Forward View.
6.There remains too much reliance on patients seeing GPs, rather than nurses, mental health professionals and other staff. In April 2016, NHS England committed to 3,000 more mental health therapists, 1,500 clinical pharmacists and 1,000 physician associates. NHS England is part-funding practices to employ clinical pharmacists, but there are also opportunities to make more use of community pharmacists, particularly as NHS England say there is a good supply coming out of training. However, patients still often expect to see a GP rather than a nurse or other professional. The small size of practice populations in some parts of the country, particularly rural areas, and the limitations of existing premises, is preventing practices from being able to employ the most effective staff mix.
Recommendation: NHS England, working with Health Education England, should explore how it can encourage GP practices to employ a wider mix of staff to improve access and capacity in an effective and efficient manner. This should include spreading examples of good practice.
25 April 2017