How to run Extended Hours under networks

GP partner Dr David Coleman offers tips on how to run the extended hours service under the new Network Contract DES

Key points

1. Requirements: Appointments must be offered outside the core hours of 8.00am to 6.30pm. You must provide 30 mins per week per 1,000 patients. If extended hours capacity is lost due to Bank holidays, it will need to be provided elsewhere in the week. If you don’t meet the hours, you won’t be paid.
2. Staff: Build a team that suits your needs. Having a number of clinicians working at once will cut your admin costs. Consider utilising the skills of non-GP clinicians to make the service more cost effective.
3. Hours: Trial early morning, evening and Saturday shifts and see what works for your practice.

The extended hours directed enhanced service (DES) has been running for several years (not to be confused with the seven-day extended access scheme, a separate scheme run by CCGs with funding from the GP Forward View).

Under the new contract, the extended hours DES has been transferred to the new Network Contract DES, to be provided and funded via primary care networks (PCNs).¹

The 2018/19 payment of £1.90 made this service worth the effort, generating around £28,500 a year for a practice of 15,000 patients.  Under the new contract, however, practices effectively receive only £1.45 per patient to offer the service across networks.

This guide outlines what the service involves and how to run it across a network as efficiently as possible to benefit your practice.

What does it involve?

The requirements remain largely the same under the new contract: 30 minutes of extended hours coverage per 1,000 patients per week. Extended hours is defined as falling outside of the core hours of 8.00am and 6.30pm. 

Practices that close for half a day each week are not allowed to participate. Critically extended hours is a separate entity to the seven-day extended accessschemes commissioned locally by CCGs, so your local Saturday morning hub run as part of that scheme will not count towards the Extended Hours DES. Extended hours lost to bank holidays and annual or sick leave need to be provided elsewhere in the week.

Any healthcare professional can provide extended hours appointments – indeed, our practice offers phlebotomy appointments with a healthcare assistant from 7:20am to 8:00am, three days a week. GP registrar appointments can be counted, too. We have four registrars, each offering thirty minutes of extended hour capacity on a Monday evening alongside two trainers.

Appointments must be provided in continuous blocks of 30 minutes minimum, and the practice must be open during these hours. Reception costs will need to be factored in, which is one reason we have a large number of clinicians offering our quota of appointments in two 1-hour evening slots each week.

A minor change in wording from the 2017/18 specification clarified that you no longer have to exclusively provide face-to-face appointments during extended hours.  The Network DES contract specifies ‘a reasonable number of these appointments face-to-face, with the rest provided by telephone, video or online consultations or a mixture of these methods’.

Remember, this guidance applies across the network rather than at a practice level; there may still be scope to offer what works best for you and your patients (for us, this is telephone appointments for GPs, minor illness with GP registrars, and phlebotomy with HCA), but it may be necessary to clarify the acceptability of your plans through dialogue with your PCN colleagues.

How to set up your service

A good starting point is to calculate the number of hours you will need to provide over the course of a year. Next I would reach out to all staff (clinical and reception/admin, as the desk needs to be manned during extended hours) to determine whether anyone has a strong desire to provide extended hours; it may be that someone would prefer to start later and finish later on a particular day. We were surprised that our HCA preferred to start at 7.20, but it made offering the necessary hours so much simpler.

To account for bank holidays and annual leave, we purposefully offer an excess of hours each week. In order to avoid debates about workload inequity, all doctors provide an equal share of extended hours. A senior receptionist logs the hours and is aware to flag up any potential shortcomings in advance. These are subsequently submitted and our practice manager monitors our accounts to ensure appropriate payment has been received.

In our practice we offered a range of appointment types to suit our population needs. Early phlebotomy appointments have been useful for both patients who work and elderly patients who rely on working relatives to bring them to surgery. GPs offer pre-booked telephone appointments, while GP registrars offer on the day minor illness appointments.

Extended hours are quieter than usual for reception staff. This allows them the opportunity to manage tasks, arrange recall appointments, and add clinical sessions to our EMIS system, free from the pressures of answering the telephones.

Funding

Prior to introduction of Primary Care Networks (PCNs), around 75% of practices had signed up to provide 30 minutes of extended hours coverage per 1,000 patients every week.

The payment of £1.90 per patient made this one of the better remunerated enhanced service, earning a 15,000 patient practice around £28,500 income per year.  When the terms were lifted to allow telephone or online video consultations it also became slightly more straightforward to deliver.

From July, however, delivery of the Extended Hours DES now falls under the remit of the networks themselves.  While practices can still choose to opt out, each network has a responsibility to provide coverage to 100% of its patients. 

This increase in provision effectively means a reduction in funding from £1.90 to £1.45 per patient for those practices taking part.² Although the BMA GP Committee has insisted that practices will be receiving an additional £30m for the extra patients covered through the global sum, the reality is that some of that funding is tied to provision of the direct access appointments for NHS 111.

Collaborating with your network 

The unnecessary complexity over funding will mean some challenging negotiations between network practices choosing to provide extended hours and those not. In theory, the BMA GP committee argument suggests practices that have received money earmarked for extended hours in the global sumshould be contributing financially to provision of extended hours for their patients.

So the biggest challenge – for practices and networks alike – will be how to manage situations that arise when one or more constituent practices chooses to opt out. This may arise from the outset or at some point down the line, and how it’s managed will require meetings, negotiation, and votes.

Of course, some more entrepreneurial practices may transform this into an opportunity to boost income by providing additional hours for patients from neighbouring practices. Obviously their fee would need to be costed up appropriately, as additional work will require more staffing, room availability, and access to the practice’s records.

Summary

• The extended hours DES now requires 100% network coverage. This adds a layer of complexity if some constituent practices still want to opt out.  Encourage neighbours of the benefits of joining in (and indeed the organisational headaches of not participating), and ensure early and clear agreements are made about funding if practices elect not to take part.
• Remuneration is broadly similar if you factor in the global sum increase.
• Keep reception staff costs down by minimising total hours of extended opening. This can be achieved by clinicians offering extended hours appointments in the same short windows.
• Don’t forget to make up for lost sessions due to bank holidays and leave – one way to achieve this to routinely provide a few extra hours every week

Dr David Coleman is a GP partner in south Yorkshire

References

1. NHS England. Network Contract Directed Enhanced Service – Contract specification 2019/20. April 2019

2. Legraien, L. Networks to receive 45p per patient less through DES for providing extended hours. Pulse; April 2019.