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Achieving and sustaining improved access to primary care

  • Last modified date:
    8 February 2007

This document has been produced by the Department of Health with key stakeholders. It offers advice to PCTs to help them achieve the access target in the NHS Plan, increase capacity and extend services in primary care, and develop demand management in primary and secondary care.

The document includes essential information for PCTs including:

  • Definitions of the Primary Care Access Targets.
  • Information on the Primary Care Access Fund including the Access Incentive Scheme.
  • Information on the new SaFF milestone of 90% which has been set for March 2003.
  • Monitoring arrangements.
  • How PCTs can access the National Primary Care Development Team Primary Care Collaborative.

If you need further information or advice from the Department of Health, please contact Catherine Davies on 0113 254 6602 or by emailing the PC Access mailbox at MB-Access@doh.gsi.gov.uk.

NHS Plan Targets

The NHS Plan sets out that

  • "by 2004, all patients will be able to see a primary care professional within 24 hours and a GP within 48 hours"
  • This approach responds to the patient centred theme of the NHS Plan. It means that patients should be seen by a GP within 48 hours or a primary care professional within 24 hours if they wish to do so. Equally, patients may wish to be seen at a more convenient time to them outside the targets' timescales or to wait longer to see their preferred GP or health professional. In rural areas, location may be a greater priority for an individual patient than when they want to be seen. These alternatives are appropriate. The target also applies to temporary residents.
  • It also reflects patient preferences as identified in two national surveys of patient views involving primary health care:
  • In 1998 the National Patient Survey reported that up to20% of patients in work put off going to their GP because of inconvenient surgery times and that around a quarter waited four days or more (with 5% waiting over a week) for an appointment.
  • Consultation with patients and professionals for the NHS Plan showed 20% identified cutting waiting as one of their top three priorities.
  • More recently the Wanless report has confirmed that people's expectations of the NHS have risen considerably.

Joint Working

  • It is the joint responsibility of PCTs and Primary Care teams to work together in order to achieve the target and to improve services. If appropriate in order to meet local needs this might also include more flexible and innovative use of Out of Hours providers.

Understanding the Target

It is alsoimportant for both patients and primary care professionals that there is a shared understanding of expectations arising from the NHS Plan target. A more detailed explanation of what we are trying to achieve is:

  • 'A GP' - any general practitioner. This is not a named GP nor is it necessarily a GP at the registered practice. Naturally, the latter is desirable wherever possible. However, in the event of a practice not being in a position to see a patient within 48 hours, PCTs should agree joint working arrangements with local practices and other health service providers e.g. a NHS walk in centre to ensure that patients can still be seen.
  • 'Within 48 hours' - within two normal working days (i.e. not including Saturday or Sunday) following the day when a request by a patient was made. For example, if a patient requests an appointment on Friday, they should be seen at a convenient time no later than Tuesday of the following week. The practice will need to make provision for out of hours services, especially at weekends for emergency care.
  • 'A Primary Care professional' - any health care professional who is a member of the practice or wider local primary care team, including practice nurses, allied health professionals, other health care staff within the practice or elsewhere e.g. in an NHS walk-in centre. It does not necessarily mean a primary health care professional working in the practice of the registered GP. Part of the PCT role will include ensuring that there is local provision for access to, for example, District Nursing or Health Visitor services. Each PCT should agree with each practice which health professionals will be available for their patients within 24 hours (both within the practice and in other locations) and make this information available to patients so that they know what to expect.
  • 'Within 24 hours' - by the end of the following normal working day (i.e. not including Saturday or Sunday). For example, if a patient requests an appointment on Friday, they should be seen at a convenient time no later than Monday of the following week. The practice will need to make provision for out of hours services, especially at weekends for emergency care.
  • 'Patients' - patients registered with a General Practitioner. It will be for the PCT to make sure there is appropriate access across their locality. This will involve clarifying how the targets will be met and monitored. Likewise GPs working in partnership should share the responsibility of providing access to patients registered with the practice.
  • 'To see' - face to face personal contact. The use of alternative consultations like telephone and email reduce demand for face-to-face appointments and can be used to support delivery of the target but should also be delivered within the target. Delivery of the target will be assessed against waiting time for face-to-face contact.
  • 'By 2004' - by 31 December 2004.

Increase to Primary Care Access Fund

1. Achievement of the Primary Care Access Target isa key Government priority.This is reflected in the Priorities and Planning Framework and the accompanying Service and Financial Framework. PCTs are supported in delivery of the target through increased resourcesand as such the 2002-03 NHS Allocations Health Service Circular issued on 6 Dec advised that the Primary Care Access Fund for 2002-03 would be increased from £84.5m to £168m. The fund will be allocated by HAs to PCTs on a weighted capitation basis. The £83.5m increase is earmarked specifically to improve access to primary care.

2. This new money should not be used to substitute for existing investment or spend on primary care.Expenditure from this increase does not count against local GMS investment floors, which PCTs should continue to deliver using other funds from their unified budgets.

3. Payments will be made by PCTs to primary care and community providers, as appropriate, through GMS local development schemes, use of HSG(96)31, uplifts to PMS budgets, variations in PMS contracts (including "PMS plus") and established GMS/other payment mechanisms.

4. PCTs are asked to concentrate the use of this money on:

  • Achieving the 24/48 hour access in primary care
  • Increasing capacity and extending services in primary care
  • Demand management in primary and secondary care

5. It is expected that at least £48m should be dedicated in 2002-03 to improving access in primary care. Advanced Access is one model of improving access that has been found to be effective. Primary Care Organisations wishing to practice Advanced Access should work directly with their nearest National Primary Care Development (NPDT) centre. See paragraphs 21 to 26 for more information on the NPDT and Advanced Access.

6. Remaining access funds should be used to boost primary care capacity and integrated whole system working to manage demand. PCTs will already be aware of the level of referrals expected and links to the Activity Fund. PCTs should help manage demand through, for example the use and development of local walk in centres, the training and provision for GPs with special interest including extra OP clinics in primary care settings; ophthalmology and dermatology in the community, integrated nursing teams, physiotherapy triage and back pains clinics and the development of local walk in centres. This will require working with and obtaining speciality specific data from local hospital Trusts.

7. PCTs should consider this against the whole system needs and where necessary should in addition use the unified budget for further investment. They should also consider how best to utilise and/or extend the contribution of other services available to them in their local health economy including NHS Walk in Centres, NHS Direct, community pharmacists and out of hours services.

8. PCT will receive their portion of the access fund as part of their allocations from HAs which fund the components their local Access Incentive Scheme. Payments will be made by PCTs to primary care and community providers, as appropriate, through GMS local development schemes, use of HSG(96)31, uplifts to PMS budgets, variations in PMS contracts (including "PMS plus") and established GMS/other payment mechanisms.

9. In addition to the increase in the Primary Care Access Fund, the National Primary Care Development Team (NPDT) will be making available, to each PCT who have not been funded as part of the Primary Care Collaborative, a sum of £25,000 per year for the two years to fund an Access Facilitator. The Access Facilitator will provide local support, advice and assistance to practices on access improvement in accordance with the successful approach of the Primary Care Collaborative. The access facilitators themselves will receive initial training and ongoing support from the NPDT. Some PCTs may wish to work together to employ facilitation across the boundaries and to look at collective PCT initiatives to help demand/capacity. The period of funding will cover the financial years 2002/03 and 2003/04, and will not be included as part of the PCT's Management Costs. Further details will be sent out shortly to PCT Chief Executives from the NPDT.

10. A quarterly Primary Care Access Survey is carried out collected as part of the Department of Health's SaFF return. In the light of this additional investment a new SaFF milestone of 90% achievement of the target has now been set for March 2003 (i.e. 90% of patients being able to access a health professional or GP within 1 or 2 working days). Achievement toward this milestone will be measured through the access survey commencing from Quarter 1 in 2002.

11. In addition the Department of Health will also require StHAs to monitor PCT spending of the Primary Care Access Fund as part of their accountability arrangements with PCTs.

Primary Care Access Incentive Scheme

  • In summaryPCTs are asked to use the additional resources to fund:
  • As the first call on funds in 2002-03 - facilitatingthe achievement of the NHS Plan targets with PCT access leads and NPDT Centres towards Advanced Access where this is required or for other general practice based methods of access improvement.

For PCTs not participating in the Primary Care Collaborative this could include:

- supplementing the NPDT contribution to fund a PCT Access Facilitator.
- Meeting the cost of Access Facilitators when the NPDT funding expires at the end of the two year programme.

For PCTs which are taking part in the Primary Care Collaborative this could include:

- Funding the appointment of an Access Lead or Facilitator

This funding for would not be included as part of their management costs.

1. As the second call on resources - PCTs should then assess the need for ongoing investment, for example in Walk in Centres and cross practice support

2. As the third call in 2002-03 - PCTs to locally agree (in conjunction with practices, other service providers and the LMC) an incentive scheme to support sustained achievement of the access targets and continued improvements to primary care services with their practices

3. The intention is that PCTs should use the Access Fund to meet the cost of a local Primary Care Incentive Scheme which would provide short-term investment in practices and other primary care service providers across the PCT to help implement strategies to improve access. In the first instance this would be a one off  implementation payment to engage practices. In order to qualify for an implementation payment, practices would be expected to agree a plan for implementation with their PCT which would cover:

  • Profiling the demand for face to face appointments within the practice.
  • Identifying and implement approaches to shaping demand within the practice in order to use face to face consultation more effectively.
  • Matching the capacity of the practice to the demand for face to face appointments on a daily basis and work down any backlog of appointments as required.
  • Collecting data on a monthly basis to demonstrate improvement (e.g. 3rd available appointment measure for GPs and nurses within the practice).
  • If appropriate, supporting the active participation of practice staff at local collaborative events for example through locum backfill for at least one GP.
  • Developing contingency plans to deal with such issues as staff sickness, holidays
  • In return practices will receive an investment payment of around £5,000 for an 'average' sized practice. PCTs should use their discretion in deciding incentive levels necessary to meet local circumstances.

Sustained Achievement of Access Target

  • PCTs should also use access funds to provide incentive payments to practices who can already demonstrate sustained achievement of the NHS Plan access targets either through practising Advanced Access or other means. Such incentive payments should include any maintenance cost of sustaining the access targets but also reward continued improvements to primary care, which result in fast and convenient primary care for patients as envisaged in the NHS Plan. The amount of the incentive payment should be agreed locally but could again be in the order of £1 per patient or an average payment per practice of some £5,000.
  • It is envisaged that after 2002-03 this incentive payment scheme will be the biggest call on the earmarked funds. Such PCT incentive schemes should allow PCTs and their practices or PMS providers' flexibility in how incentives should be paid e.g. as team bonuses, personal payments to GPs as extra income or investment in services.
  • This approach will allow flexibility locally on the uses of the funds, depending on existing local achievement of the NHS Plan access targetsand PCT and practice/PMS provider preferences on how delivery of advanced access should be recognised.

Relationship to Primary Care Incentive Scheme

1. This approach, encouraging schemes to be developed and agreed locally between front-line professionals, practices and PCTs is consistent with existing incentive schemes introduced in 2001-02 as part of "Investing in Primary Care". The two schemes should now be considered side by side. In some instances PCTs may need to use both incentives schemes in tandem to achieve the access target locally. On other occasions, where the target has already been achieved or can be achieved by using funds solely from the new Access Incentive Scheme, PCTs and practices should utilise "Investing in Primary Care" monies to develop and improve other aspects of primary care services for patients.

2. In particular PCTs and practices working in partnership across the local health economy may seek to:

  • Take forward implementation of National Service Framework standards
  • Develop intermediate care services (step up and step down facilities)
  • Expand the range of services delivered in the practice (especially where these will result in improved access and the delivery of reduced waiting times for patients)
  • Encourage an increasing number of outpatient appointments to be provided in a primary care environment
  • Improve the 'Working Lives' of staff
  • Quality improvement initiatives, including,
    - Continuing Professional Development
    - Risk Management
    - Clinical Governance
    - Education and training

3. The Department will be discussing with PCTs and primary care organisations the operation of all primary care incentive schemes with a view to ensuring that they are flexible and supportive to practices and PCTs. These discussions will also need to accommodate the emerging recommendations of the new GMS contract discussions in due course.

National Primary Care Development Team (NPDT)

  • The National Primary Care Collaborative - managed by the National Primary Care Development Team - is working with practices and PCTs to help them modernise their services to better meet the needs of their patients. A key priority for the Collaborative is improving access to primary care using an "advanced access" model. Advanced access helps improve patient access and choice, whilst providing clinicians and managers with greater control over how they manage their time and deploy resources within their practices.

Advanced Access

1. Advanced access consists of a framework of change principles and change ideas, which are grounded in practical examples drawn from general practice. The change principles are:

  • Understanding the profile of demand in terms of number and types of requests for appointments
  • Shaping the handling of demand to safely and effectively reduce demand for face to face consultations with GPs
  • Matching the capacity of the practice team to the shaped demands of patients
  • Establishing robust contingency arrangements to deal with staff holidays and sickness, and peaks in patient demand (e.g. epidemics)

2. The practices and PCTs on the Collaborative have delivered impressive results in improving access because practices have developed a better understanding of their demands and using proven strategies for managing that demand more effectively. This has included increasing the use of telephone management of same day requests, telephone consultations and follow ups, introducing e-mail advice and prescription ordering, and looking creatively at group consultations. A key element of this work has been improving skill mix within the practices and making more effective use of highly skilled nurses and increasingly using health care assistants to enable nurses and GPs to target their skills more appropriately.

3. The NPDT are actively disseminating the "advanced access" model developed by the Collaborative across the country. The spread phase started in December 2001 with the creation of a network of local NPDT Centres which will be active by April 2002 and have direct links to SHAs.Additional top-sliced funding of £2.5m will be used to support the accelerated spread of the collaborative. A key role of the Centres will be to facilitate the contribution of other existing sites, project managers and practices in the area to deliver this effectively across a broad geographical area.

4. Information on the work of the NPDT and the advanced access model for improving access in primary care is available on www.npdt.org.

Further Advice

  • If you need further information or advice from the Department of Health, please contact Catherine Davies on 0113 254 6602 or by emailing the PC Access mailbox at MB-Access@doh.gsi.gov.uk.

Primary Care Access Team 7 March 2002
GPMS Policy Division
Department of Health

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