News that a GP practice in Dorset is offering private GP appointments in its NHS clinic opens a fault line in NHS general practice. Those able to pay will be called out of the GP waiting room ahead of those who can't.
Paying for rapid access to a GP appointment is not new. Medicentres set up on station platforms over a decade ago and providers such as Push Doctor are offering this privilege from the comfort of your sitting room via phone apps.
Nevertheless there are several fundamental problems with this latest twist in GP services.
First, although the Dorset GPs offering this private service are only allowed to see patients who are not already registered with them, it is dissonant with the NHS value of access to health care according to need and may adversely shape the experience of other patients in the waiting room.
Second, this approach fragments general practice and risks creating additional demand for appointments. What happens if you need investigations or prescriptions? Will they be requested privately or will you be sent back to your NHS GP? Many of the new NHS ‘access hub’ services have been set up in this way. While they may be able to resolve simple problems such as sore throats and urinary tract infections, anything more complicated may require an additional appointment with your usual NHS GP.
Third, this creates yet another service soaking up the time of a diminishing pool of GPs, making them less available to provide NHS care. Reports of the recruitment crisis faced by GP practices are widespread, caused partly by GPs who cannot face the stress of running a GP practice and choose to spend part of their time working in clinics which generate little follow-up or admin.
Fourth: the high price. A single 40 minute appointment costs 51 per cent more than the total Personal Medical Services (PMS) contract for a full year of care for a patient in my practice.
The list could go on.
Yet this development clearly speaks to a growing frustration among both doctors and patients. Doctors want to provide high quality appointments tailored to the needs of different patients but are unable to do so in the face of overwhelming demand. Patients want rapid, convenient access to general practice when they feel they need it.
So what alternative – and more equitable – ways are there to address these frustrations?
There is no easy answer to this question. I have argued before that the main national policy response – establishing more and more extended rapid access clinics – has significant unintended consequences. If the aim is to tackle the A&E crisis, then extended GP access is an expensive option which can – at best – help type 3 services (such as urgent care centres and minor injury units). Few of the ‘access hub’ clinics that were established through the Access Challenge Fund are fully integrated with local GP practices, so many patients are sent back to their usual GP for follow up or further investigation. That said, where extended access is fully integrated with wider primary care it can work well.
Policies to increase the GP workforce are slow to take effect. NHS data on overall GP numbers show a glacially slow increase from 2015. Proposals in the recent Primary Care Workforce Commission to develop a wider skill mix will also take time to implement. It is likely to be some time before new clinical roles such as physician’s assistants significantly ease the pressures that might drive some patients to private appointments.
GPs themselves have a part to play in the short term, although most are too busy to do this without significant support. The GP Forward View argues for the development of larger scale general practice and our report Is Bigger Better provides insights into how large-scale GP organisations can help to improve access and efficiency. Scale is not a universal panacea –there is plenty of evidence to show that patients prefer small practices and that quality of care is unrelated to organisational size. However, our report does describe how larger scale organisations can help practices to increase access and reduce patient recall by harnessing innovations in organisational processes, skill mix and technology.
While GPs have taken their share of flak for failing to provide adequate access, there is also a debate to be had about the role patients can play in this conundrum. The NHS ‘Choose Well’ campaign provides guidance to patients about alternatives to A&E and GP services but media coverage of this important national initiative is overshadowed by headlines about GP access failures.
Research on public information campaigns like Choose Well has shown little impact but that can’t mean we ignore the part that patients can play. The idea is hidden in the back pages of the NHS constitution and in chapter one of the Five Year Forward View, but receives little media attention. The Local Government Association tried to highlight the issue last year, triggering some media coverage, but it soon faded from the front pages. Jeremy Hunt’s request to people in January to stay away from A&E caused an element of media backlash rather than public debate.
Ultimately, frustration at an overburdened system has paved the way for what we’re seeing in Dorset. If we’re to keep the NHS afloat without asking people to pay for access, both professionals and patients need to be involved in the conversation.
Rebecca is a Senior Fellow in Health Policy at the Nuffield Trust and a General Practitioner in Greenwich.
Rosen R (2017) 'Private appointments are no solution to the GP crisis'. Nuffield Trust comment,14 February 2017. https://www.nuffieldtrust.org.uk/news-item/private-appointments-are-no-solution-to-the-gp-crisis