The Doctor won’t see you now: Patients locked out of Cameron’s NHS

This is NHS Check report no 2 originally published by Labour’s Shadow Health Team in  July  2012

Revealed:

• New evidence shows patient care is suffering as a result of another NHS broken promise by David Cameron
• Patients struggle for appointments as GP practices end evening and weekend opening and walk-in centres close
• A&e visits increase by 1 million this year
• Corridor ‘trolley waits’ double

Labour conducts survey of GP opening hours to establish true picture after the Department of Health drops national data collection.

Survey shows 5.7% drop, equivalent to 477 GP surgeries across England, opting out of offering evening and weekend appointments in the last year.

In 2011/12, half of PCTs in England report a drop in the number of GP surgeries offering opening hours during evenings and weekends – the first-ever drop since the extended hours service was introduced.

The following PCTs have seen the biggest falls: Hartlepool (31.3%), Newcastle (25%) and Haringey (24.3%).

In addition, analysis of weekly NHS hospital activity statistics shows there are now 26 fewer non-hospital providers of emergency care compared to June 2011.

12 NHS Walk-in Centres have closed (Bolton; Barnsley; Victoria (London); Ashfield (Nottinghamshire); Stapleford (Nottinghamshire); Tooting (London); Newcastle Central; Leeds (The Light, Headrow); Salford (Pendleton); Manchester Piccadilly; Manchester Withington; Haringey (London)) and further closures are planned – adding to the difficulties families are facing in getting access to care.

Submissions to NHS Check indicate that people are waiting up to three weeks for GP appointments.

Pressure builds on A&E departments as patients’ options become more limited: 1 million extra visits to A&E are recorded this year and corridor ‘trolley waits’ double.

More patients are waiting longer in A&E as 46 NHS trusts are missing the Government’s lowered A&E standard with some dipping below 90%.

Labour’s NHS Check website (www.yourNHS.com) receives reports of widespread problems in booking GP appointments as Department of Health figures show increased demand for evening and weekend appointments.

Before the General Election David Cameron promised to improve GP opening hours made a specific promise saying: 

“Under the Conservatives you will be able to see a GP in your area until 8pm seven days a week. This will make a huge difference to all those people who struggle to get an appointment with a GP at a time that suits them.”                                                   David Cameron, General Election campaign, 12 April 2010

Labour calls on the Government to:

1.      Restore the national survey of GPs opening hours and instruct CCGs that it remains a priority.
2.      Work to restore GP extended opening hours to 2010/11 levels with immediate effect.
3.      Call a halt to the closure of NHS Walk-in Centres pending a review.
4.      Take urgent action to ensure all A&Es in England are meeting the  4-hour target.
5.      Investigate and publish the reasons why the Govt believes GP extended opening hours are declining.

1. Introduction

The NHS in England is currently undergoing is biggest-ever top-down re-organisation at the same time as facing the toughest financial challenge in its 64-year history. This has led to concerns that standards of patient care will deteriorate.

To monitor the situation, Labour introduced its NHS Check website earlier this year.  This aim was to give people a simple way of reporting their experiences with NHS care and expose the reality of what is happening on the ground in the NHS. The issues being reported through NHS Check, including the rationing of treatments exposed in June’s NHS Report and the restrictions on access to GPs detailed in this report, point to the effects of the Government’s reorganisation. Labour has said all along that the Government’s reorganisation combined with the financial challenge will have a destabilising effect on the NHS which will negatively impact on services for patients.

Since NHS Check opened in May, 1,352 people have reported problems with deteriorating standards.  It quickly became clear to us that one of the most common complaints received was from people reporting difficulties in accessing timely and convenient GP appointments.

Here is a selection of the reports that NHS Check has received:

Prompted by these reports, Labour decided to conduct a survey of all PCTs/CCGs in England to establish the true picture on GP opening hours.

PCTs were asked to provide figures on the number of GP practices offering extended opening hours in 2010/11 and 2011/12.  Some also provided information for 2012/13.

Overall, information has been received from 91 Primary Care Trusts (PCTs) in England.  More than two thirds of the data was directly provided by Primary Care Trusts and data given to the Health Service Journal earlier this year has been used for 27 PCTs.  The HSJ data was collected through Freedom of Information requests and included deprivation scoring (http://www.hsj.co.uk/primary-care/exclusive-poor-patients-face-shorter-gp-opening-hours/5043677.article).

KEY FINDINGS

Fewer GP surgeries offered ‘extended hours’ opening in 2011/12 compared to 2010/11

• Over half of PCTs (56% / 51 PCTs) reported a decrease in the number of surgeries offering extended opening hours in the last year; a third (32% / 29 PCTs) reported a flat-lining following consecutive increases under Labour.
• Amongst the 91 PCTs, 234 fewer GP surgeries offered extended opening hours in 2011/12 compared to 2010/11.
• PCTs registered a 5.7% decrease from 4087 to 3853 – the first fall since the initiative started.  If applied across England, a six per cent reduction in practices offering evening and weekend opening across the 8316 practices equates to 477 GP surgeries opting out.
• Only 11 PCTs reported an increase in the number of surgeries seeing patients during evening and weekends – with one or two additional practices.

Of areas losing large numbers of surgeries, the 10 PCTs most affected were:

•  Hartlepool – 15 of 16 down to 10 of 16 surgeries.  Was 93.8% now 62.5%.  Decrease of 31.3%.
•  Newcastle – 33 of 36 down to 24 of 36 surgeries. Was 91.7% now 66.7%.  Decrease of 25%.
•  Haringey – 47 of 51 down to 36 of 53 surgeries. Was 92.2% now 67.9%.  Decrease of 24.3%.
•  Central Lancashire – 56 of 87 down to 40 of 85 surgeries. Was 64.4% now 47.1%.  Decrease of 17.3%.
• Ashton, Wigan & Leigh – 55 of 65 down to 45 of 65 surgeries. Was 84.6% now 69.2%.  Decrease of 15.4%.
• Cumbria – 69 of 85 down to 55 of 81 surgeries. Was 81.2% now 67.9%.  Decrease of 13.3%.
•  Hull – 38 of 53 down to 30 of 51 surgeries. Was 71.7% now 58.8%.  Decrease of 12.9%.
• Enfield – 55 of 62 down to 45 of 57 surgeries. Was 88.7% now 78.9%.  Decrease of 9.8%.
•  County Durham – 69 of 86 down to 61 to 84 surgeries. Was 80.2% now 72.6%.  Decrease of 7.6%.
• Medway – 53 of 63 down to 47 of 61 surgeries. Was 84.1% now 77.1%.  Decrease of 7%.

Please see Appendix 1 for full list of PCTs who responded to the survey.

Policy context

During the 2005 General Election campaign Tony Blair was tackled on live television over difficulties in booking GP appointments and the issue emerged as a major nationwide concern. Following the election, Labour put renewed energy into ensuring patients were able to see their doctor within the 48-hour target.  More GP practices were required to offer extended opening hours services to enable patients to see their GP in the evening or at weekends. As incoming Prime Minister in 2007, Gordon Brown made the issue of GP appointments a priority for his Government with the evening and weekend extended opening hours scheme in his first year.

“Today we know that too many GP surgeries are not open out of hours or at weekends. We will increase access to existing GP surgeries so that patients can get the services they want at times that are convenient to them and to bring more choice.”

Gordon Brown, 5 October 2007

Negotiations with the British Medical Association meant that year after year increasing numbers of doctors agreed to keep surgery doors open into the evenings and weekends – allowing patients to book appointments around work and family life. In May 2008, 1,644 GP practices offered extended opening hours out of a total of 8,068 GP practices.  In 2009, that figure had increased significantly to 6,322 out of 8,262 GP practices. Yet last year saw the first fall in the number of GP practices offering extended hours.  Labour has identified 3 factors which may be behind the drop.

1. The Government’s NHS re-organisation has distracted and destabilised the NHS. When maximum grip and focus was needed to deal with the efficiency challenge and maintaining standards of patients care, the Government chose to put the NHS through unnecessary upheaval. As a result, Primary Care Trusts took their eye off the ball due to focussing on enforced changes to structures and the resulting loss of clinical and administrative staff. Primary Care Trusts themselves are being dismantled before the new Clinical Commissioning Groups are ready to take control – leading to drift and chaos in the system.

2.  The Government’s decision to discontinue the national survey, which collected and published the data on the number of GP practices offering extended opening hours in each PCT area, sent a signal that increasing the numbers offering extended opening hours was no longer a priority.

1. As the Government hands over control of the NHS to GPs, excluding other clinicians from commissioning decisions, serious questions are raised over potential conflict of interests. Family doctors have more than a personal interest in decisions surrounding extended surgery hours – acting as both the commissioner and the provider they are in an ideal position to heavily influence the provision of primary care.  It has raised questions over whether the public interest rather than professional interest will take precedence when decisions about extended opening hours are being made.

We are calling on the Government to investigate and publish the reasons for the fall in the number of GP practices offering extended opening hours.

An important part of Labour’s drive to improve access to primary care was the Walk-In Centre programme, which opened up access to doctors and nurses without the need to make an appointment. Patients had the choice of seeing their own doctor at a more convenient time or visiting a Walk-in Centre for quick access to primary care. In turn the NHS benefited from the cost-effectiveness of keeping expensive A&E visits to a necessary minimum.

The cost to the NHS

GP

An average GP appointment costs the NHS £25

Walk-in-centre

Each visit to a walk-in centre costs the NHS from £63

A&E

A visit to A&E can cost the NHS from £59 to £117

It is far more cost effective to the NHS for patients to be seen by their GP in the first instance.  The costs of patients going directly to A&E is potentially far more than if they were to go to a walk-in centre, but in addition to the cost issue, the increase in patients referring straight to A&E departments puts added pressure on those departments.

Another Cameron broken promise

As with many other successful Labour policies on the NHS, David Cameron promised at the election to keep the family-friendly hours.

In fact, during the General Election campaign, he made a specific promise to go even further:

“Under the Conservatives you will now be able to see a GP in your area until 8pm seven days a week. This will make a huge difference to all those people who struggle to get an appointment with a GP at a time that suits them.”

David Cameron, Daily Mail. 12 April 2010

Yet the opposite is happening.  On Cameron’s watch, patients in practices across England are seeing evening and weekend openings being stopped.

Yet now that surgery hours are being reduced and Walk-in Centres are closing, A&E units are placed under increasing strain – exposing the growing gap between David Cameron’s hollow promises and the reality of a shrinking NHS under his Government.

David Cameron promised:

No top-down reorganisation of the NHS – BROKEN

The Government promised no top-down reorganizations of the NHS, a promise included in the Coalition Agreement.  Yet they imposed the biggest reorganisation of the NHS in its 64-year history and at a time of financial challenge.

To increase spending on the NHS for every year of this Parliament – BROKEN

The Government promised to increase spending on the NHS for every year of this Parliament, yet figures show that spending on the NHS has fallen for the each of the last two years.  Treasury figures released recently (Public Expenditure Statistical Analyses 2012) show that in the current year 2011/12 the Government has cut spending on the NHS by £20m and in 2009/10 to 2010/11 by £766m.

A moratorium on hospital closures – BROKEN

Before the General Election David Cameron and Andrew Lansley posed for photos promising a moratorium on hospital closures.  Since the election hospital closures have continued.

No rationing of treatments based on cost – BROKEN

Health Ministers have repeatedly said that treatments must not be rationed for reasons of cost and that if evidence were presented they would act.  Last month Labour presented a dossier of evidence showing 125 treatments being rationed across England, a number of them based on cost.  This was supported by an RNIB survey of PCTs/Trust about cataract treatments which also showed the treatment being rationed due to cost rather than clinical need.

Access to GPs surgeries at evenings and weekends – BROKEN

Before the election David Cameron promised that patients would be able to see a GP up to 8pm, 7 days a week.  This report exposes the reality on the ground where walk-in centres are being closed, fewer GPs are offering extended hours and there is growing pressure on A&Es.

Patient survey reveals increased demand for evening/weekend opening

An official Department of Health[1] survey of patient satisfaction with GP services has revealed that the demand for surgeries to open before 8am, in the evenings and at weekends has increased in the last year.

Responses from patients in 2009/10 primarily (52%) called for surgeries to be open on Saturdays, with only 26% calling for evening appointment and 4% on a Sunday. Yet two years later the 2011/12 data shows an even higher percentage wanting Saturday surgery (71%), an almost trebling of patients wanting evening appointments (66%) and calls for Sunday rocketing to 29%.

NHS Walk-in Centres closed, facing closure or hours cut back

Next Tuesday (31^st July) another NHS Walk-in Centre will close its doors to patients.  Yet the Department of Health has admitted to not keeping track of their closures.

Analysis of weekly NHS hospital activity statistics, by the House of Commons library, show there are now 26 fewer non-hospital providers of emergency care (including urgent care units) compared to June 2011 – a 25% reduction.

Visits to Walk-in Centres increased annually until 2009/10 and relieved pressure on A&E departments by providing easy access to treatment for minor ailments.  Yet in 2010/11 visits dropped from 2,699,798 to 2,486,793 as centres began to close their doors – resulting in more patients visiting A&E with non-urgent cases.

Since May 2010:

• Bolton Closure expected: 31/7/12
• Barnsley Walk-in Centre Closed:  30/11/11
• Victoria (London) Walk-in Centre Closed:  December 2011
• Ashfield (Nottinghamshire) Closed:  September 2011
• Stapleford (Nottinghamshire) Closed:  September 2011
• Tooting (London) Closed:  2011
• Newcastle Central Closed:  May 2011
• Leeds (The Light, Headrow) Closed:  30/11/11
• Salford (Pendleton) Closed:  1/9/11
• Manchester Piccadilly Closed:  2011
• Manchester Withington Closed: 2011
• Haringey (London) Closed: March 2011

Facing threat of closure

• Tollgate Lodge (London)
• Springfield Health Centre (London)

Reduced opening hours since May 2010

• Doncaster
• Harrow (London)
• Bedford
• Stockport
• Bath
• Southampton

Extra pressure on A&E units

Patient numbers increase by 1 million and ‘trolley waits’ double.

The cumulative effect of a number of Government policies is piling pressure on A&E Departments resulting in higher numbers missing their waiting targets and having a dramatic impact on patient care.

Whilst the lack of alternative access to care for minor injuries and non-urgent conditions has driven patient visits up, cuts to local authority social care budgets have left increasing numbers of older people turning to A&E at the same time as nursing job losses have left the frontline under-resourced.

A&Es across England recorded close to 1 million extra visits in 2011/12 compared to 2009/10 – as the annual number of visits rose from 20,511,908 to 21,480,589.

The number of people waiting longer than 4 hours in A&E to be admitted to hospital, so-called ‘trolley waits’, also doubled in a single year – from 51,569 in 2010/11 to 106,945 in 2011/12, according to the Department of Health’s weekly statistics[2].  Whilst 8-hour long trolley waits had more than doubled between 2009/10 and 2010/11 – 4,862 to 10,093 in just 61 hospital trusts, according to a new Freedom of Information request by the Labour Party. The statistics confirm fears raised by the Royal College of Nursing in May 2012 who stated that more than half of A&E nurses reported daily sightings of patients treated in corridors, whilst a fifth said they saw this happening hourly[3].

At present 46 hospital trusts are on average missing the A&E target to treat 95% of patients within 4 hours. The ten worst performing A&E trusts this year according to the Government’s target are:

Please see Appendix 2 for a full list of trusts failing to meet the Government’s lowered 95% target.

Government letting patients pay the price

Patients suffering from minor injuries or conditions want the quickest possible access to primary care.  More available appointments with the family GP at evenings and weekends, in addition to centres treating patients without pre-booking, helped to keep the pressure off A&E.  Patients felt more comfortable presenting themselves at a doctor’s surgery or Walk-in centre with a seemingly minor ailment – yet whilst many appear to have turned to A&E, others will not have sought any other professional medical advice in its place.

David Cameron’s recent Health & Social Care Act has given control of NHS budgets to GPs at a time of unprecedented financial challenges within the NHS and against a background of growing patient need.  In stark contrast to his pre-election promises, David Cameron has betrayed the NHS – budget cuts, staff losses and ward closures – and the Department of Health’s own data shows that patients are paying the price.

The Department of Health – incredibly – does not know how many Walk-in Centres are being lost and can only confirm that the GP-led Clinical Commissioning Groups have the power to close them down.  There could be no clearer illustration of random chaos of the NHS re-organisation as the Government tries to wash its hands of service reductions on the ground.

The Government offers warm words on moving health care “into the community” and away from the hospital – yet primary care access is being drastically slashed while social care budget cuts damage long term care provision.

It abandoned Labour’s strict 98% A&E target soon after the General Election and now curbed access to primary care has contributed to the factors applying fresh pressure on A&E units across England.  Patients are left facing longer waits for a GP appointment and longer waits in A&E – experiences widespread amongst contributors to Labour’s NHS Check.

Conclusion

David Cameron urgently needs to set out a convincing plan for how he will deliver his election promise of all patients having access to GPs open in the evening.

Specifically Labour makes these calls on the government:

Labour calls on the Government to:

1.      Restore the national survey of GPs opening hours and instruct CCGs that it remains a priority.
2.      Work to restore GP extended opening hours to 2010/11 levels with immediate effect.
3.      Call a halt to the closure of NHS Walk-in Centres pending a review.
4.      Take urgent action to ensure all A&Es in England are meeting the  4-hour target.
5.      Investigate and publish the reasons why the Govt believes GP extended opening hours are declining.

Appendix 1

Appendix 2

[1] Department of Health reference needed

[2] http://transparency.dh.gov.uk/2012/06/14/weekly-ae-sitreps-2012-13/

[3] RCN reference