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Last Updated: Monday, 25 June 2007, 06:33 GMT 07:33 UK
Out-of-hours demand riles doctors
By Adam Brimelow
Health correspondent, BBC News

GP consultation
Patients want better access to GP surgeries
Gordon Brown could be on a collision course with doctors over his big priority in the NHS - improving access to GPs.

The British Medical Association has accused the government of trying to unpick the contract which allowed them to give up responsibility for out of hours care.

It says if ministers want GPs to open for patients early or late in the day, or on Saturdays, they are going to have to find more money, or services will suffer at other times of the day.

Is there a way out of the deadlock?

A few days ago at a BMA gathering in London a Yorkshire GP, Dr Andrew Green, proposed charging patients for routine care at evenings and weekends.

There was a backlash in the papers, and from politicians. They accused doctors of being greedy for demanding yet more money on top of big pay rises.

The idea was voted down. But the BMA's GP chairman, Dr Hamish Meldrum, said it had promoted an important discussion - one that is clearly exercising Mr Brown, who has made improving access a priority.

Feeling of anger

Dr Meldrum said there was no going back on the GP contract, agreed a few years ago.

Dr Hamish Meldrum
There is a feeling of anger towards the government
Dr Hamish Meldrum

This defined their core hours - 0800 to 1830 on weekdays - and allowed them to give up responsibility for out-of-hours care.

He said: "I think there is a feeling of anger towards the government in that an agreement was reached in good faith between both sides, voted on by the profession after a very extensive ballot, and now government are trying to unpick it.

"We are actually seeing the government trying to either change the definition of in-hours working or ask for more work for the same money."

There is a perception among many doctors that many people feel that under the contract they are not providing value for money.

They insist this is unfair. But the government is ready to wield the weapon of public opinion.

Unhappy about access

It is preparing to publish a survey of more than two million patients, which is likely to show a significant minority are unhappy about GP access. Dr Meldrum is defiant.

"If the government is saying that, with essentially the same workforce, GPs can extend their normal working hours very significantly, while at the same time many GPs are still are still working out of hours, then I'm sorry, that is unsustainable."

A lot of GPs are quite anxious about some of the many changes which have been occurring over the last few years
Dr Maggie Walker

So how do you get round this?

The patient survey will release small financial rewards for practices where patients are happy with access.

Trusts can also buy in alternative providers, including private companies, to plug gaps in services.

Dr Michael Dixon, chairman of the NHS Alliance, which represents primary care trusts, says local solutions will work best.

"A showdown would happen if this had to be negotiated at national level as things stand," he said.

"That is why my advice to Gordon Brown would be to hand the problem to local patients, local PCTs, local practices, and say: 'You find out locally what you want, and then mutually you decide on how you are going to pay for it'."

Extended hours

That is what has happened at the Churchill Medical Centre in Kingston Surrey, where patients have the option of early morning or evening appointments during the working week, or a Saturday surgery.

Opening hours were extended last autumn, in response to a patient survey.

One patient I spoke to, Aisha Javaid, said this was a great help.

"For me it's actually crucial because I'm a really busy childminder, and I have loads of kids during the day.

"If I wasn't able to come in the evenings I literally would have to bring the whole crew to go and see the doctor when I need to."

This is a big practice, with 11 GPs. That made it easier to organise evening and Saturday surgeries favoured by people with jobs, without cutting back on daytime services which see more older patients and children.

The GPs don't get any extra money, but Dr Maggie Walker says it has been a great success for patients.

"It's probably true to say that a lot of GPs are quite anxious about some of the many changes which have been occurring over the last few years," she said.

"I suppose our experience will say it's not that difficult to do this.

"It just requires a little bit of lateral thinking, but actually, given that the building is there, it's actually quite an easy thing to do, and it does really provide increased patient satisfaction."

Health minister Andy Burnham said the GP contract had been "extremely innovative" and was being examined as a possible way forward by other countries.

However, he said: "Primary Care Trusts need to develop local solutions where patients are telling them that access to GPs is not good enough."

But if local solutions are the way forward, where would that leave the national negotiator - the BMA?

Many doctors already feel it mishandled the crisis over junior doctors training. It can't afford a further loss of face.

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