GP waiting times: learning from the past

1 November 2019

The outgoing chair of the Royal College of General Practitioners has warned politicians against repeating mistakes by setting new GP waiting time targets – so what lessons should manifesto authors learn from past policies?

No major party has announced such a target, at least not yet. But with an election in the offing, all parties will be looking for eye-catching policies that talk about issues beyond Brexit. And there are clear signs that tackling waits for GP appointments is on the to do list.

The prime minister promised to make sure ‘’ in his first speech from the steps of Number 10. Jon Ashworth, Labour’s shadow health secretary, also talked about  at the recent party conference.

Tackling waiting times in general practice directly would be a major departure from the recent past. For nearly 15 years, successive governments have taken a broader approach – pursuing better access by increasing the availability and convenience of primary care services, with practices retaining discretion in how appointments are allocated.

This was the common thread in interventions as varied as , , ,  and, most recently, . All were tried, sometimes more than once.

Complexity of primary care

While a new waiting time target would be a big deal, it’s not without precedent. From 2000, the last  had a comparable target for seeing a primary care professional within 24 hours and a GP within 48 hours. That experience is instructive.

In an era where practically everything had a target attached, 24/48 hour access was a  backed by ,  and ‘‘. The impact on performance was dramatic and, by 2005,  could access appointments within target times.

That was based on data collected from practices, but . It certainly wasn’t matched by people’s experiences –  having been seen within 48 hours.

There were problems with booking appointments more than three days ahead too,  to hit the target. This when Tony Blair was taken to task on live television by an understandably frustrated patient.

24/48 hour access is arguably the textbook example of unintended consequences of a target probably undermining apparent improvements in performance. Patients at ‘Advanced Access’ practices got slightly , and may have been . Overall satisfaction with general practice opening hours actually fell between .

The past problems with booking advance appointments might be reduced by balancing the urgent appointment target with one for advanced bookings – . But that still wouldn’t come close to reflecting the full complexity of primary care and the  that shape patient experience.

Patients value speed of access, but also place considerable value to convenience of access, choice of time and location, choice of professional and – with general practice  – mode of access.

These aren’t just ‘nice to haves’. In particular, continuity of care is linked to reduced hospital admissions for some types of common health condition. For some patients, seeing their preferred GP matters far more than speed of access.

And there are considerable differences in patients’ willingness to . This is why accommodating patient needs and preferences in a clinically appropriate way is not easy – just ask a practice manager or receptionist.

The 24/48 hour target made that task more difficult and it’s hard to see how a similar target wouldn’t do the same.

Measuring performance is another challenge. Data on what happens in general practice is better than the 2000s, but measures of waiting time are limited to the . The collection being developed by  is becoming a rich source of data on activity, but doesn’t illustrate the scale and nature of patients’ needs.

Fundamentally, there’s the overall state of general practice to consider. GP numbers increased in the early 2000s but are now falling, with the biggest impact in areas of high deprivation. While  fell relative to the rest of the NHS between 2004 and 2014, demand continued to grow and the increased pressure exacerbated shortages of GPs and practice nurses.

Meeting a new target would require a substantial increase in appointments, which means confronting the daunting issues with increasing the number of GPs. If that fails to materialise, a target could only be met by cutting appointment lengths or time spent on other essentials that also affect patient care – such as the fledgling Primary Care Networks expected to deliver much of the long-term plan. Not to mention the risks of repeating past mistakes by ramping up the pressure to make rapid progress.

The politicians have alighted on a genuine problem – public satisfaction with general practice has been falling steadily for some time. But a meaningful response needs to go beyond the set of incentives and improvement support likely to accompany any new target, with a wider blend of policies to fill staffing gaps, support new roles and changes to skill-mix and invest in practice premises. Otherwise, there is a serious risk that pursuing a narrowly-focused solution to fix such a complex issue will simply make things worse.

Tim Gardner () is a Senior Policy Fellow at the OnlyWan.

This blog previously featured in .

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