The resourcing of GPs is facing an all-time crisis. Existing GP training posts in England are not being filled. Nicola Sturgeon’s announcement on increasing GP training posts in Scotland by 33 per cent (increasing their numbers from 300 – 400) is no doubt an attempt to “bring the horse to water” – but there are already insufficient numbers of doctors qualifying, let alone electing to pursue a career as a GP, available to take up these posts. On top of all this, we are now told that surveys have revealed that 80 per cent of GPs plan to quit the profession, to take a career break, or to reduce the hours they work, within the next five years.
How then is it realistically possible to fulfil the Government’s well-intentioned objective of providing a seven day service across the board – not least when many GP contractors are already facing difficulty fulfilling an 8am – 8pm commitment over only a 5 day week?
The requirement to “sweat the asset” (i.e. the healthcare premises) is a well-established principle. GPs are reimbursed the “user” costs of their premises through the Rent and Rates Scheme at the taxpayers’ expense – and these costs naturally fund the cost of the premises on a 24 hour day/365 day year basis.
It clearly makes sense to make maximum use of each facility as this enables the overhead carry per patient/per property to be kept to a minimum. It has been clearly established that the cost of treating a patient with a minor ailment in general practice is significantly less than the same patient presenting with the same condition at A&E – which presents the added benefit of freeing up the more expensive (hospital) facilities to deal with the real medical emergencies.
So on the face of it, making greater use of general practice premises is a win-win situation which makes perfect sense. However, there are other challenges as well as workforce issues which need to be faced before this common sense idea can become a reality.
In terms of the premises themselves, there are a number of issues, some of which may be insurmountable. Most significant is the imposition of any restrictions on the use of the facility at weekends. This may include a restriction on the opening hours outside specified time restraints and on specified days. Such restrictions may be imposed either through planning restrictions, on the registered title to the property or within a lease.
The lifting of such a restriction is unlikely to be straightforward. Planning restrictions are often imposed at the behest of neighbours who may be concerned about noisy interruptions outside usual week-time working hours – and most commonly about parking! Restrictions on the title or in the lease of the property may be imposed for other reasons, some financial and others more practical.
Either way, any suggestion that the restriction may be lifted is likely to be unpopular – and may possibly require a compensatory payment to be made. And any suggestion that the restriction may simply be ignored (and therefore breached) would be most unwise as it could lead to the closure of the property altogether (as well as the threat of incurring significant legal fees). Other more practical issues may arise when the premises have several users.
Is it really worth opening up a large healthcare facility, simply for the purposes of providing one or two consulting rooms at the weekend? To do so could risk incurring considerable, and potentially disproportionate, additional costs associated with the heating and lighting – and perhaps more significantly, the security issues, including responsibility for ensuring the premises are safely locked up at the end of each session (not least for insurance purposes). Weekend use by only one of several tenants will also require the re-examination of the apportionment of the service charge. This could also necessitate physical alterations being made to the premises to “lock down” those areas which are not being used and which might otherwise be too easily accessible to the public. In addition, there will clearly be a responsibility on the part of the owners of the business to ensure the (perhaps relatively few) staff in attendance can operate in a safe working environment.
Turning to the staff, it is one thing to impose a contractual requirement on GP principals to provide the service, but quite another thing to expect them to do so on a rolling seven day a week basis! But will the contractors be able to find adequate numbers of staff to fulfil the contractual requirements, including not only GPs but nurses, and support staff such as receptionists, cleaners etc.? Employers have to be aware of family friendly policies – and many staff have children and other commitments at weekends and may not be available to work then – especially if childcare facilities are not available.
Furthermore, will there be a demand to pay weekend staff a higher rate of pay? If practice staff are unwilling or unable to provide the service, meaning the contractor has to resort to locums, there are bound to be additional costs for working anti-social hours. No one would realistically expect any individual to work a seven day week continually – and yet that is potentially the fall-back position if the Contractors are unable to secure the necessary numbers, or skill-mix, of staff to fill the required number of clinical sessions.
Another concern may be the knock-on effect on professional indemnity insurance as a result of the additional working hours. How long will it be before we see a headline linking harm caused to a patient to an over-worked/ over-tired GP (or other clinicians)? And how long after that would it be before professional indemnity rates increase (or heaven forbid) cover is withdrawn entirely?
A final question to ask, is whether the service is really required? Turkeys won’t vote for Christmas – and in the same way, patients, when asked, are bound to say they would like the option of knowing their local GP surgery is open at the weekend should they wish to avail themselves of the facility. But the evidence does not yet seem to demonstrate that patients are queuing up to use the existing walk-in centres which provide extended hours and easy access.
Against this background, and with all the other pressures currently imposed upon the primary healthcare community, one wonders whether this additional pressure is simply a step too far?
Click here to read our newsbrief in full.
Full articles:
Integrated care models: the estate consequences for provider trusts; Client spotlight: Pennine Acute Hospitals NHS Trust; New care models: the workforce issues; Healthcare startups.