Access to GPs

People A doctor talking to a patient
ViewsDecember 16th, 2014

The recently published Welsh Government’s four year plan for primary care points out that while patient satisfaction with their service “remains eye-wateringly high” there is a problem with access. As the paper points out “About a third of adults say they find it difficult to make a convenient appointment with a GP.”

Access can no longer be seen as consumerist froth on an over-flowing pint of “real” healthcare need. Patients do need timely access. And what is timely is determined not just by a person’s clinical condition but also by a wider range of other circumstances which dictate how we live our lives in the 21st century.

Considerable effort is being spent on advising patients to see help and advice appropriately.

As patients are better informed they are aware that certain symptoms can signify serious illness e.g. chest pain in adults, high fever in children or the early signs of stroke. Ready access, though not always a face to face consultation, is needed to guide an appropriate clinical response.

In the past when single-handed practice was the norm people could reasonably walk to their local surgery. But as practices initially amalgamated into partnerships and now as many partnerships are located in bigger primary care  centres getting there is becoming a greater challenge which can require use of public transport or a car. This means that journeys to the surgery have to be planned.

When people use the health service they also have to juggle many other commitments such as work, child care or being a carer.

Almost 30% of the working population travel over 10km to work with 7%  travelling over 30kms. In many local authorities across Wales 40% of the working population travel out of their local authority area to their job. In these circumstances it is not reasonable that patients should have to sacrifice half a shift’s pay to attend the surgery, even if their employer was willing to accept these absences.

Over 12% of the Welsh population are carers of whom considerably over one third are caring for more 20 hours per week. As well as supporting others these carers are more likely to have a range of their own personal needs. These patients require flexibility in when they can arrange to visit their surgery or health centre.

The changing nature of primary care activity also has its implications for how access issues are managed. More time is spent in the management of chronic condition when patients are not acutely ill. When patients felt ill they were unlikely to feel able to work. This is not the case with the management of chronic illness where patients will very often continue with their everyday activities and responsibilities. But this anticipatory care can require more visits to the surgery. The average Welsh patient now sees their GP about six times and the practice nurse four times per year.

The Welsh Government’s plan recognises the need to address the access deficit and proposes a range of options. Surgeries will need to be open for longer hours to allow people to attend before or after work. There will also be a need for mid-day access to fit in with local transport arrangements or with breaks in  work time.

Patients will be provided with greater opportunities to make their own appointments. This should improve continuity of care with patients being able to “pick” their preferred doctor more often and it should also reduce the incidence of non-attendance.

Prudent healthcare is the Welsh Government’s by-word of the moment.

In the context of improving patient’s access to care this will mean not always being seen by a doctor but by an alternative  professional with a level of training for that condition.

This pattern is well established in many part of the NHS. Midwives deliver most of maternity care and health visitors have a key role in working with young children. Practice nurses play an important role in chronic disease management and a range of preventive services such as ‘flu vaccination and cervical cancer screening. It is envisaged that these roles will develop and evolve with enhanced responsibilities such as prescribing becoming more common place. Pharmacists are increasingly involved  in repeat prescription monitoring and advising on minor acute illnesses. And there may be more referral pathways as well.  Already optometrists in Wales manage many chronic eye diseases and refer emergency eye patients for further professional advice.

As these new pathways are put in place, patients will need to be better informed of their options to allow them to access the service more appropriate for their needs. In effect patients should be able, in the words of the BMA, “sort it out in one call.” Crucial to this is a more more integrated medical record.

However there is a real risk that these innovations will weaken the “personal nature” of a primary care service.

The specialisation and sub-specialisation in our hospitals has been at the expense of holistic care. Primary care generalists are an important counterbalance to this complexity. The quality of this generalist role is build on a personal relationship of trust and continuity. Too many primary care pathways will erode this cornerstone value.

Prudent healthcare means patients will have a greater say, choice and responsibility in their own health care. Those who have chronic illnesses should have agreed care plans in place which should not only be accessible to care professionals but also to the patient themselves as they play their part in the co-production of their health.

Improving access will require more primary care capacity. In relative terms primary care  investment  has dropped significantly over recent years from a peak of 10.3% of NHS spend to 7.9%. And while the numbers of GPs in Wales have passed the 2,000 threshold for the first time the 11% increase in the last 13 years is considerably less than the 62% increase in consultant numbers. List sizes have only gone down by 2% since 2008 and it is still the case that health boards with the biggest average list size are also the areas with great health care needs.

This increase in capacity however is not just about an increase in numbers. It also requires creating time. There is little doubt that the Quality and Outcomes Framework has achieved a shift in primary care focus towards chronic disease management but it also created a bureaucratic feeding . This is now being recognised by the Welsh Government which has radically streamlined the system through removing a large number of its process components. This will free up time for more direct patient care as will the drive to end half-day surgery closing which was a feature of many practices across Wales.

This extra time capacity can be used in new ways. The Health Minister, Mark Drakeford AM, recently told that National Assembly that he is engaged in a pilot scheme in Newport, Cardiff and Swansea where patients can attend a surgery close to their place of work for routine care while retaining their “home” GP. This should be particularly helpful for those who work in these cities and if it is successful it could be spread to other locations in Wales including work places that have an established occupational health care service.

Since our new, bigger LHBs have been put in in place in 2009 primary care has slipped down the priority list.  This four plan provide a clear vision and a sense of direction which underpin a “prudent” Welsh NHS.

Making it happen is now the real challenge for the Welsh Government and our Health Boards.

Brian Gibbons is a member of the Socialist Health Association Cymru. He was Minister for Health in the Welsh Government from 2005-7 and also had ministerial roles for local government and economy and transport. 

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