Enhanced access: How it works for PCNs, practices and patients

Enhanced access was introduced to support patients who wanted appointments in general practice and to help ease the 8am rush at surgeries. Pulse PCN editor Victoria Vaughan talks to experts to find out whether it has eased workload pressure, how it’s being managed and the impact on PCNs and practices.

Dr Shanika Sharma, clinical director of West One PCN, East London

Dr Stefan Waldendorf, clinical director of Newport and Central PCN, Shropshire

Dr Gayan Perera, enhanced access lead at Medics PCN, Luton

Dr Michihiro Tomonaga,  enhanced access lead at Central and West Warrington PCN, Cheshire

Clive Elliott, board member and finance lead at South East Telford PCN, Shropshire

OVERVIEW

Victoria Vaughan (VV): Can we start with an overview of how enhanced access works in your respective areas?

Dr Shanika Sharma (SS) Before enhanced access came in, we had extended access, funded across London to help practices meet on-the-day demand. Our ICB has continued to fund extended access. So when enhanced access came in, we decided to build on that rather than creating something new for each of our six PCNs because our PCNs are very close in geography to each other. So enhanced access is provided for all of them, borough-wide, by Together First, our GP federation, of which I’m the chair.

It eases the pressure off me a little bit as a PCN CD because I know that it’s being looked after by a dedicated, bespoke team. And the outcomes are very good. Patient satisfaction rates are always above 95% satisfaction and DNA rates are very low – the last time we looked at our DNA rates, it was less than 4%.

Our way of working has enabled us to keep enhanced access protected for proactive care and chronic condition management.

Dr Stefan Waldendorf (SW): We have taken a different approach. We didn’t do extended access before, so we had no vehicle in place.

We have a split between the in-week and weekend services. In the week, we deliver in our practices on rotation and that is no different to before. But on a Saturday, we set up a completely new service, running in one of our branch surgeries, which is roughly geographically in the centre. Saturdays are from nine to five and there are usually three clinicians there – one or two GPs and then maybe a paramedic or pharmacist. In total, we’ve delivered close to 4,500 additional appointments.

From the beginning, we wanted to offer the same service as you get in week so it means that all four surgeries can book directly into the Saturday appointments and get the same services – clinicians have access to the medical records, are able to prescribe, request blood tests and things like that. That was the biggest challenge we had because it’s tricky to pull that off and it took us about a year to get the full functionality up and running.

Simple things like requesting a blood test were difficult because we needed our own organisational code, and we needed to liaise with the lab and develop pathways so that results could go to the surgeries. It took a lot of planning but we are now at a point where we have achieved it, I think, and can share between those working on Saturdays and others. So, we quite often have a pharmacist working or paramedic who will see patients and offer services and, more recently, we have started to offer additional service like smear tests on Saturdays. Again, that was tricky because you need a proper code for each practice to be able to do that.

Clive Elliott (CE) We have three practices in the PCN and it was as straightforward as ‘you do that’, ‘you do that’, and ‘you do that’. No long discussions about it.

The approach we have is that one practice does two evenings, the other does three, then the following week we swap them over. The larger practice already did Saturdays so they just carried on doing that.

We take the view that this is complete nonsense. It’s about ministers being able to stand up in Parliament and say, ‘We’ve done all these extra appointments’. It doesn’t actually change the relationship between capacity and demand. If you’re going to match capacity to demand, you have got to go into neighbourhoods and you’ve got to get integration working, which is what we as a surgery are trying to do. The PCN takes a different view.

I’m not a doctor, I look at it purely from a business case point of view. Is it going to save us money? Or is it going to cost us money? If it’s going to cost us money then we probably can’t do it. To my mind, the [access] money would be much better spent on community and neighbourhood working and allowing practices to get on with the work that really needs doing.

Patient feedback is that they like the fact that they can come on the weekends or evenings to see a doctor in person and that they like the extra appointments with the nurses

Dr Gayan Perera

Dr Gayan Perera (GP) We have a very good federation called Evexia that does our enhanced access for us. They deal with all the recruitment, running the clinics, booking appointments, all the admin such as sick leave, HR, and so on, which the practices appreciate.

We’ve been running it through Evexia for about two years now and we employ 12 or 15 staff members through Evexia. We use four or five different physician associates (PAs) and we’ve designed it so that we’re more doctor heavy, so we don’t generate the extra work we find when using PAs. Usually there’s one PA to one doctor, every evening, Monday to Friday 6.30 to 9.30pm. There is also a nurse who does out-of-hours nursing appointments. We also have one advanced nurse practitioner (ANP) working once a week. And then on weekends, we do 8.30am to 4.30pm.

All the appointments are booked through the practices – we have five practices in our PCN, which is around 58,000 patients. Practices are given appointments according to the list size so bigger practices get more appointments and it gets blocked off electronically once they’ve used up their appointments.

The doctors are probably 98% – 99% full and the DNA rates are low because we send a message to patients 24 hours before the appointment. With the physician associates, again, it’s pretty good. The DNR rates are probably about 3 or 4% in a month.

The nursing appointments are less utilised. Patients prefer to see their own practice nurse. As our PCN is quite large, some surgeries are further away from the enhanced access site, and those patients are less likely to come, but we offer face-to-face or telephone depending on the patient’s preferences.

Patient feedback is that they like the fact that they can come on the weekends or evenings to see a doctor in person and that they like the extra appointments with the nurses.

I’m also the cancer lead for the PCN and we’ve set up enhanced access smear clinic on weekends too. Some practices are in deprived areas and our smear rates were quite low so we wanted to improve that. That’s been well received as well.

Dr Michihiro Tomonaga (MT): At our PCN, we didn’t really want an external organisation providing enhanced access. So, on weekdays, we’ve agreed each practice will take turns to provide it on a given day and, on Saturday, we have one practice that opens to provide enhanced access.

WORKLOAD

VV: Has enhanced access relieved pressure on GPs during the working week and has it eased workload? Or has it created more demand?

GP: Overall, it does provide better access for patients, which is a positive. But there’s no way around it – the more access you give, the more work is generated.

It’s difficult to say how efficient the access is because it generates investigations and those investigations come back to the doctors. So, there are extra blood tests and extra scans that we’ve got to deal with. It’s a snowball effect.

From the patient’s perspective, yes, they get seen, but all that extra admin and extra investigation is work that goes unnoticed. We don’t usually book slots to review letters or do all the admin stuff and it does lead to us staying late to deal with the investigations coming through. The person who generated the investigation is not there anymore and obviously we need to do something.

Also, there’s no continuity. When you give access, it does take away from continuity of care, which is the core medical practice principles that we need to get back to.

So, enhanced access is good for patients but it doesn’t solve the burden on GPs.

At first, we had problems in that people were inappropriately booked in – we introduced a triage system and now we can make sure it’s a relevant appointment 

Dr Stefan Waldendorf

SW: Our approach has delivered for us.

At first, we had problems in that people were inappropriately booked in – for example, they were booked in with a paramedic with something that the paramedic didn’t have expertise in. So, we introduced a triage system and now we can make sure that if patients go to a paramedic or the pharmacist, it’s a relevant appointment. With a triage system, you can use that capacity much more efficiently.

We have increased access for patients to be able to book appointments outside their work time. The most benefit we get during the week is in the mornings because we opened seven o’clock for blood tests which is very popular with patients.

SS: We’ve tried to keep it as proactive as possible. It’s not just providing more appointments; it’s a service.

The majority of our practices are on EMIS and that means that everything goes into the notes so any medication changes that need to happen go straight on to the clinical system. Any onward referrals needed are done by enhanced access because we want to try and reduce work that’s shifted to day-to-day general practice. The last thing we want is to put ‘GP to action’ so that’s why we try and do as much as we can within the enhanced access service.

The federation goes along to each PCN meeting on a monthly basis and they ask what they need support with. So, for example, if they’re not meeting their eight care process targets for diabetes, and they need a little bit of support with diabetic foot checks, then the enhanced access appointments, which are bookable two weeks in advance, are then tailored to try and help support the practices meet that target.

So, it’s a very agile system in terms of supporting primary care and the wider neighbourhood and public health priorities as well.

MT: My own practice actually hardly ever uses enhanced access because we’ve got quite good capacity, and a lot of our patients don’t want to go and see someone else. That’s echoed by another practice, which is pretty much a single hander, and another one with an average population age of 60-something where patients don’t want to travel to an enhanced access site.

But if I talk to other practices – my PCN is six practices – who mainly use the enhanced access service, they say their patients really appreciate it. When we’ve done the patient survey, it came back fairly clear that the people who attended found it useful.

SUPERVISION

VV: How do you manage oversight and continuity? If there are non-GPs running the appointments, is that a concern? Does supervision become burdensome?

SW: We always ensure we have a mix at a clinic. We have at least one GP, if not two GPs, on a Saturday working with a paramedic or pharmacist or another ARRS role and there are always supervision slots with a GP so they can debrief or ask questions if it’s something they’re not sure about.

We use the same system as in the week with good supervision of our additional workforce. As soon as we started, we very heavily invested in our workforce and focused on training right away. So, they are members of staff who are working quite independently already.

As I said before, in combination with the triage system, you make sure the right patients get to the paramedics. Often in winter, when there are a lot of coughs and colds and you can’t fit them in [at the practice], they can go to see a paramedic. The paramedic will check them over and can prescribe because they’ve had prescribing training. We have had really positive feedback from our patients; they have really taken to our paramedics.

We also have the pharmacist prescribing. He also runs some chronic disease clinics like hypertension to manage long term conditions.

But because we were focusing on proactive chronic condition management, our practice nurses, advanced nurse practitioners and clinical pharmacists probably do the reviews better than the majority of our GPs

Dr Shanika Sharma

SS: In Barking and Dagenham, we have two main sites where we deliver enhanced and extended access. They run in parallel. Enhanced access is running with the nurses and pharmacist, and then, at the same time, you’ve got the extended access running with the GP. So, there’s always GP support on site.

But because we were focusing on proactive chronic condition management, our practice nurses, advanced nurse practitioners and clinical pharmacists probably do the reviews better than the majority of our GPs. We’ve got a nursing clinical lead, who looks after the nursing workforce and a pharmacist clinical lead for the pharmacists.

Enhanced access has given us a little bit of flexibility. It’s flexible for patients, obviously, who can come at weekends or evenings, but also our staff – it gives our staff a lot of flexibility. If they want to do additional work out of hours, then they’ve got the enhanced service.

GP: As I said, our ARRS roles are mainly PAs, an ANP and we’ve got a diabetic pharmacist who does reviews as well.

The ones who are prescribers – the ANP and the diabetic pharmacist – we’re less nervous about. The PAs are the ones we’ve always been extra cautious about. It’s not that we’ve had any big incidents, but we know about the lack of experience and PAs, in particular, we find are overly confident, and that’s a worry, you know. They’re not aware of the unknown unknowns, which is something we’ve always been prepared for.

So, we’ve designed our enhanced access service accordingly. There’s always a doctor who’s supervising the PAs, and this doctor doesn’t have any appointments; their pure purpose is to go through the PAs’ appointments, support them, sign their prescriptions and deal with the workload that’s generated by them.

Is it efficient taking a doctor away? It is a bit extra than other PCNs, but we just felt like we needed to put that in place for extra safety. And it means that we can make sure that work generated by the PAs is not passed on to the practices because we do find that they tend to over-investigate. They aren’t doctors and we just have to be mindful of that. So, we have those safety measures in place.

CE: Our service is run by the individual practices so it’s not an issue for us.

FUTURE

VV: We have a new government now, which has talked about more investment into primary care. So, what do you want it to fund?  And what is the future of the enhanced access service at your PCN?

SS: I’m really hopeful that there will be a shift from primary care just being about access. It’s not just about on-the-day access. Primary care is about continuity of care and GPs knowing their patients over a period of time. We need to have a complete mindset shift from this Amazon culture that we’ve developed in terms of the mad rush to try and get a GP appointment.

I would really like to keep the way we’ve built our infrastructure of enhanced access in Barking and Dagenham because we’ve kept it very proactive. If we are going to be moving towards looking at neighbourhood teams – which we’ve got a borough-wide model for in Barking and Dagenham – I would like to see enhanced access help facilitate that. So, for us that’s to try and do as many proactive care reviews, increase our prevalence registers and support those who need to be supported.

I’d also like to continue because the other main issue we have is retention and recruitment of our workforce. And that’s not just for GPs; it’s also our ARRS roles and nursing workforce. So I’d like to give our workforce the flexibility and the option to work in different services during different hours as well and to take on leadership and management skills. I think enhanced access provides a really good opportunity to be able to do that.

Our doctors don’t like working in the evenings. They’ve had a working day and they want to go home to see their families. You can get locums, but then you have the continuity problem

Dr Stefan Waldendorf

SW: I think investment in primary care needs to be in the workforce because it’s the biggest problem we face. Having a sustainable, well-trained workforce in place is much more important than having the patient convenience to be able to come in on an evening or at a weekend. It’s bad enough to work a busy week and then you have to go out on the weekend to do a shift here and there – that is just very stressful.

Our doctors don’t like working in the evenings. They’ve had a working day and they want to go home to see their families. You can get locums, but then you have the continuity problem again. So, I do think a proper focus on a properly resourced workforce in the week is needed.

Integration across a neighbourhood is a really a good approach, being more proactive to prevent people from getting ill. That would be a good investment in the long term to prevent this shift to an increasing elderly population, which is not cared for, which then goes to hospital, which clogs up hospital beds, and there’s no service in place when they’re discharged.

So, I think you need to look at the problem as a system, and to step in earlier and invest in that.

GP: I feel that we’ve been decimated just like all public sector services over the last 14 years. Morale is really low for general practice, and partly, it’s because of a lot of unfunded extra work that we get from secondary care. I think 30% of my appointments every day is dealing with extra work that’s generated by secondary care because letters are being sent to patients with test results instead of a doctor calling or seeing them to explain it. Then patients can’t get through to secretaries in the hospitals so I end up going through test results that other doctors have done in the hospital. This is a daily occurrence now and it needs to stop.

So, if Labour’s going to invest, it has to be in primary care and prevention. Primary care is where prevention lives and breathes, and the focus has to go on lifestyle medicine. We need to invest in care coordinators – people who will follow people up and make sure that they’re getting into certain groups to tackle loneliness and inequalities.

We need to try to lift these neighbourhoods from the dire straits that they’re in. It’s not all about a tablet, or a pill, and GPs are in a good place to coordinate that. Enhanced access is here to stay probably and that’s fine. But I just hope the new government can see the bigger picture.

CE: Enhanced access is politically difficult to drop, but really the money would be much better spent elsewhere in my view.

Personally, I would like to see a doubling of the general practice budget, but with some really tough targets of making that circle of care – admission, treatment, discharge to community care – move again within five years. I think it could be done if we were trusted to do it.

I recognise from a government point of view that there is a worry about putting more cash into general practice because, no disrespect to GPs, but there are some partners who will just take the money. But putting money into the ARRS roles means you’ve got to have the people doing the work, which I think is very good. Why aren’t we employing care workers through the ARRS roles?  We could pay them properly, not make a profit, and they can give people proper care.

From what I understand, [health secretary] Wes Streeting does take this seriously and understands that neighbourhood working is really important, so I’m optimistic. I’m not optimistic about more cash, but I’m optimistic about lots more investment.

MT: I’m not sure about your optimism; I’ve got my doubts. The health secretary has been widely reported in media about how he feels primary care needs more funding and support, but he’s actually not that clear about what he means by that nor how that’s going to help general practice. Only a year ago, he said he wants all the GPs to be in a salaried model and he mentioned about there not being enough access and that GPs shouldn’t be the only gatekeepers to the NHS.

In terms of enhanced access, I think it’s here to stay. It’s a service that’s been running in most places for a couple of years, and in order to stop that service, you’d probably face a challenge in terms of having to run a public consultation, which most ICBs would not want to do.

With ARRS, I think it can create inefficiencies. So, you know, you might have clinical pharmacists who we put through the course to become independent prescribers, and then some of them dig their heels and say they’re only willing to prescribe some medications and, by the way, can they be paid at band 8a. You can have a salaried GP for only £10-20,000 more who will do all of that and more without having to be put on a course.

So, I think each model will have a different way of working and different ways of achieving efficiency. I don’t think we can have one model – it may be that NHS England would like to have that, but it actually creates inefficiency.