GPs are the gateway to NHS care – nine out of ten times, the first contact a patient has with the health system is through their GP. Yet access to GPs has become a major policy and political issue.
The crisis in A&E has led some to blame a lack of available GP appointments for people heading to emergency departments instead. Weekend opening hours for GPs has been touted as one solution – by improving access, many patients won’t need to take up other care services.
Since the summer of 2013, a number of GP surgeries in London have been piloting seven-day opening, as part of the Challenge Fund initiative (funding for which was recently increased from £50m to £100m). Through the Challenge Fund, GP surgeries were asked to bid for funds for extra opening hours, but this was solely for set-up costs (for example, the sharing of medical records). Running costs had to be covered by surgeries from existing budgets.
We wanted to know whether the flow of patients to A&E from four of these pilots in central London changed compared to a control group of 30 other surgeries in central London. In our study, we found an 8% drop in A&E attendances among patients of the pilot surgeries compared to the control group.
We also found an 8% drop in A&E admissions among elderly patients (those aged 65 or more) of the pilot surgeries. This is because cautious doctors at the A&E are more likely to admit elderly patients to hospital, while GPs, familiar with their case histories, may be more comfortable treating and sending them back home.
The effect was also largest at weekends. And the fall was only in cases of mild to moderate severity. There was no effect in the most urgent cases such as those caused by accidents or brought to A&E in ambulance.
Based on these findings, we calculated that this 8% fall would translate into 2m fewer visits to A&E each year if weekend opening was made available nationally. Given that the average cost of a GP consultation is about £27 while that of an A&E visit is £114, 2m fewer A&E visits would imply a cost saving of £194m in savings.
Lower incentives to visit A&E
From research carried out by Thomas Cowling and colleagues, we know that there is an association between GP access and the number of non-urgent A&E visits. In 2010-11, the GP surgeries that were most accessible also had lower A&E non-urgent visits compared to the GP surgeries with the least access. A one point increase in the percentage of registered patients who seek GP appointments within two week days increases non-urgent visits by 0.7%. Increased travel time to hospital also reduces non-urgent A&E visits.
Out-of-hour services and walk-in centres, of course are already available. The last Labour government encouraged extra hours but the policy was eventually dropped.
On the whole, most of us are happy with access to our GP. In a survey of GP patients conducted in 2014, three-quarters of respondents said that they found opening hours convenient. But among those who found GP opening hours inconvenient, 74% wanted surgeries to be open on Saturdays, 71% late hours (after 6.30pm) and 37% wanted them open on Sundays. Around 24% of people said it was not easy to get through to their surgery on the phone.
One issue is also about the demographic of service users. As one GP put it:
Longer opening is a fine idea but the problem is that the people who see us the most – young children and elderly – are the ones that don’t have a problem with appointments on a Monday afternoon.
Seven-day opening
Labour has promised a 48-hour target for GP appointments (at a cost of £100m), while the Tories have promised a seven-day access to GP services by 2020. David Cameron said that the move could take pressure off A&E wards which are “not the right place for frail, elderly people”.
Seven-day opening, however, does not actually mean all surgeries are open all week. In many places, weekend or late opening is rotated between nearby surgeries. It’s a practical and cheap solution, especially for small surgeries which have less resources to spend (fewer GP and nursing staff, so less flexibility in adding weekend shifts). Further evaluation of other pilots may point us towards the most cost-effective arrangement for weekend openings.