The British Medical Association has found itself stuck between a rock and hard place after being made to choose between two options the government has laid on the table for provision of extended access to GPs, neither of which it agrees with.

The government has been pushing hard to provide better access to primary care since the issue reared its head during Lord Ara Darzi’s consultations with the general public over the National Health Service as part of his Next Stage review. But although the doctor’s union agrees that GP hours could be extended to better meet patients’ needs, it has been at loggerheads with the government since October on how to best go about it.

Talks between the two factions broke down towards the end of last year after they failed to reach an agreement on how to proceed with extending surgery opening hours to evenings and at weekends, with the BMA claiming that the government was refusing to consider its proposals and threatening to impose a “draconian contract if GPs won’t agree to the deal on the table”.

A spokesperson for the BMA told PharmaTimes UK News that no reasons as to why the Association’s plans were rejected have been offered, and added: “We thought we were close to agreeing a deal with the NHS Employers - but then the government stepped in and put its own non-negotiated offer on the table.”

According to the BMA, the government has put forward two options for the expansion of GP access on the understanding that, if the organisation doesn’t agree to the first one (Option A), then the second (Option B) will be imposed.

Choices, choices
Under Option A, the government has put forward extended access of 30 minutes per week per 1,000 registered patients - in blocks of 1.5 hours after 6.30pm or for one hour prior to 8.00am or on Saturday morning - depending on agreement between the practice and the primary care organisation and local patients’ wishes. An additional investment of 1.5% in services and reallocation of 58.5 points from the Quality and Outcomes Framework (38.5 from the holistic/organisation domains and 20 from the patient experience domain) would be made available to support these arrangements.

But the BMA spokesperson told PharmaTimes that its GP Committee believes Option A is too inflexible. “Under Option A, surgeries that choose not to open longer - because local patient surveys have shown no need or desire for extended hours - will still see their practice funding slashed by an average of £18,000,” she said, and warned: “Despite GPs' best efforts this could destabilise their service and have a knock-on effect on the care they provide to patients”.

In addition, GPs will also have to work on their own in their practices in the evening, which is something many of them find worrying, she said, and added that further “inflexibilities”, such as the lack of an option to have a nurse working alongside a GP in extended hours, “means many of the services patients get in the daytime may not be available in extended hours”.

Under Option B, however, 135 points would permanently removed from the QOF, including clinical areas such as flu vaccination and management areas such as computer security. Funding would be allocated to PCTs for them to agree local contracts for longer opening with any practices - including newly established private APMS practices - but “experience has shown that it is likely that only a proportion of the funding would end up with any general practices if allocated to PCTs,” the BMA argues.

The Association itself has proposed that an average practice of six thousand patients provide an extra two hours of surgery time, with further improvements to the QOF - an annual incentive and reward scheme for GPs - to encourage a greater focus on better care of patients with heart failure and osteoporosis.

“Our deal involved no new money - it would have recycled points from the QOF which an expert panel had already agreed should be recycled,” the spokesperson told PharmaTimes. “It would also have provided extended hours in a way that allowed practices to implement it flexibly according to the needs of their local population.”

Moreover, she said, the BMA’s proposals “would also have led to new clinical work being brought in through the QOF [but] this will not happen now. Instead, the QOF points we wanted to reinvest to improve clinical care are being used to fund extended opening hours”.

The lesser of two evils?
Following an analysis of both scenarios put forward by the government, and spurred by Health Secretary Alan Johnson’s move last week to write to all doctors urging them to accept the government’s proposals, the BMA’s GP Committee has decided that Option A is less damaging for general practice. “The alternative option will harm the underlying fabric of NHS general practice and patient care more quickly and more lastingly,” it concluded.

The Association is planning a nationwide poll of all GPs later this month to gage opinion on the matter and agree a course forward. “We are not recommending any course of action and GPs are free to come to their own decision on how to vote,” commented Committee chairman Dr Laurence Buckman, and stressed that the BMA’s move signalled “neither a climb down nor a U turn but a recognition that between two bad alternatives, one is worse than the other.”