Could shared medical appointments help the NHS and patients?

In medicine, the private one-to-one consultation is sacrosanct.

Yet shared medical appointments have been used successfully for years at the Cleveland Clinic in the US. Patients appreciate them. They compare experiences with other patients, learn from their questions, gain more advice than they might otherwise, and improve their understanding of their symptoms.

For the hospital, the gains are seen in improved outcomes, higher patient satisfaction, dramatically reduced waiting times and lower costs.

Here, then, is an innovation that could help the NHS, caught between rising demand and squeezed budgets, which is leading to longer waiting lists and growing discontent. By sharing appointments, more patients could be treated more quickly, reducing waiting times, saving costs, yet raising standards of care.

They have been tried by GPs in Edinburgh, Sheffield and Newcastle, following the lead of doctors in the US and Australia. As a surgeon, I can see the potential benefits in bringing together patients undergoing the same procedure for pre- and post-surgical care.

Shared appointments are not appropriate for all patients or all conditions. They should always be offered, never imposed, and patients would always retain the option of a one-to-one consultation, if that was what they preferred. There might, however, be trade offs. Patients might be offered a one-to-one consultation in four weeks or a shared appointment in 48 hours.

They can yield real benefits in the routine care of chronic illnesses such as asthma, diabetes and heart disease, where patients can learn from and motivate each other. We already know the secret of Weight Watchers’ success lies in creating peer pressure among group members who compete to see who can shed most pounds. Alcoholics Anonymous similarly allows people to share a problem and begin to tackle it together. There are websites such as PatientsLikeMe which connect people to others with similar conditions.

However, shared medical appointments work differently from self-help groups. Each patient is examined by the doctor, diagnosed and prescribed treatment in exactly the same way as they would be in a one-to-one consultation. The benefit for the patients comes from observing how the other patients are managed, or manage themselves. In one example, a patient with heart disease was persuaded to get on an exercise bike by hearing about a teenager with a heart condition who had a passion for basketball.

The doctors are spared having to repeat the same information a dozen times a day, saving time and costs. Whereas a heart patient might require a half-hour appointment for a routine follow-up visit, with a shared appointment six or seven patients could be seen in 90 minutes.

In certain cases, only part of the appointment might be shared. For example, in a typical shared appointment for female patients at the Cleveland Clinic, the doctor performs breast and pelvic examinations and discusses test results in private, while the remainder of the appointment includes the other patients.

Given these benefits, it is surprising that shared appointments have not been taken up more widely. In an article in the New England Journal of Medicine, Professor Kamalini Ramdas of London Business School and I suggest there are four principal reasons: the lack of rigorous scientific evidence of their value, the absence of easy ways to pilot them, missing incentives and lack of awareness among both patients and clinicians.

There is another reason. Innovations in healthcare typically take 17 years to spread, from proof of principle to widespread uptake. And this is an average – some take decades.

We need smart ideas – and disruptive innovators to implement them – if we are to improve the outlook for patients and for the NHS. Shared appointments is an idea worth pursuing.

Lord Darzi is a surgeon and director of the Institute of Global Health Innovation at Imperial College London. He was a Labour health minister from 2007–09.

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Could shared medical appointments help the NHS and patients?

Why are GPs having to beg for appointments to get their patients treated in hospitals?

Ever wondered why it sometimes takes ages for you to have an ailment treated? Mavis is wondering. She has been waiting for weeks to have an infected scar checked, after the removal of a cancer, but was referred back to the wrong hospital much too late, even though her GP had begged for an appointment asap. And Rosemary’s GP asked for investigations into a worrying ailment last April, but her request was returned twice, with a demand for more information, but no explanation about exactly what information, confusing and enraging the poor GP.

Could these hold-ups be caused by third-party scrutiny by a clinical commissioning group (CCG)? Your GPs or consultants can’t just refer you for surgery themselves any more. They must first beg a CCG for your procedure, explaining why you, in particular, need treatment, especially if it’s some minor thing, no longer routinely NHS funded: a knee/hip replacement, hernia, varicose veins, cataracts, or a chalzion cyst on your eyelid, because after all you won’t die without treatment, even if your cyst is like a big boil, eye “out like you’ve done a couple of rounds with Mike Tyson”, as one man put it on Radio 4’s Inside Health, even if you can barely see, and it hurts. You’ll live. So the CCG (32% privately run) may say no, or send you somewhere for a “holding test”, or back to outpatients, or ask more questions, which all often costs more than the procedure would have done if they had just got on with it straight away.

This is all getting a bit scary now that my peers and I are going physically down the pan. If the CCG’s weren’t that fussed about Rosemary’s worrying mystery ailment and Mavis’ cancer, what hope for hips or eyelids? We’ll have to all limp around blindly and in horrible discomfort until we are nearly dead. And I have rather worrying pains in my hips. Should I join the replacements queue now? It is rather long already. I have a friend who has been in it for months, after years of waiting for permission to see the consultant who could tell him he ought to be on it. Is there even a queue to join any more?

Why are GPs having to beg for appointments to get their patients treated in hospitals?

Charges proposed for out-of-hours GP appointments in England

Patients could face paying their family doctors for out-of-hours appointments and minor procedures that fall outside the surgery’s contracted NHS work, under new plans being proposed by some GP leaders.

The scheme would see doctors use their own time to treat and charge patients and involve the setting up of a third-party company to manage the payments to GPs.

Dr Prit Buttar, leader of Oxfordshire’s local medical committee (LMC), told Pulse magazine there had been discussions with LMCs across England about rolling out the system nationally by the end of 2017.

The move is driven by anger among GPs about the amount of money put forward for general practice by the government. Buttar said it was essential to look at alternative ways of funding that allowed practices to still operate within the rules.

He added: “They will offer practice services, for example, if someone wants a minor operation but can only do this in an evening, then they can do this by charging a small fee.

“It will allow GPs to value their own time more and puts pressure on the government. The government is a monopoly customer, they can dictate how much they are willing to pay.”

GPs would be able to provide private services to their own patients through the third-party company, which would deal with the doctor-patient transactions.

LMCs are made up of NHS GPs and represent their interests locally and nationally, and work with the British Medical Association’s (BMA) general practitioners committee (GPC).

Last year, LMCs called on the GPC to hold a ballot among GPs for mass resignations from the NHS unless the government came up with more funding, but the GPC has said it would not ballot members due to promising negotiations with NHS England.

A spokeswoman for NHS England reiterated that GPs could not charge patients for accessing normal NHS services, such as routine appointments, but said nothing about family doctors possibly levying fees for private care.

She said: “All patients have a right to access high quality primary care services which are free at the point of delivery. Strict safeguards are in place to ensure that GPs cannot charge patients for NHS services.”

Some GPs – who are not employed directly by the NHS – already charge patients for writing letters for them relating to, for example, insurance claims or holiday vaccinations.

The BMA insisted the plans set out by Dr Buttar were “not a BMA proposal” and described them as “clearly not fully developed”.

Dr Chaand Nagpaul, BMA GP committee chair, said: “All GP practices are contracted to provide free care to every patient irrespective of their financial ability to pay. This is a key cornerstone of the NHS, which the vast majority of doctors support.”

Nagpaul said GPs were not allowed to charge their own patients for private services that were not available on the NHS, including minor surgery to remove benign lumps. He said the immediate priority for Downing Street was tackling a severe shortage of several thousand doctors and the spectre of 300 surgeries facing closure.

A BMA survey found eight out 10 GPs said they struggled to provide safe, effective care because of heavy workload.

Charges proposed for out-of-hours GP appointments in England

Patients forced to make appointments to boost profits, says Labour MP

Healthcare provider Virgin Care has been forcing patients to attend extra appointments to boost profits, says former employee and the Labour MP for Dewsbury, Paula Sherriff.

Speaking in the House of Commons, where she had been granted the first question to the prime minister, and where her words were protected by parliamentary privilege, Sherriff accused Virgin Care of insisting on, “extra consultations before surgery, boosting their profits at the expense of the taxpayer, and patient safety”.

Before she stood for parliament, Sherriff worked in Virgin Care’s dermatology service, in West Yorkshire. She claims patients were obliged to book a second, follow-up appointment before receiving treatment – for a suspect mole, for example – when the NHS would previously have carried out the same work in a single booking.

She told the prime minister this was “amongst many unethical practices” she had witnessed. The process of “double appointments” allows Virgin Care to levy the £100 to £150 appointment fee from the NHS twice, Sherriff said.

The MP, who has made a name for herself in her short time in parliament by campaigning against the so-called “tampon tax” on sanitary products, believes the outsourcing of NHS work increases costs, and produces worse outcomes for patients.

Virgin Care, which is part of the Virgin Group, has the contracts to carry out over 230 NHS and social care services, from running GPs’ surgeries to providing healthcare in prisons. Virgin bought up private healthcare provider Assura Medical in 2010 to capitalise on the fast-growing market in healthcare.

The prime minister replied that it was the last Labour government, not the Conservatives, that had significantly increased privatisation in the NHS.

Patients forced to make appointments to boost profits, says Labour MP

NHS to have one website for appointments, prescriptions and advice

A one-stop NHS website where patients book appointments, order prescriptions and access medical advice is being developed, health officials have announced.

For minor ailments patients will be able to check their symptoms online and read up on all manner of diseases.

The NHS.uk website will also enable patients in England to register with a GP and download their own medical records.

Patients will also be able to compare how well their local health service performs against others for areas including cancer, dementia, diabetes, mental health, learning disabilities and maternity care.

Information about individual trusts performances on dementia, diabetes and learning disability services will be published through the MyNHS website immediately, with more information added in the autumn. This data will be taken in to the NHS.uk site at a later date.

The NHS.uk system, which is hoped to be ready by the end of next year, will offer a new online triage system for the NHS’s 111 service. Patients will be able to enter symptoms online and get tailored advice or a call-back from a healthcare professional, a Department of Health spokeswoman said. The triage system is being developed with patients and clinicians and will be trialled before it is available for the general public to use.

The move, which is to be announced by the health secretary, Jeremy Hunt, at the NHS Expo event in Manchester, aims to give the smartphone generation easier access to NHS services. “We live in the age of the smartphone and we want the NHS to reflect that,” Hunt said.

“Our new plans will make it easier for patients to get the medical support and information they need, and should encourage more of us to use the growing range of online NHS services available. This is a way of supplementing patients seeing their doctor in a more conventional, face-to-face setting, and crucially it will give people more choice and the opportunity to access healthcare in a way that works for them.”

The announcement has been made at the same time as a review of IT in the NHS is published. Prof Robert Wachter was commissioned by the Department of Health to look at the English healthcare system’s approach to IT.

He made a series of recommendations to help the NHS, including highlighting “exemplar” NHS trusts that are leading the way. Prof Wachter said: “The NHS is a gem – delivering excellent outcomes at costs well below other international systems such as those in the US. However, for it to continue to provide a high quality and accessible service for staff and patients it simply must digitise. The one thing that the NHS cannot afford to do is to remain a largely non-digital system – it is time to get on with IT.”

Responding to the review, Hunt said he will make 12 trusts exemplars, so others can learn from their experience. He also outlined plans to introduce an academy dedicated to training NHS staff in digital skills.

In the past UK health leaders have been heavily criticised over a failed multi-billion-pound IT system. Ministers shelved an ambitious scheme, designed to create electronic patient records for use across the NHS in England, in 2011.

NHS to have one website for appointments, prescriptions and advice

GP appointments should be five minutes longer, says BMA

GP appointments should be extended to 15 minutes because an ageing and increasingly overweight population means that many patients need extra time at the doctors’ surgery, according to the British Medical Association (BMA).

The standard slot currently stands at 10 minutes but the BMA GPs committee (GPC) believes that increasing the length of appointments by 50% would allow for improved decision-making and service, as well as reducing the administrative burden for doctors outside clinic hours.

In order to lengthen the contact time, the BMA says, in a report published on Monday, there should be a reduction in the number of patients each GP has to see every day. Dr Brian Balmer, who is on the GPC’s executive team, said: “In a climate of staff shortages and limited budgets, GP practices are struggling to cope with rising patient demand, especially from an ageing population with complicated, multiple health needs that cannot be properly treated within the current 10-minute recommended consultation. Many GPs are being forced to truncate care into an inadequate timeframe and deliver an unsafe number of consultations, seeing in some cases 40-60 patients a day.”

He said this was well above the 25 consultations a day recommended in many other EU countries. “We need a new approach that shakes up the way patients get their care from their local GP practice,” he said.

Until April 2014, GP appointments in England were fixed at 10 minutes. The requirement was dropped following a negotiation with doctors’ leaders. The length can be varied but it remains the standard: the NHS Choices website tells patients they should expect doctors to spend an average of 8-10 minutes with them.

Based on a widely accepted formula of 72 appointments per 1,000 patients each week and an average list size of 1,600 patients, the report, Safe Working in General Practice, proposes that GPs should be offering 115 appointments a week – an average of 23 a day over five days.

The committee is not suggesting doctors suddenly slash the number of appointments but said the health service should be aiming for this target to enable patients to get proper care. Its members did say more government money would be needed to fund longer appointments but did not say how much – although the likely expense will make the idea of longer appointments difficult to achieve.

Dr Zoe Norris, a GP locum, said the current 10-minute appointment might be just enough for a fit and healthy patient with a single condition but even then the time taken for them to enter the room, talk about their problem and then be examined added up. “As soon as you throw anything unusual into the mix you’re scuppered,” she said. “That might be you have got a complex patient, you might have a patient who needs help getting undressed. There’s no time to do the preventative things you need to do. It’s heartbreaking. I feel as though I’m doing half a job.”

Nevertheless, she said there was a reluctance to cut patients short, which led to GPs working 14-hour days.

The GPs committee said it would be possible to achieve greater efficiencies, helping fund longer appointments by linking together several surgeries into hubs, allowing them to work together to manage demand.

A report by the NHS Alliance and Primary Care Foundation published last year estimated that 27% of GP appointments could be avoided through greater integration, use of a wider primary care team and improved administration.

But Balmer is adamant that increased government funding will still be necessary. “More GPs must be put in front of patients so that the number of consultations per GP a day falls to a sustainable level,” he said. “General practice cannot be allowed to continue being run into the ground: it’s time for positive change that gives patients the care they deserve.”

An NHS England spokesman emphasised it no longer required appointments of a fixed length: “How long to allocate to individual patient appointments is at the discretion of individual GP practices, based on patient need, and there are no national limits suggesting 10 minutes should be the norm,” he said.

GP appointments should be five minutes longer, says BMA

NHS can"t afford "utopia" of 7 day a week appointments, medical doctors say

Nonetheless he said the wellness services was concentrating on enhancing urgent and emergency care at the weekends.

After this was in spot it would ‘inevitably’ lead to a lot more program care getting supplied, he mentioned.

Dr Bruce Hughes, a member of the BMA’s GP committee, attacked the idea of a ‘seven day a week utopia which is just for the sake of a political gimmick’.

He said politicians have been creating wellness policy using soundbites.

The program was ‘a pathetic try to get re-elected in twelve months’, he said.

He additional: “You do not count on regimen appointments with your lawyer or accountant on Sunday evening.”

Krishna Kasaraneni , a Midlands GP, said: “Both GPs and secondary care need significant investment before any suggestion of program care is considered. If not it will not only lead to closures of hospitals but also of GP providers.”

Psychiatrist Prof Reinhard Heun, proposing a motion that 7 day regimen and elective services ‘is not feasible within recent NHS budget contraints’ mentioned that physicians would want a raft of assistance providers at weekends which would demand significant investment.

He extra: “You may possibly have to make use of far more people and at times you would have to pay a premium to get folks motivated. Individuals have further costs linked with working the weeknd.”

His daughter who was hoping to enter medication but who also desired a family members was concerned that weekend operating was ‘not family friendly’, he said.

Dr Robert Harwood, an anaesthetist and member of the BMA’s consultant’s committee, stated: “We have actual reservations about what can be afforded.

“Most medical doctors are fairly supportive of offering extra urgent and emergency care if that is needed. What they are clear on is that they never want to give schedule and elective care at weekends just for the sake of it.”

He stated the health support wsa ‘unlikely to be ready to afford it’.

Dr Harwood extra that some hospitals could be forced to near in purchase to transfer employees to fewer, more substantial hospitals to provide 7-day rotas. “There could be some degree of reconfiguration of services. You would want fewer hospitals simply because of the want to focus personnel,” he mentioned.

A spokesman for NHS England stated: “Individuals need to acquire large good quality care each time they require it, and we agree with the numerous medical professionals who are functioning to make certain urgent and emergency care standards are the very same on weekends as the rest of the week.

“NHS England is delighted so a lot of medical doctors and nurses support moves to guarantee senior determination makers are offered to assess and treat patients anytime they need it.”

NHS can"t afford "utopia" of 7 day a week appointments, medical doctors say

GPs vote towards charging individuals for appointments

GPs at the BMA annual regional health-related committee conference back portion of the movement that says ‘general practice is unsustainable in its present format’. Photograph: RayArt Graphics/Alamy

GPs have voted towards a proposal to charge sufferers for appointments in a bid to assist money-strapped surgeries.

A motion advocating expenses was defeated at the British Healthcare Association’s yearly regional healthcare committee (LMC) conference in York on Thursday. GPs, nonetheless, backed part of the motion that stated “basic practice is unsustainable in its recent format”. A large quantity of GPs queued up to examine the proposal, with twice as numerous wanting to communicate to oppose it as to back it.

London-based GP Dr Laurence Buckman, a former chair of the BMA’s standard practitioners committee (GPC), described the proposal as harmful.

“We do not control demand by producing individuals pay,” he explained. “You then get survival of the richest.” He stated the proposal, if adopted, would lead to reduce pay for GPs, who would be anticipated to prime up their earnings with fees paid by sufferers. The present chair of the GPC, Dr Chaand Nagpaul, also opposed the motion, arguing that it would lead to a less equitable NHS. “In the United kingdom we don’t tax sickness, that is what charging would do,” he said.

But Dr John Grenville, from Derbyshire, mentioned supporting the movement would give the government a essential “kick up the backside”, incorporating: “It grieves me to have to communicate in favour of this motion but we have heard an awful whole lot about what is incorrect with the NHS and general practice.”

Dr Lee Salkeld, from Avon, also favoured the movement, arguing that charging would facilitate much better entry and longer appointments.

The most contentious part of the five-element movement proposed by the BMA’s Avon LMC called on the GPC “to discover nationwide charging for common practice services with the Uk governments” and was not passed. But a less contentious element that criticised the “inadequate help for several practices” was carried by delegates. The motion did not specify a charge but a fee of £25 was believed to be under consideration.

There has been a growing clamour for folks to be charged for utilizing some NHS companies, amid worries that the standing quo is financially unsustainable. Former Labour overall health minister Lord Warner, who served under Tony Blair, has proposed that absolutely everyone pay out a £10-a-month NHS “membership charge” to save it from sliding into a decline. The King’s Fund has stated charges for hospital and GP appointments may need to have to be launched. But health service campaigners have expressed alarm about the affect charging would have on accessibility.

The Department of Well being stated prior to the vote that it was “definitely clear that the NHS should be totally free at the point of use, and we will not charge for GP appointments”.

Motions to charge for GP providers have been rejected by the BMA in prior years. A ComRes poll in March discovered that even though one in 4 (27%) men and women mentioned they would be ready to pay out £10 to visit their GP rather than see the practice shut down, far more than double that – 56% – had been towards any charges.

GPs vote towards charging individuals for appointments

GPs must be ashamed of patients" waits for appointments

GPs should behave far more like actual enterprise people, and find out the disciplines which stability assets with sustaining great buyer support, argues Dick Vinegar. Photograph: RayArt Graphics/Alamy/Alamy

Doctors’ leaders are always moaning that the profession is overstretched and underpaid, is at the finish of its tether, and is about to up-sticks to Australia en masse, exactly where the government treats its doctors with respect. But, when I check out my GP’s surgical treatment, all is calm. The staff welcome me with a smile. It is clear to me that they perform quite tough, and operate prolonged hours, but they present no signs of stress or imminent breakdown.

Why, I inquire myself, is there this gap in between the rhetoric, and what I knowledge as the actuality? Is it that the medical doctors, nurses and receptionists who treat me are consummate actors, hiding unbearable amounts of tension, and managing to child me that my symptoms are all that matter to them?

Or is it that the noisy “politician” GPs, who attend conferences and pass motions condemning any stage government can make in any direction at all, particularly the ones that motivate them to adjust their 19th century doing work routines, are not extremely excellent at managing their time or their budgets? They are abetted by GP columnists and correspondents in the trade press, who all seem to be to be on the verge of boarding a plane to depart the country, since of disgust with the NHS.

Obviously, these doctors need courses in time management and resource allocation. Or they ought to employ much more personnel, to lessen tension amounts. Or they must organise much more effective rotas, to remain open longer. Or, dare I say it, they might even pay out themselves less to shell out for the extra staff.

GPs pride themselves on currently being not just clinicians, but independent company men and women. They should behave far more like true business folks, and learn the disciplines which stability assets with keeping a great buyer – ie, patient – services. They may well then grow to be more like my productive GP practice.

It seems to me that some GP practices have permitted their standards to slip. They are now in a spiral that they can not get out of. Consider accessibility, for illustration. I usually get an appointment on the day I ring. But I study in the Guardian that “the proportion of individuals acquiring a GP appointment in 48 hrs has fallen from 80% underneath the final Labour government to forty%. Almost a quarter of individuals now can not get an appointment in the identical week.”

Possibly I have been spoiled by the excellent service I get from my GP, but I wonder how can anybody who calls themself a physician not be ashamed by this kind of a delay in providing his individuals with care? Possibly undesirable routines have crept up over time, and a week or two weeks have come to be regarded as an acceptable norm. So a lot so that I study that Ed Miliband’s daring promise to ensure individuals a GP appointment inside 48 hrs “is likely to be deeply unpopular with medical doctors”. So, these medical doctors are so wedded to their accessibility delays, that they reject an inititiative that is good for their patients.

Why can not the badly-performing GPs get suggestions from family medical doctors, like mine, who do offer their patients an sufficient booking service? Physicians do seem to be to be reluctant to understand good practice from one yet another.

And, why don’t individuals of individuals medical doctors with appalling waiting instances rebel, and move to yet another practice with shorter waits? To assist individuals decide on the prompt GPs, the “selection” web sites like Patient Opinion could publish appointment waiting times for personal GPs. That would title and shame the poor performers. And boost patient electrical power.

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GPs must be ashamed of patients" waits for appointments

Doctors" surgeries to offer out-of-hrs appointments and Skype checkups

The scheme will give funding for more personalised care for 800,000 elderly and vulnerable individuals. Photograph: Alamy

1 in ten surgeries are to offer sufferers the selection of seeing a GP at evenings and weekends, reserving appointments on the web, getting electronic prescriptions and having checkups more than Skype, David Cameron will say on Monday.

The prime minister unveiled the £50m scheme in October amid fears that also many men and women are turning up to A&ampE when they can not get appointments with their GP, placing too much strain on emergency departments.

Medical professionals have been invited to apply for funding, and demand for the money indicates seven million patients at far more than 1,a hundred practices – rather than the 500,000 sufferers envisaged – will benefit from the trials from up coming month.

Nonetheless, Labour raised concerns that the vast majority of folks nevertheless have unacceptably lengthy waits to see their GP because the government eliminated a requirement for individuals to be noticed within 48 hrs.

Andy Burnham, the shadow well being secretary, mentioned it had become a lot tougher to get a GP appointment under the coalition.

“The big difficulty with this new strategy is that it will not benefit hundreds of thousands of people,” he stated.

“For the huge bulk who are outdoors of this scheme, items will carry on acquiring worse and they are being told to assume to wait a week for a GP appointment.

“No wonder more and far more individuals are turning to A&ampE, which has just had its worst year in a decade.”

Beneath the ideas, a lot more surgeries will offer seven-day opening and 8am-8pm appointments. There will also be greater use of Skype, email and telephone consultations for those who would uncover it easier.

There will also be funding for more personalised care for 800,000 older and vulnerable individuals, who will get a lot more assist, a named GP responsible for their care and very same-day access to a GP when they need it.

Cameron will say: “Back in October, I said I wanted to make it less complicated for folks to get appointments that fit in all around a hectic doing work week and loved ones commitments.

“There has been a fantastic response from doctors, with plenty of innovative suggestions, and we will now see more than seven million sufferers provided weekend and evening opening hrs, alongside a lot more accessibility to their family members medical doctor on the mobile phone, by means of e mail or even Skype.”

Simon Stevens, chief executive of NHS England, said the plans would assist totally free household medical doctors to spend much more time with their sickest patients.

Dr Chaand Nagpaul, chairman of the British Healthcare Association’s GP committee, explained the government should be cautious that additional accessibility to surgeries is not supplied at the cost of availability for the most vulnerable.

He additional: “Outside of individuals signed up to the pilot, there will even now be close to seven,000 GP practices across the country who will not be obtaining extra support to improve patient entry or keep existing solutions. Furthermore, given that this funding is only for a single yr, there is no assurance of these changes becoming reasonably priced in potential many years.”

Doctors" surgeries to offer out-of-hrs appointments and Skype checkups