Management in Practice
The GP opening hours issue has unfolded in the manner of a national soap opera over the last few months, following faltering negotiations between the Department of Health (DH) and the British Medical Association (BMA) last December.(1)
This divide, between a government seemingly insistent on practices opening later in the evenings and weekends, and the BMA's GPs' Committee (GPC) fraught with concerns, led to further sides being taken. The Confederation of British Industry (CBI) entered the debate, demanding more flexible hours due to "millions of lost working days" as a result of GP appointments in normal working hours.(2)
Media distortions of overpaid GPs, no longer providing out-of-hours care and enjoying the financial fruits of an overly generous new contract, seemingly aided calls by those wanting to see a GP outside core working hours.
Then, a GPC opinion poll of more than 27,000 UK GPs revealed that 96% were opposed to both of the options the government presented the GPC with, which required practices to open for around three additional hours per week.(3)
Despite the objections, an announcement was made in April for a new directed enhanced service (DES) for extended access, after 92% of GPs had reluctantly selected the "less worse" Option A.
Amid the furore of debate between business, government, GPs and patients, one voice seemed absent – practice managers, those charged with overseeing the additional HR, security and financial demands that working the additional hours would require.
Hence the Management in Practice survey, which received 537 responses. Of these, 83% were practice managers, 7% were business managers, 4% practice directors or partners and 2% were assistant practice managers; the remainder mainly comprised practice administration staff, nurse managers and GPs.
The vast majority (91%) of respondents were from England; 6% were from Scotland; 2% from Wales and 1% from Northern Ireland.
While the majority were not opposed to opening longer in principle, the results nonetheless mirror GPs' frustration over government negotiations evident from the GPC poll. They also reveal a potentially damaging impact on existing staff resources as well as additional responsibilities for practice managers over security and risk assessment.
Nearly one in five respondents said they were considering reducing the practice's outgoings to cover the additional costs of opening longer – many saying staff redundancies would be necessary.
And more than 70% said they had concerns over the safety of isolated GPs and receptionists working the extended hours. In addition, almost nine in 10 said they believed the extra funding for access would be better used to improve other areas of patient services – and only one in four managers sympathised with patients wanting more flexible appointment times.
Practice managers are clearly agreed with GPs over the two options for providing access funding – 91% preferred Option A (in which funding extended hours will be made through a new DES) to Option B (in which funding would have been allocated to primary care trusts [PCTs] to agree local contracts for extended opening).
And 89% of respondents believe the government's method of negotiation has been "unacceptable" – just slightly fewer than the 98% of GPs who felt the same way.3 Many spoke of the government's "bullying tactics", and of the "imposition" of this policy.
Tom Brownlie, Chief Executive of AMSPAR, was unsurprised by this response: "I don't know of anyone who doesn't feel the government's actions fall short of acceptable", he said. "What irks people is the resources effectively wasted on renegotiating an arrangement that had already been put in place."
One survey respondent said: "After 15 years in practice management, this is perhaps the most naked attempt by the DH to assert political control over GPs, and the justification in terms of patient demand is wafer thin."
Of course, it was unlikely that a demand for staff to work longer hours would have been hugely popular. Yet the survey results do not show a strong unwillingness among managers to work longer. On the contrary – 60% of managers said that, in principle, they were happy to take part in an extended hours DES if funding allows (see Figure 1).
Despite this, less than half (44%) said they would definitely fulfil an extended hours DES, with 30% saying they would "probably" carry out the DES. Thirty-five respondents were clearly not onboard, even at this early stage, saying they would definitely opt out of the DES and take the consequences.
As a practice director from Norfolk commented: "If the government had approached this subject in a more friendly and open manner, and practice managers had been included in the discussions, I believe that you would have seen a totally different outcome and less opposition to the proposals."
However, responding to these survey results, a DH spokesperson told Management in Practice: "The government is committed to working with GPs to improve access to services and to support wider improvements in the quality of GP services."
While the survey results suggested hostility towards the "topdown" approach of the DH, it suggests there is little pressure from PCTs or health boards – most managers (60%) said that they had been encouraged to open for longer by their PCT/board, but not forcefully so. And more surprisingly, nearly a third (31.7%) said they had heard nothing from their PCT over extended hours.
While the finer financial details for an extended access DES have not yet been announced, our survey set out to compare managers' calculations of how they could be financially affected under the Option A proposals following the announcement, in April, that 58.5 Quality and Outcomes Framework (QOF) points would be removed to fund access.(4)
Just 30% of respondents believed that practice finances would be fully recouped through the new DES. The majority of those who believed they would still lose money despite participation estimated an annual loss of up to £5,000.
When asked to estimate how much their practice could stand to lose if they did not participate in the DES, the largest group (28.8%) believed this would be between £10,000 and £20,000 per annum.
This would appear to be a fair assessment. The proposals for an access DES under Option A stipulated a rejiggling of funding equivalent to £2.95 per registered patient, and the largest group (38%) of our survey respondents had a list size of between 4,000 and 8,000 patients.
Dr James Kingsland, Chairman of the National Association of Primary Care (NAPC), warned Management in Practice that all practices should be aware that by not participating, they would indeed lose existing income, rather than gaining additional money.
"A practice of 6,000 patients, for instance, already has an allocated £18,000 within its current budget and is doing certain things to earn it," Dr Kingsland explained. "What's going to happen is that £18,000 will be taken out and you re-earn it if you do the access. So there's a potential for practices with 6,000 patients to be losing that order of money by not doing it."
He added: "That's a concept I don't think enough practices understand. This DES is not new money to do new work, but recycled money from existing contracts. By opting out, practices will have the same opening hours for less money."
It is clear from the survey that a significant number of practices are already considering cutting the existing costs of running their surgeries to fund the additional opening hours. Nearly 20% of respondents said they would be considering reducing their current outgoings – the majority of these saying this would be done through staff redundancies and cutbacks.
"We have a part-time GP leaving soon and will not be looking at a replacement," said a practice manager from Derbyshire. "A fulltime administrator has already left and has not been replaced."
"This is the most surprising statistic to me!" said Tom Brownlie of AMSPAR. "Twenty percent can afford to lose staff?"
Yet Cathryn Bateman, Consultant Editor of Management in Practice, acknowledged the sad necessity of such decisions: "If resources are being rationalised then unfortunately it's a fact of life that other areas have to be rationalised too. It's one of the downsides of the job that you have to make harsh decisions at times."
In response to this finding, Dr Laurence Buckman, Chairman of the GPC, told Management in Practice: "It was always inevitable that some practices would cut costs by reducing staff. Of course, this is not an ideal solution as we need our staff in order to deliver service to patients. We should be offering better service at a time of challenge."
The survey indicates that many practice teams are in for a shake-up. More than one in five practice managers said their practice teams were "vehemently opposed" to working longer hours – whether or not adequate funding was in place.
Eight respondents said that the issue of extended hours had led to resignations. While the resignations were from both clinical and admin staff – including those who were happy to stay past retirement age but did not wish to work the longer hours – the majority, perhaps unsurprisingly, were receptionists.
This could be unfortunate – the survey suggests that receptionists will now have a greater role to play in surgeries, as in many cases (43%) it appears they will be the only nonclinical member of the practice team working the later hours – along with just one GP (60% of respondents said only one of the practice's GPs would be seeing patients during the
A small number of respondents (14) said that one GP would be working without any administration staff. Just 7% said the whole practice team would work longer.
In such circumstances, the security implications are obvious. This is no doubt why more than 70% of respondents said they had concerns over the safety of their staff. Comments included:
Considering these results, Dr Buckman said: "I am very worried by the prospect of so many practices operating with little safety back-up. Nobody should have to work like this."
Cathryn Bateman said: "Most practices should have a lone-working policy. It is a concern though, we are all vulnerable. While practices do have some flexibility about how and when they deliver the service, they will need to ensure that their operational policy covers this area."
It has been pointed out – not least by the NHS Alliance, the independent body for primary care – that good general practice involves the whole team, rather than one doctor.(5) Will the services of a single GP be enough for patients?
According to the majority of survey respondents, extended access is not a fundamental requirement of most patients. Many cited the DH's own access survey, in which 84% of patients said they were happy with their practice's current opening hours.(6)
In the MiP survey, just under half of managers said their patients were "perfectly happy" with the current hours –though, surprisingly, more than a quarter had not consulted their patients over access (see Figure 2).
And most managers – an overwhelming 88.8% – believed there were more important areas than access where patients would benefit from extra funding. The most deserving area for money, according to 42.5% of respondents, was addressing the needs of the elderly and those with chronic illnesses.
Dr Buckman is in agreement. "The evidence that patients require extended access simply is not there and paper after paper shows this," he said. "This DES has been introduced to fulfil a government pledge designed to appeal to healthy voters who rarely use the surgery and who want it open when they can get there, not the other way round."
Yet a DH spokesman said: "We know that where surgeries already offer more convenient appointment times they are popular with the public and GPs."
But managers did not even sympathise with a desire for longer opening hours. While 27% said they understood the need for enhanced access, and that "we should try to improve patient services where possible", 73% believed that this is a patient "want" rather than "need", and that patients should recognise that the services of a trained GP cannot operate around the clock in the manner of a supermarket (see the difference of opinion in Box 1).
It may be that the notion of "supermarket surgeries" opening all hours has led managers to be even more sceptical of the private sector. More than 83% said they believed the expansion of private commercial provision of NHS general practice "poses a major threat to the quality of general practice and to patient care". In our first survey, conducted in October 2007, just under 70% believed this.
This was not the only shift. Those who said their morale was "quite low" had increased from 15% to 22%. In our first survey, more than 36% said their morale was "quite high"; in the latest survey, this has decreased to 22%.
So why is this? Many blamed "political intervention" and "constant changes" to primary care policy. Responses included:
Are such comments pocketed instances of discontent, or do they reflect a wider malaise? Dr Kingsland believes the latter. For years a regular speaker at primary care conferences, he said that, in the last few weeks, he had noticed "an ever-increasing mixture of hostility and despondency, which is unusual."
He puts this down to several factors, not only access targets but also the recent GP pay freeze and polyclinics – "you mix it all up and you have a fairly confused and disillusioned primary care system at the moment," he said.
Dr Kingsland also attributes this to a negative attitude among the public, nourished by unbalanced press. "While we're still seeing high levels of satisfaction with general practice and a high regard for GPs, more and more in the media the line is spun that we're getting lots of money and not doing very long hours for it – and the public is starting to believe it."
Cathryn Bateman agrees with this last point: "The constant media spotlight being hung very closely over the heads of GPs over recent months has added to the feeling of low morale. No one seems to think that we do a good job."
In response to our survey results, Dr Buckman said: "I am saddened by the demoralisation of practice managers and am concerned that our managers feel that the direction of the NHS is wrong and that they are ignored by the DH".
Nonetheless, it would be wrong to ascribe an overwhelmingly negative attitude among practice managers. Despite the findings, almost a third of respondents described their morale as "high", with more than 40% saying it was "moderate".
And, of course, it remains to be seen whether the introduction of extended opening hours will drastically affect the way that practices work. The DH is insistent that more flexible access is vital. "This change will ensure more convenient surgery opening hours for millions of patients," a spokesman said.
There also appears to be help in hand for those practice managers who are wringing their hands in anticipation of the new directive. The DH told Management in Practice: "We will be bringing forward a national programme to support both PCTs and GP practices in delivering the primary care access commitments."
"We look forward to continuing to work with the BMA, GPs and other primary care professionals to put patients at the centre of improving the quality of care and preventing ill health in the first place."
1. See http://www.managementinpractice.com/article_7060
2. See http://www.managementinpractice.com/article_8000
3. See http://www.bma.org.uk/ap.nsf/Content/pollresults0308
4. See http://www.managementinpractice.com/article_9824
5. See http://www.nhsalliance.org/media.asp?display=press_release&press_release...
6. Department of Health. GP Patient Survey 2007: National Results. July 2007. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/PublishedSurvey/GPpati...