Podcast | Hub life

After several pilots, Extended Access (EA) or hub working is being rolled out nationally. This article captures the experience of working in such setting as a sessional GP, based on my own and that of colleagues.

EA shifts provide a shared overflow capacity for same day care to improve access, and relieve pressure on A&E. Patients registered with local practices are offered 15 minute appointments with a GP who has access to their full medical record. Services are sometimes slightly more restricted than their own practice (e.g. no routine referrals (only 2ww), repeat prescriptions or fit notes).

The patient is usually seen in one or two central locations, either a surgery or walk in centre, and appointments booked by the home practices (patients cannot book into them directly).

Puzzlement

Patients seem to really value the same day access and the extra time they get, unless they are booked in error by receptionists who do not understand the limitations of the service. Where these slip through, a difficult consultation can ensue. Patients can also seem puzzled to be seeing a doctor they recognise from their own practice, having been told that their own practice doesn’t have appointments that day.

Top-up

Many sessional GPs are choosing to top up part-time salaried work with more ad-hoc and manageable hub work in term time or less busy periods. This work can be appealing because, as well as 15 minute appointments, there are no visits, administration or scripts and therefore the workload is manageable and importantly defined with a clear end point.

Caseload

The typical consultation is naturally more acute than your average surgery, and can provide a welcome break for those of us in salaried roles where our usual clinics are heavily booked with complex multi-morbidity and chronic disease reviews. It provides a good setting for brushing up on more acute care. Urgent admissions can be challenging if attempted 30 minutes before the end of your shift when the building is being locked… as most ambulance services are struggling to provide prompt responses.

Practice perspective

Practices and partners seem to view the hubs with a mixture of scepticism, resentment and disdain, and this inevitably seems to tarnish their opinions of even the most diligent consultations offered by hub doctors. They resent the funding being invested outside of practices, see the work as easy and overpaid, and the length of appointments as unjust considering the apparent reduced complexity of the majority of the caseload. There is also the grumble that hub consultations don’t result in completed episodes where tests are required, which need follow up, or where an issue may need a referral which was not anticipated prior to booking. A well-documented Hub consultation should allow a seamless follow up at the home practice, and possibly even a referral without a repeat consultation, but the grumbles about duplicated or unfinished work are frequent.

Practices and partners seem to view the hubs with a mixture of scepticism, resentment and disdain, and this inevitably seems to tarnish their opinions of even the most diligent consultations offered by hub doctors.

Risk

Initially deemed as “OOH” level of indemnity risk, and so unaffordable for many GPs to work in, Hub work is now categorised as “scheduled”, which is lower risk providing there are booked appointments, they are registered patients and GPs have access to the full record. However as Hubs have become integrated into accepting bookings from patients redirected from a first presentation to OOH or Walk in centers, some GPs have been told they have to pay retrospective premiums at the unscheduled care (costlier) rate. The MDOs have broadly aligned their categories, but each still retains distinct terminology about the nature and setting of the work which leaves GPs uncertain about where they stand and whether they have taken the right level of cover for work which seems to be subject to so much change.

Occasionally, no medical record is available either due to an IT/technical glitch or failed consent process. The Hub doctor then has two unenviable options: 1) decline to see the patient (due to not being indemnified) but risking a complaint, or 2) agree to see them in breach of GMC guidance on indemnity (and be penalised with retrospective indemnity costs for what has turned out to be unscheduled work).

In house

Local GPs are keen to have such services staffed by doctors who are “local to us who know our services and guidelines” as if a) there will be a choice from a plentiful supply b) their own are a cut above others who may be prepared to work flexibly across several areas. The reality is that most Hubs will be lucky to recruit willing GPs, even from a wider regional flexible pool, and will need to ensure they have robust induction mechanisms to local service pathways. Effective service development will need to ensure it has a means of learning from the experience of these coalface clinicians who typically have no organised “voice” or representation when working freelance. They deal with disappointing working experiences by walking away. The work can be an isolating experience in a setting where you have no real colleagues, reporting to people who have never done this role first hand and “supported” by staff who have little vested interest in ensuring things run smoothly for you.

The other common theme is the concern that Hubs, resented as they are, will entice an already scarce resource (locums) away from practices, and so there is considerable political pressure to keep payments rates in Hubs at or below standard market rates for practice locums, leaving many hubs empty in busy summer and school holiday periods where works in practices is more plentiful and better paid.

Some upsides

For all its downsides, the 15 minute appointments as provided through these hubs, when accompanied by adequate induction and support, and a listening organisation, can provide a fulfilling addition to other GP work, and a glimpse of what general practice should really feel like: satisfying time to listen to patients.

Paula Wright

pfwright@doctors.org.uk

Resources

There are important themes from the Taylor Review (Good work) which are also relevant here.

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