2Extending access
The risks associated with extending hours
12.The 2015 Conservative Party election manifesto committed to guarantee access to a GP at evenings and weekends by 2020. In implementing this commitment, the Department and NHS England have used pilots to test which times of the week are popular and to define the requirements for extended hours.23 NHS England told us that by March 2018 half of the country will be covered by GPs who can provide evening and weekend appointments, with all of the country being covered by March 2019. NHS England explained the level of additional capacity will be the same across areas, but commissioners will be free to decide how this is organised, for example the length of appointments or use of group consultations.24
13.NHS England expects clinical commissioning groups to provide at least an additional 30 minutes per 1,000 patients.25 The National Audit Office calculated that this minimum additional capacity will cost £230 per appointment hour per 1,000 registered patients if the funding is spent on delivering just this minimum requirement. This is 50% higher than the cost of core hours, at £154. NHS England intends that the additional funding is used to create wider changes than just additional appointments, such as developing systems to share access to medical records between practices. Commissioners were required to submit plans to NHS England by December 2016 to set out how they will use the funding to improve access. However, the National Audit Office found that NHS England had not set out how it will assess whether these plans provide good value for money. In addition, these improvements may require one-off rather than recurring costs, meaning NHS England gets less value from its continued investment in future years.26
14.There is an overlap between the period covered by the new extended hours services that NHS England is funding, that covered by existing out-of-hours GP services, and an existing enhanced service to extend hours. All three services provide care at weekends and after 6.30 pm on weeknights.27 NHS England accepted that there is a definite risk that this overlay of hours means services will be paid for but not fully or effectively used. NHS England is expecting local commissioners to ensure they do not pay twice for the same service. NHS England said it is scrutinising clinical commissioning groups’ plans, and has asked them how they will know that there will be no duplication between the three services. This scrutiny will rely on knowledge about the utilisation of out-of-hours GP services, but NHS England admits there are currently gaps in these data.28
15.Extending access into evenings and weekends may also affect continuity of care. NHS England accepted that continuity of care for certain patients at particular points in their lives is critical to achieving good outcomes. However, the National Audit Office found that patients from practices with longer opening hours during the week and those opening on the weekends reported that they were, on average, less likely to see their preferred GPs. NHS England explained that some of the pilot schemes have used additional capacity to create longer appointments or group consultations for patients they see on a routine basis or who have more complex needs.29
Information on the availability of appointments
16.The Department and NHS England have pursued this commitment to extend hours without fully understanding how patients’ needs are currently being met during core hours. They do not have data on the availability and use of appointments during core hours, including those periods that might help improve access for working people, such as before 9 pm or after 5.30 pm. They also do not know when and how long practices spend with patients.30 NHS England said that from April 2017 it is introducing a ‘practice workload tool’ that will measure how appointments are utilised at practices.31 It also said that during the course of this year it will start collecting data on the availability of routine GP appointments, and that it would seek to publish these data so that the public can see waiting times at different practices.32
17.This lack of data means that the Department and NHS England have only a limited view of what patients need and what services they can currently access. NHS England explained that working age people find it much harder to get an appointment, with patients aged 18 to 50 who work having a particularly worse experience of general practice.33 But the Department and NHS England do not know whether practices are offering appointments at times during core hours that could better serve the needs of working people, such as before 9 pm or after 5.30 pm. The Department does not believe this undermines the case for extending opening hours.34 NHS England said it has been carrying out patient surveys to ensure the additional appointments are put where they are most needed.35
23 Qq50, 62; C&AG’s Report, paras 2.5, 2.7
24 Qq42, 44–45
25 Q43
26 Qq49–50; C&AG’s Report, para 2.7
27 C&AG’s Report, para 2.9, Figure 6
28 Qq61, 63, 65; C&AG’s Report, para 2.9
29 Q66; C&AG’s Report, para 2.9
30 Qq56–60
31 Qq28, 46–48
32 Q41
33 Q52
34 Qq57–60
35 Q48
25 April 2017