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It’s time to embrace seven day services – David Geddes

Dr David Geddes, NHS England’s Head of Primary Care Commissioning, gives his views on the Call To Action challenge facing GPs and how team work is the way forward:

Over recent weeks I have attended a number of events hosted by area teams to discuss with CCGs and key local stakeholders ‘Improving General Practice – A Call To Action.’

Across England, the story appears the same, general practice and wider primary care services are facing increasingly unsustainable pressures, and there is recognition that primary care wants and needs to transform the way it provides services to reflect these growing challenges.

The challenge for primary care and the wider NHS is how to enable primary care to play an even stronger role at the heart of a more integrated out-of-hospital services, delivering better health outcomes, more personalised care, and excellent patient experience, in a sustainable way and as efficiently as possible. The elephant in the room is that we need to deliver all this seven days a week.

Arguably, the current model of primary care is no longer fit for a modern NHS. We know increasing numbers of patients are presenting in general practice with multiple long term conditions, working days are longer and retirement is getting later. For many of the population, (myself included) they never see their surgery open. At one event, the chief executive of a local hospital told how a consultant had to cancel his entire clinic, so that he could see his own GP.

If general practice is serious about offering health promotion and early intervention, then we need to be available to do this for people at a time that suits them. We have to be able to provide a service that fits with the modern lifestyle, providing accessible services to those of us already leading busy and hectic lives.

How can this be done when we are already facing a workforce crisis, when our own working day is too long and GP morale feels to be at an all-time low? How can capacity, that already feels so stretched, now be extended over 7 days? Whilst it is true that answers to these questions did not come thick and fast, there was some interesting debate about what could be achieved.

A recurring theme at the Call To Action events was that we don’t need more of the same! Many described how they already have upwards of 40-50 consultations a day, seeing ever more complex problems, but with no slack in the system to give a corresponding increase in appointment length.

I work one day a week in a small practice of 5,200 patients with three other part-time partners. Stand alone, we can’t offer a service 8am-8pm, seven days a week. But we could if linked with other practices using the same IT system, to create a practice network.

In the past, we have worked as a small GP cooperative, where a relationship existed between practices and we could ensure an effective ‘hand over’ of care for our most vulnerable, sick and dying patients. We told patients who they would see if they deteriorated, and we could share information with the attached community team.

That was more than 10 years ago. Now, with the highly systematic use of IT in primary care; we should be in a better position to provide coordination of care across the seven day week.

Where is the additional human and financial resource to deliver this care? There won’t be a single solution. The challenges facing rural communities are far different to those facing inner city general practices, and resource issues will differ.

However, I believe that this challenge offers us an opportunity to stop and reflect on our current way of practice. We should not see this as an additional 40 per cent of work, but a chance to re-distribute our working week, and to ask how we can do things differently and more effectively as a consequence.

We should create opportunities to meet with community health and social care colleagues to develop the team approach. Continuity of care should be measured in terms of how care is delivered by a well-informed multi-disciplinary team. Continuity is a team working in a coordinated manner to support patients with long term conditions and complex health needs, not the availability of a particular doctor.

I believe there will be advantages for the profession. As presentations in surgery become ever more complex, is it appropriate still to offer a 10 minute appointment with the option of an occasional ‘double’? Do we get professional satisfaction trying to manage a patient with three or four long term co-morbidities within such restraints? Creating space for consultations across a seven day period could be an opportunity to offer patients a range of appointment times, using skill mix and spreading the workload differently.

For many GP colleagues, juggling a working career with a young family, working at weekends may provide much needed flexibility and an option some would actively choose to do. And am I alone in finding it increasingly hard to know my colleagues across the GP community? In the days of the GP cooperatives, there seemed to be far more coming together, opportunities for discussion about patient care, about general practice and about life.

Working across seven days will give many practices opportunities to work together in a different way, I believe this will reduce silo working professional isolation, and increase opportunities to collaborate in new and different ways which means that general practice truly will be able to play an even stronger role at the heart of a more integrated out-of-hospital service.


david-geddesDr David Geddes qualified at the Royal London Hospital (Whitechapel) in 1987.

Married to a nurse, he has three children, and lives in York where he is a GP partner in a small (5,200) practice working one day a week.

He has a special interest in mental health and got into ‘clinical management’ in fundholding days, then he was a PCG member. He was PEC member of Selby and York PCT, before becoming appointed initially as medical Director for Selby and York PCT, (2004-2007) then Medical Director and Director of Primary Care in North Yorkshire and York PCT (2007-2012)

He was appointed as head of Primary care Commissioning in the Operations department in November 2012.

He is a medical panellist for GMC Fitness to practice hearings, a non-executive of Medipex – a healthcare innovation hub, and a trustee for a number of mental health charities

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8 comments

  1. David R Way says:

    I totally subscribe to you idea and feel it could go a little further in health centres and doctors surgeries charging a nominal booking fee. I do feel it would be important for the government to make it absolutely clear that all funds raised would contribute to the actual unit receiving the fund for the direct benefit of there own local community. I have had this view for years.

    ( Subject fee for medical ) Attention DAVID GEDDES

  2. It would be very helpful if NHS England were to make a more evidence-based argument in favour of 7-day GP opening rather than relying on a series of anecdotes. There are costs and unintended consequences of any change to a health system, and these should be considered as well as the benefits before reaching a decision to make far-reaching changes to primary care in the NHS.

    Prof. Azeem Majeed, Imperial College London, Twitter @Azeem_Majeed

    • John King says:

      I have read your comments on 7 day working. I have also read some of the (difficult) responses (on other media) from the GP fraternity. Linking into Prof Majeed’s comments (which I agree with), we are working on whole systems simulation tools with number of CCG/CSUs (and AHSNs on the research side). The end objective is to present the case for change (or narrative in the modern vernacular) before any (inevitably risky) implementation. In simple terms using interactive and visual simulation to get patient and stakeholders ‘on the same page’. The approach has been successful over the years on one-off service improvement works but move now is to ‘scale’ these systems using modern web technology to make them available on a consistent, repeatable basis. Although solutions are ALWAYS viewed locally, this is an ideal way of bringing external evidence alive at that local level.

  3. Dr Kailash Chand OBE says:

    GP opening hours are not a ‘one size fits all’ issue; while commuters in cities like Manchester and London may prefer evening appointments, the older demographic in areas like Bournemouth and Eastbourne rely on GP access during the day. This shows why GP practices need to have flexibility in order to offer their patients the care they require, and why some practices already provide extended opening hours.

    The increased demands of an ageing population combined with other pressures means that GPs are already seeing more people than ever before and in many areas services are badly overstretched. GP practices are also struggling with declining funding, new targets and increased bureaucracy that is reducing the number of appointments available to the majority of patients.

    Given this environment, if there is a move to substantially increase GP opening hours across the board we will need to address how we are going to deliver this. In particular, we will need to consider the impact on the existing workforce, including support staff, and current resources, which are already struggling to meet current demand
    And yet the question remains – how do the politicians who call for a fully functioning 24/7 NHS expect to resource it when the government can hardly afford its current model, and when demands are being made to take out a further £20bn from the NHS budget by 2015 as part of the Nicholson challenge?

    These measures will only fuel the demand culture, and fail to take into account the available resources, investment required, and flexibility that will be needed to achieve this.

  4. Lynsey Fielden says:

    Whilst I appreciate the sentiment I can’t believe the naivety of the reasoning.

    As a GP and mother of three young children, and married to a GP, the weekends are our chance to breath a sigh of relief, and enjoy our time together as a family. We chose general practice as a career because the opportunities not to work at weekends were greater than for our hospital colleagues. What are the chances that if both of our sessions are spread across 7 days we will rarely have time together?

    Also, what about the availability of childcare? Who will look after our children when we are both working weekends? If we can find childcare what about the added costs? Working weekends we will then have to pay for our two school-age children to be looked-after, where currently there is some respite from childcare costs Mon-Fri when children start school.

    Currently my children attend out-of-school activities at the weekend, which would be an impossibility logistically if one or both of us is at work, further impacting on their life and routines.

    My experience of working in general practice is that when supply goes up, demand goes up. Making more appointments available has increased my time spent consulting the worried well, rather than caring for the people who really need the care. If we spread our care over 7 days initially we would be less pushed for time, but I would bet anything that by making ourselves more available gradually our workload would increase until we are working with the same intensity daily as we are now.

    I can’t believe that it’s so simple that people can’t get the appointments at times they want, so GPs have to work 7 days a week. Whenever I’ve worked until 8pm or from 7am a small proportion of the people that I’ve consulted have been those who’s work commitments forced them to attend at those times, and a greater proportion were patients consulting at those times because they were the appointments available. Would it not be more prudent to a shift in thinking to promote more widespread flexible working, so that employers could allow their employees to leave work to attend doctors appointments and make the lost time up later?

    How much of the theory behind this ‘idealism’ is evidence-based, rather than anecdotal and driven by political spin?

    I strongly believe that if the seven day week is brought in for all GPs (and I am under no illusion that we would have a choice in the matter) there would be a corresponding increase in retirement, immigration, and career changes.

    Please canvas wider opinion from GPs. I just can’t believe that the sample of doctors’ opinions you’ve based your piece on are representative of the GP workforce.

    Dr Lynsey Fielden

  5. Mike says:

    Why stop at 8pm, GP’s should be providing a 24hr service, working in an Emergency Department we bear the brunt of inaccessible GP services even with a co-operative in the area!

  6. Dr Andy Sutton says:

    Upwards of 40-50 patient contacts a day?? I and my partner handled 75 contacts (phone and face to face contacts) each on Monday.
    Unsustainable.

  7. Dr Ruth Brown says:

    The problem with the 7 day ROUTINE working is not that we are returning to the past ( I have been a GP since 1991 and so initially we did all our own w/ends and nights) but that we are being asked to have 24 hours more Doctor time, nurse time, receptionist time, and infrastructure-rent, rates, cleaning etc. time when the income ( as of the accountants meeting this week) has dropped by £50K for an 8000 patient practice. In the past the NHS paid a fixed sum for me to carry a bleep all the time, regardless of patient demand- so at the weekend I was at home with a bleep with no infrastructure costs or staff time – this is not what is wanted now, and the hostile rhetoric is both offensive and economically naive. Furthermore- as an inner city Practice which has always had a Saturday surgery- we see the same multiple attenders on Saturday that we see in the week, with the exception of those whom we ‘filter’ by a daily Doctor telephone triage. Despite this increased OOH commintment-with late evening surgeries as well- the patient still go to A and E.
    The notion of having different docs at the w/end would work- but not within the current cost-cutting agenda.