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Focus on access (England) - 2006/07

March 2006 (revised January 2007)

This guidance note has been produced by the General Practitioners Committee (GPC) to help GPs and local medical committees (LMCs) understand the changes and developments that have been made to the GMS contract for 2006/07. We would advise all GPs to read the contract guidance ‘Revisions to the GMS contract 2006/7 – delivering investment in general practice’ available on the BMA website. This guidance note should be read in conjunction with the other ‘focus ons’ that have been, or will be, published following the contract review.

Please note that this guidance note deals with changes to the access arrangements in England. The final details of changes to similar arrangements have been put in place in the other three countries and details can be found at the following websites:

• Scotland
• Northern Ireland
• Wales

Background and summary
Improving access to primary care is one of the Government’s major policy objectives at the moment, as it sees this as a key to tackling health inequalities. It is a policy being enforced not just from the Department of Health, but directly from the Prime Minister. An entire chapter of the recent White Paper “Our Health, our care, our say: a new direction for community services” is dedicated to this very subject. The other political parties are highly unlikely to oppose this in parliament. The word “access” is used broadly to cover both ease of registration with practices but also the responsiveness of practices i.e. the ease with which registered patients can access a practice’s services. This guidance note concentrates primarily on the second of these, as it is the subject of a new Directed Enhanced Service (DES) negotiated with NHS Employers, as part of the general medical services (GMS) contract review, to replace the 2005/06 Access DES, together with the 50 additional Quality and Outcomes Framework (QOF) points for access. Chapter three of the White Paper is appended as further information for readers interested in the broader policy context. The GPC believe it is important to understand this context, given the considerable political weight it currently carries.

The current provisions for an improved access scheme, the previous DES, will be removed from the 2006/07 SFE. It will be replaced by Directions implementing the new access DES, the value of which, assuming maximum achievement, in England, is £108 million (the value of the 50 QOF points associated with access plus the value of the 2005/06 DES).

The 2006/07 access DES consists of 4 areas

• Opportunity to consult a GP within 2 working days
• Opportunity to book appointments more than 48 hours in advance
• Ease of telephone access to the practice
• Opportunity to be seen by a practitioner of preference

This covers more access areas than the 2005/06 DES, but given the intense pressure to deliver improvement, the investment tied to this DES was strictly conditional on its expanding the range of access markers for which practices could be paid. The 2 working days target, however, now refers to “consult a GP”, rather than “see a GP”, a small but significant difference as this can now include telephone or e-mail consultations.

Another condition was that the investment would only be released if the majority of it was tied to achievement measured by patient survey. The GPC fully realises that this is controversial and understands the problems that this approach may cause, but took the decision that it was better to secure the availability of this investment for GMS and personal medical services (PMS) practitioners, rather than seeing it diverted entirely to alternative provider medical services (APMS) providers, which would have been the likely alternative.

A patient experience survey project board, on which the GPC and the GPC/local medical committee (LMC) axis group are represented, has been set up to develop the survey. The GPC understands the many potentially controversial and complex factors associated with determining achievement payments in this way, such as confidentiality, language, what happens if no valid sample is returned, and will seek to address these thoroughly through its participation in this group.

As with all DESs, participation in the access DES is voluntary. The GPC appreciates that the terms of the DES are not ideal but believes that it is for individual practices to decide whether or not to participate, given the anticipated workload and the level of reward on offer.

Payments
The DES consists of 2 payments

Component 1 represents a third of the total investment available and is equivalent to 0.69p per patient. It is payable in two halves;

1. on agreement of a practice plan showing how the practice aims to work towards delivery of improved access in the first three areas above
2. on receipt of a the practice’s written commitment to continue participation in the Primary Care Access Survey (PCAS). However, payment will no longer be dependent on the level of achievement in this survey

Component 2 is paid according to the results of the national patient experience survey, to be carried out in the fourth quarter of the year, which will seek patients’ views on a practice’s performance in all four access areas above.

The weightings for each area and minimum and maximum thresholds for payment are set out in the agreed DES specifications. Again, we appreciate that some of the minimum thresholds will be considered high, but these were negotiated down from even higher levels.

For information of developments regarding the patient experience survey please read the 'Focus on the patient experience survey' guidance note.