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General Practitioners: Appointments

Volume 769: debated on Thursday 17 March 2016

Question for Short Debate

Asked by

To ask Her Majesty’s Government what assessment they have made of how quickly an economically active patient should be able to secure an appointment with their GP and how that compares with other professions.

My Lords, the Committee will recall the fabulous opening ceremony for the 2012 Olympics held in London and its NHS component. Interestingly, some young indigenous Brits take for granted our fabulous health service, free at the point of delivery. They do not really appreciate how clever we have been as a nation, but hard-working immigrants from other countries certainly do. We have much to be proud of and I salute the efforts of all those involved. Our European partners have a variety of health systems that appear to work for them. However, you have only to look at the political challenges with the health system in the United States to see the problems that we have avoided and to understand that their healthcare costs are considerably higher than ours. There is no doubt that the NHS is very good if you are seriously ill, which is one reason why I am not the slightest bit interested in private healthcare. However, we would be deluding ourselves if we denied that we have some serious difficulties with the NHS; the most obvious are A&E and ambulance services, but I want to concentrate on GP services, although they are related.

I recently had to move house from one parish to an adjacent parish, but which was in a different GP catchment area. My original surgery was co-located with a rather good convenience store and the nearest ATM to my house. The surgery met all my requirements, I never had any difficulty in securing an appointment when I needed one, and the practice premises were purpose-built and relatively new. My new surgery’s building is old and small and there was local evidence that appointments could be a problem, probably due to increasing demand from a growing and also ageing population. Your Lordships will not be surprised to hear that I did not want to register at that new, nearest surgery but I was told that I had to. I am sorry to say that my worst fears were realised. The administration of the surgery was relatively poor from the start. Clearly not all practices operate to the same standard—though I hope that my noble friend Lord Bridgeman will describe to the Committee how a good practice works.

Worse still, several weeks ago now, I developed some slightly worrying symptoms. However, my judgment was—correctly—that I was not an urgent case and I was not prepared to claim otherwise. Unfortunately I could not secure an appointment at all. Given that men are notoriously bad at presenting with unpleasant symptoms, how can it possibly be right to deny a patient an appointment with the doctor? The fact is that people who are fit, well and working ask to see the doctor only when absolutely necessary. All they need is a bit of maintenance from time to time to keep being productive and generating the money needed to fund the NHS.

Before suggesting to the Committee what is going on, I want to make it clear that I fully appreciate that GPs have to deal with a wide range of patients, many of whom have serious conditions or are even terminally ill. I feel that practices fall into the trap of believing that they are providing a service to a certain standard and that patients should be grateful for what they get. Surgeries do not regard themselves as being competitive, which means that there is no mechanism for them to individually determine the appropriate level of service, although no doubt they try hard. It also means that they cannot determine what services to offer or how to provide them.

Take the appointments issue. Suppose I rang my solicitor’s office and said that I had had a fairly worrying meeting with another businessman who claimed that I was infringing his patent. I do not think that the solicitor’s office would say, “Well, we have no appointments available for the next two weeks. Try again next Monday, but make sure you ring early because the available slots go quickly”. I suggest that any professional services outfit with that sort of ethos would not stay in business very long. I have to tell the Committee that that is exactly what I experienced with my new GP surgery and I doubt that this is unusual. This is why my Question compares GPs to other professions.

Or take blood tests. GPs no longer seem to take blood samples. A separate appointment has to be made, either with the practice nurse or with a local hospital. This is fine if one is retired, but if one is working it is another appointment to be made which conflicts with economic activity. It also tends to lower productivity, which we know is a general UK problem. I have not been to an A&E department for many years, but it seems to me that the majority of walk-in patients could equally well be dealt with by a GP surgery, and far more quickly than the four-hour target, which is itself an admission of total failure. At present, GP surgeries do not market themselves for that business because they do not need to.

Surely, a practice in a competitive environment would say, “Why wait at least four hours in an A&E department for a minor injury when, if you were registered with us, you could be on your way within an hour?”. I am not suggesting for a moment having mini-A&E centres. Serious injuries and life-threatening conditions are clearly a matter for a large A&E department with the appropriate range of facilities.

Since the time when I was forced to change my GP the rules have changed, I am pleased to say, and with certain, sensible caveats one can register with whichever surgery one wants. I am pleased about this but there is still no evidence of any commercial competitive pressures between GP surgeries. I hope the Minister can tell the Committee what, if anything, he is doing to introduce competition between GP surgeries. Does he see this as being important, so that economic output is not lost due to a GP service that does not suit busy working people, especially if they work a long way from home? Does he agree that GPs should be doing more to relieve the unnecessary load on A&E departments?

My Lords, I am extremely grateful to the noble Earl, Lord Attlee, for bringing this important subject to debate. I fear that it is now widely acknowledged that the situation in primary care is dire. However, I have to say that my own general practice seems to be an exception; perhaps because it is in leafy Hampstead, perhaps because it has enough partners and staff to withstand the buffeting of the rest of the NHS, and perhaps because it has such excellent leadership. Or, most likely, because it has all three. Elsewhere, in much of the country, general practice lacks all three and the picture is less than rosy. Many practices are small, with two or three partners, and if one goes off sick, retires early or goes abroad, the remaining one or two are stuck in an almost unsustainable situation.

One young GP I know is struggling with just such a burden. She is about to lose her partner, who is retiring early, and she is now running her practice with little or no support. She is finding it impossible to attract any staff to join her and cannot find another GP to come into her practice. There are just too few around who want to work in a less than affluent part of London, despite the Government’s blandishments. It is very hard for her to find other staff too. Meanwhile, she is running around, sitting on committees and the local CCG, as well as dealing with the mound of NHS-inspired paperwork and trying to look after her young family at the same time. Working from eight in the morning until eight at night is an impossible burden to place on anyone. I fear that that is the experience of far too many GPs and it is not much wonder that too many are leaving early and too few are willing to join.

It is absolutely vital that the Government rethink their efforts to encourage and support GPs. Whatever they are doing now is clearly not working properly. Of course, every area of the NHS is suffering from underfunding but primary care, once the beacon of the service, is now merely a flickering candle. If there is anywhere that the NHS needs to see reignited, it is primary care. Of course, a move to larger group practices, with added support, where that can be achieved, would help. But too many practices are too small at the moment. Some GPs gain comfort from being salaried rather than self-employed. That at least cuts down their administrative burden. If it can be made a more attractive option—something the Government might pursue—it offers advantages to some.

Finally, I will say just a few words about research in primary care. I express my interest as scientific adviser to the Association of Medical Research Charities, an organisation whose member charities well understand the valuable role that GPs can play in research. But at the moment too many GPs are so stretched and overworked that there is no way that they can even think about research in the face of everything else they are asked to do. If we are to achieve what Ministers, the Chancellor and even the Prime Minister have spoken about, which is to embed research in the NHS as a major function, and if we are to see what is mandated in the Health and Social Care Act 2012 on making research an inextricable part of the NHS, we are going to have to give GPs all the support necessary for them to be able to fulfil their part. We are still way off that and if, as I understand it, NHS England has not even signed off its research strategy for last year, never mind this year, what hope do we have that we will see any change here? Is there anything the Minister can do to persuade NHS England to do more to support research in primary care and, incidentally, stimulate it into publishing its long-awaited research strategy?

To return to the main thrust of my remarks, is there anything the Minister can do to persuade the Government to look at how we can get general practice out of the black hole it is heading for before it is too late?

My Lords, I declare my interests as in the register. There is of course much controversy at present concerning what I will call the Government’s preoccupation with the weekend working practices of junior hospital doctors but it seems to me that many people in need of medical support would have preferred the Government to keep concentrating on issues such as strengthening out-of-hours services for GPs and using modern technology to enable people more easily to interact with a GP.

Of course, much progress on these issues was being made prior to the general election and I am seeking some reassurance in this debate that that progress will continue. Just prior to the general election, it was announced that GPs in more than 1,400 practices across England would receive £550 million of government funding to reorganise their services so that surgeries could be open from 8 am to 8 pm, seven days a week. My good friend Norman Lamb, who was then the Care Minister, told me he hoped that some of this funding would lead to much greater use in those practices of patient consultations by videolink, email and telephone, together with a greater provision of online booking services. I hope that the Minister will be able to tell us about progress since that announcement last March.

That funding, however, was directed at slightly fewer than one in five GP practices in England so I hope that we might also hear more today about how the remaining 80% of GP practices can be supported in improving access for their patients. This is both very important in terms of improving patient care and essential if we are to avoid the crisis in our hospitals getting even worse. I would like to hear from the Minister about how the £250 million infrastructure fund, which was first announced in the 2014 Autumn Statement, is helping to improve and provide more integrated health centres and more use of technology. The Government’s press release at the time claimed that they would help to fund additional services, including on-site pharmacists, speech therapists, minor surgery and diagnostic tests. It was also intended to make it easier for GPs to return to the profession following a career break, encourage more medical students to take careers as GPs, and enable GPs considering retirement to work reduced hours in the interim. This timely debate will allow the Minister to describe, I hope, progress on these issues over the past 12 months.

However, we need to go much further and be much bolder in using new technology to improve access to GPs. Ten years ago I visited India and looked at the provision of health services in remote rural areas, where access to a GP, let alone a hospital, was bound to be extremely difficult. I was very impressed by the use of webcams in specially equipped vehicles that could tour rural areas and with the help of a trained nurse allow some basic tests to be undertaken and a face-to-face conversation to be held with a GP or even a consultant. This made me think about how we could do much more in this country, using new technology, to let people talk to a GP without necessarily visiting the surgery. As technology develops, those GPs or other people, including carers and family members, can monitor certain conditions remotely.

My own Fitbit tells me how many steps I have walked each day, and what my heart rate and my sleeping pattern are. While I do not wish to share this information with anybody else, it is easy to do so. I acknowledge at this point that it was active intervention by my own GP’s practice that led me to undertake a more active exercise regime and improve my own diabetic control. In time, I expect that my blood pressure and glucose levels will be monitored remotely by health professionals.

For some elderly or housebound residents, this could be a good way for GPs to help keep an eye on them without clogging up their surgeries, while enabling the professionals to determine properly whether or not an appointment is really necessary. At the moment, getting an appointment when needed is often very difficult. Getting access to a doctor at night is usually extremely difficult, but this was not always so. Something has gone wrong when people feel the need to turn up at A&E if they can or call an ambulance when they should really have been seen by a GP at a surgery or in their home.

These problems are well illustrated in the recent report by the Public Accounts Committee in the House of Commons, which highlighted the following facts. There are simply not enough GPs to meet demand. Deprived areas are particularly short of GPs and nurses. Finally, there is much variation in patients’ experience of getting and making appointments, with people who work full-time among those who are most disadvantaged.

It is also clear from that report that information about basic facts, such as services provided at GPs’ surgeries and the availability of those services, is sometimes difficult to obtain. The report also makes it clear that the Department of Health and NHS England do not have the data that they need to make well-informed decisions about how to improve access to general practice or where to direct their limited resources. In the long run, these issues come down to improving the way in which we try to do things, endeavouring to make efficiency savings. But without a doubt, funding is the major issue.

The results of the most recent general elections show people’s reluctance to pay higher levels of taxation and politicians’ reluctance to ask them to do so. This is in spite of the fact that people now expect a pension from the state for a much greater proportion of their lives than ever before; with this comes the probability of them needing greater provision of health and social care. Improving access to GPs and funding the health and social care services that we need may require the introduction of a hypothecated tax in future. I believe that all parties should be considering this option if they are to be honest about addressing these problems. I would welcome the views of the Minister on that.

My Lords, I, too, thank my noble friend Lord Attlee for initiating this debate. We heard from him that in his view the conduct of the practice of which he is now a patient leaves something to be desired. He has also been good enough to indicate that I might be able to sketch out for your Lordships a somewhat contrasting view. These two interventions, from my noble friend and myself, have not been co-ordinated; we only exchanged views two days ago.

I and my family are fortunate to be patients of a practice in central London which tells a different story. This practice has a walk-in surgery open for an hour and a quarter in the morning and two and a half hours in the evening Monday to Friday, with the exception of Wednesday evenings. I have never had to wait more than 20 minutes to see a GP. The practice has first-class support in practice nurses and receptionists. Repeat prescriptions can be requested online—this is now fairly common among GP practices. Significantly, and in many ways this is the acid test, the practice has some of the lowest referral rates to A&E in central London. In other words, more patients can be treated for minor ailments in the surgery without going to A&E. The cost of an A&E admission is approximately £80. Your GP is paid that same sum to have you for one year, so if you go to A&E for a runny nose that is the same money paid out again.

In 2006, under the GP settlement, practices could opt for PMS premium status where for extra work undertaken they received extra pay. On the whole the more enterprising practices—including the one where I am a patient—took advantage of this offer. Now I understand that the latest proposal from NHS England is for this premium to be substantially reduced or eliminated over a period of four years to bring the funding of PMS practices in line with the GMS practices that did not take advantage of the 2006 premium. It would be interesting to know if my noble friend Lord Attlee’s practice is one of the latter. It is policy to recycle the resultant savings thus made back to CCGs and through them to the practices within their groups. Where PMS practices are in a group with a substantial number of other PMS practices, the clawback available to CCGs will be considerable and as I understand it there will be significant funding available for improved services and financial support. However, PMS practices that stand virtually alone within their groups will not enjoy the same level of support. Note also that all funding deriving from the cutback to PMSs will be available to both PMS and GMS practices—a further subtle discrimination against the former.

Let me attempt to be constructive with three examples of welcome initiatives instituted by NHS England. The first is integrated care: a structuring for the patient to formulate with his GP a health plan. In my case, this involved an hour-plus session with the doctor—just think of that length of time being made available in an NHS practice. As I understand it, that model draws on experience in the US and elsewhere where patients with planned maintenance prove to be much less of a demand on healthcare services. This is being funded by CCGs, which are investing very considerably in it. It is a nation-wide initiative and much to be welcomed.

Another development in our part of London is the rapid response teams under the control of local health trusts but funded by CCGs. These consist of doctors, nurses and paramedics and I understand they are extremely effective in saving GPs in practice from having to leave their surgeries to answer emergency calls. The noble Lord, Lord Turnberg, suggested the damage caused by such calls in terms of the time of doctors in small practices.

Thirdly, I draw attention to the development of GP federations, where GPs join together in a unique and largely unprecedented way. These are set up as limited companies and their mission is to bid for services that hospitals may wish to contract out. Examples I know about are smoking cessation clinics, cardiograms, testing patients on warfarin for anti-coagulation and looking after airways disease—in short, widely disparate procedures. I think we can assume that in all cases there will be cost savings for NHS England and any profits made by the federations will be available to their GP shareholders.

I revert to the subject of my noble friend’s debate. My question for the Minister is how NHS England is to reconcile the very different standards that are emerging from this short debate. The challenge for NHS England is how to bring the less adventurous practices up to an acceptable standard without effectively dumbing down the forward-looking practices which, as I have tried to illustrate, have the potential to introduce new, co-operative practices with a substantial contribution to cost savings.

My own NHS practice reckons it will lose around £400,000, resulting in a cutback to the PMS premium over four years. From the resulting benefits that are to be made available by the CCGs to the practice, and I have given three examples, it is estimated that the practice will reduce the loss to about £200,000. Why should any loss be acceptable in this of all branches of healthcare? This is one branch of healthcare which is showing real initiative, particularly in regard to enterprise and its financial viability. Surely the NHS is in danger of killing the goose that lays the golden egg. I shall very much welcome my noble friend the Minister’s comments on that. I am in danger of mixing my metaphors, but general practice is one of the jewels in the NHS, which has been made clear by all the speakers today. Let the entrepreneurial practices not only be an example to their less-motivated colleagues but also lead the way in taking advantage of the imaginative developments that NHS England has initiated—but free from the financial penalisation that many practices are now facing.

My Lords, I thank the noble Earl, Lord Attlee, for allowing us to debate this very important question and congratulate him on the quality and range of his contribution, which was extremely interesting. I echo his initial comments about the value of the National Health Service. However, he also referred to the considerable challenges we face, not least the amount of money that is being made available. I note the comments that the noble Lord, Lord Rennard, made and I will be most interested in the Minister’s response to his suggestion that we need to move to hypothecated taxation. Interestingly, we have a recommendation from the Liaison Committee—of which I am a member—which I hope will come to the House next week to establish a special Select Committee in the next Session looking at the long-term sustainability of the NHS. I think that that will be a very interesting discussion, not least because it is clear, as the noble Earl said, that alongside A&E and ambulance services, general practice is facing considerable pressure.

Like my noble friend Lord Turnberg I am very lucky to enjoy an exceptional GP practice, which is a small branch of a large inner-city practice. It is clear from the comments of noble Lords and from the regular GP patient survey that people’s experiences are very mixed. The noble Earl focused on economically active members of society, but his comments could have applied to all patients. Noble Lords are often fond of quoting the Commonwealth Fund’s international comparators, which do not always compare with the OECD research covering the same ground. I was interested in its latest report on public perception of primary care in the UK and the fact that there has been a dramatic drop in the positive view of how primary care works, with the percentage of those expressing satisfaction going down from nearly 50% in 2009 and 2012 to just over 20% in 2015. So there has no doubt been an appreciable change in attitude by the public in relation to GP services. The GP patient survey shows, for instance, that only 70.4% of patients find it easy to get through to someone at their GP surgery on the phone. This is down from previous figures. It also showed that 6.5% book their appointments online, up from 3.2% in December 2012. It is really disappointing that such a low number of people actually take advantage of online booking or, indeed, that such a low number of practices promote online booking. Obviously, it would make life so much easier if it were easier for people to do that, and it would deal with the problem that the noble Earl, Lord Attlee, described, about the differentiation between an urgent appointment and one that is important but does not have to take place within 48 hours. Many GP practices seem quite unable to devise a system to cope with those circumstances.

It is also interesting that the GP patient survey showed that 23.1% see their preferred GP a lot of the time. We need to think through the implications of that, particularly with seven-day working, because I suggest that with the move into larger federations, which I support, the seven-day working concept inevitably means that people will have less opportunity to see their preferred GP—particularly, as we know, when many GPs do not want to work full time any more. That seems to me to depend on information, particularly electronic information, being available, so that a patient does not have continually to tell different GPs in a practice about their conditions, because they actually have systems where that is noted down.

I also note that in the survey 57.7% were happy with the amount of time that they had to wait for an appointment. Again, that is down—it is not a great figure. The overall satisfaction with GP opening hours, at 74.8%, is down and again not very satisfactory.

The noble Lord, Lord Rennard, referred to the PAC report on access to general practice, which came out only a couple of weeks ago. I thought that it was a very interesting report and, no doubt, the Government will respond in due course. But it showed that we have problems with retention and recruitment, that good access to GP care is too dependent on where patients live, and there is an unacceptable variation in patients’ practices and in the appointments system. Tellingly, it said that the Department of Health and NHS England do not have enough information—that is a point that the noble Lord made—on demand, activity or capacity, which one would have thought might have been of interest to NHS England. I think that it is clear that both the department and NHS England has really failed to ensure that staffing in general practice has kept pace with growing demand. I think that they have been complacent about general practitioners’ ability and, indeed, willingness to cope with the increase in demand caused by rising public expectations and the needs of an ageing population.

No doubt the Minister will tell us about recent initiatives, which are welcome in themselves, but a lot of changes will come about because GPs themselves will make them happen. I am really impressed by the large federations that have been established. There is one very large one in west Birmingham and the Black Country, which has had some incredibly impressive results in relation to access. It is through having a large enough federation that you can meet the work patterns of individual GPs, and it is through the simple use of phone and email to have much more flexible appointments. I do not know whether the noble Lord has read a report from David Pannell, the chief executive of Suffolk GP Federation, which complains that the department is not really giving support to the development of provider networks and federations and that the only initiative promoting working at scale was the Prime Minister’s GP access fund, which was doing little to diverge from the traditional model of contracting with individual practices.

The point being made here is that every single contract which is part of the PM’s access fund has been a traditional primary medical services or general medical services one with an individual practice. Would the Minister be prepared to have a look at this and to talk to the National Association of Provider Organisations? Its chair has commented:

“Whereas NHS England supported the vanguards programme, there has been virtually no support for the leadership of federations which are not part of a vanguard”.

I have quoted from a story in the Heath Service Journal and I have also looked at comments which have been made on it. One comment, which was anonymous—I do not know why—said:

“Brighton and Hove CCG have been developing a really innovative and ambitious contract with GPs working at scale which the LMC have supported”.

It may well be worth looking at that to see whether more can be encouraged.

Finally, I wonder if the development of federations means that the Government need to look at CCG governance. If you have a large-scale federation covering an area roughly the same size as a CCG, I can see a potential conflict of interest. The federation could dominate the election of members to the CCG board. The contracts should be at that level, not held by NHS England, so I wonder if we need to go back to the issue of CCG governance and have a majority of lay people on CCG boards. That would enable the Government to be much more proactive in supporting these federations. I am convinced that they are the only way we can deal with the problems raised by the noble Earl.

My Lords, I also thank my noble friend for raising this issue. General practice has been a golden thread running through the NHS since 1948. It is worth reminding ourselves that although the situation may be dire in some parts of the country, as the noble Lord, Lord Turnberg, mentioned, the NHS is still almost unquestionably the most efficient, highest-value healthcare system in the world. Not long ago, I was with some people from the Mayo Clinic who made that point—we are very self-critical. It is right that we should be but also right that we should remember that much of what we do in the NHS is absolutely world class and we do it with very little resource. My noble friend Lord Bridgeman and other noble Lords made the point that the NHS is, in their own individual experience, absolutely first class. If you read the newspapers every day you might think that everything is going to hell in a handbasket but most people’s individual experience of the NHS is extremely good. I have not seen the Commonwealth Fund report to which the noble Lord, Lord Hunt, referred but I would like to.

We should be extremely concerned if confidence in primary care is diminishing. I will write to the noble Lord, Lord Turnberg, about research. I could answer his question if it was directed at specialist research, but I am not sure how much money or resource is going into research into primary care. The noble Lord, Lord Rennard, raised the issue of hypothecated tax. The argument for hypothecating tax for health is no stronger or weaker than doing so for education or overseas aid, or other areas. He will know, as well as I do, that the Treasury has wrestled with and discussed this issue for many years. Any decision will be made in the Treasury, not by me. I could argue both sides of the case with equal conviction and sincerity, so I cannot give the noble Lord the answer he might want to elicit from me.

The noble Lord, Lord Rennard, and my noble friend Lord Bridgeman raised the issue of variation. We have got thousands of GP practices and there will inevitably be variation. The question is how we reduce that variation and shift the curve to the right in terms of getting a great general practice. I happen to believe that one way of doing that is through networks and federations. The noble Lord, Lord Hunt, referred to Vitality in Birmingham. Unquestionably, it will spread best practice within that group. The good CCGs are measuring the performance of GPs in their area much more intelligently than they used to. My noble friend Lord Bridgeman mentioned that his practice has very low referral rates. That is exactly the kind of information that should be measured on a GP-practice basis across all GP practices in CCG areas. For example, I have seen the metrics that the CCG in Camden looks at. You can see very clearly what the referral rates are from practices. The outliers can be seen and you can manage that down. They have had some very good results. If noble Lords would like to look at the atlas of variation, or at the Right Care model that NHS England is using to try to identify variation on a disease on a population basis to drive down that level of variation, I can well recommend that they do that.

I have come to the view—it is almost a statement of the bleeding obvious—that of all the tools that we have in our toolkit to try to secure improvement, be it in clinical outcomes, performance of trusts or in general practice, the best is identifying variation. The crucial thing about variation is that you have good-quality data. The first thing when you shine a light on clinical practice, for example, is that the clinicians will dispute the data—often rightly—so you have to demonstrate that the data are good. If you can prove the data, GPs, psychiatrists, acute physicians, surgeons and the like will take that as a challenge, because they tend to be competitive individuals. They like their own practice to be better than anybody else’s. Variation based on good-quality data is essential.

I will take away the comments made by my noble friend Lord Bridgeman on PMS. NHS England is committed over the five years to increasing spend on primary care by some 25% in real terms, whereas in the rest of the NHS it will be more like 15%. There will be more resource relative to other parts of the NHS going into primary care. They will want to be sure that they are getting real value out of any premium payments made under the PMS contract, but I will take that away if I can and write to my noble friend on that matter.

Governance is an extremely important issue. I had not thought about it in terms of where a network of general practice is almost the same size as the underlying CCG, which raises another issue about governance. We thought about it in terms of conflict of interest and the award of contracts, but that is a very serious point. NHS England is looking at these governance issues. I will bring this aspect to its attention.

I turn to what I had pre-prepared. My noble friend Lord Attlee is quite right that people should receive the right care from the right professional at a time convenient for them. However, we know that there is variation in people’s ability to access a GP and that those in full-time employment report lower levels of satisfaction with surgery opening hours than other groups. This is one of the reasons why, by 2020, everyone will be able to access routine GP appointments at evenings and weekends as part of our commitment to a seven-day NHS. That does not mean that every practice will be open seven days a week. We hope that by 2020 most general practices will be part of a network or federation and they will be able to offer that kind of service across the federation.

As I am sure my noble friend will understand, it is not possible to make a direct comparison between accessing GPs and other professionals such as solicitors, but he is, of course, right that people should be able to access a GP appointment when they need it. This is why the Government have already invested £175 million in the Prime Minister’s access fund to test improved and innovative access to GP services. I know that it is very spotty across the country still, but there is a growing understanding that the traditional model of GP practice—lots of small practices with two or three partners, as described by the noble Lord, Lord Turnberg —is not a viable model of delivering primary care for the future.

The traditional model is going to change. We will have networks and much bigger practices with 10 to 20 salaried partners supported by a much larger team of skilled people—pharmacists, physios, OTs, physician associates, prescribing nurses and the like. As well as providing extended hours, schemes are also looking at other ways of improving access for patients, including better use of telecare and health apps. This is an issue that noble Lords raised in the debate today. Not only will we see much more use of the telephone but, for example, the Hurley Group has an e-consultant system, and more people will use other ways of accessing primary care rather than being seen by the GP. This has a lot of legs, if you like. Apps such as Babylon, with which noble Lords will be familiar, and many other apps will make a face-to-face consultation with a GP less critical than it has been in the past.

My noble friend also asked about competition between surgeries. Here, I will point to what we are doing to increase choice for patients. In particular, my noble friend raised a concern about having to move from one practice to another when he moved house. I was pleased to hear that he is now aware of the steps that have been taken to make it easier for patients to exercise choice over which practice they are registered with. The GP contract for 2014-15 brought in a measure allowing GP practices to register new patients from outside their traditional boundaries, but without a duty to provide home visits for such patients, which seems reasonable in the circumstances. This measure is designed to increase flexibility in the system and the freedom that patients have to choose a GP practice that suits them. For example, commuters may wish to register with a practice close to their work as opposed to where they live or a patient who moves house may wish for continuity.

I return to the technology point about booking systems raised by the noble Lord, Lord Hunt. Take-up may be low at the moment—I think that 6.5% of bookings are done online—but I have no doubt that it will grow. If you look at the number of people now ordering basic food from supermarkets online, that is the direction of travel and it will speed up as time goes by.

The noble Lord raised the issue of reducing pressure on A&Es. In January, there was an increase of 10% in A&E attendances on the previous year. This is putting huge pressure on hospitals because if the front end of the hospital is being flooded, it makes it increasingly difficult for it to meet its waiting times on elective surgery, for example. Delivering more care to people outside hospital will not only lower the cost but provide better care because going into A&E with a fairly minor problem is not a great way of delivering care.

The noble Earl raised an issue about blood tests. Examples of improved access to diagnostic tests can be seen in both the vanguard sites which NHS England is developing. They are part of the new models of care programme and access fund schemes. For example, a vanguard in Birmingham offers consultant-led outpatient clinics and diagnostic facilities, such as X-rays. We often talk about integrating social care with healthcare, but integrating healthcare is also not a bad way to go. We have talked in the past about collocating GPs in A&Es or just outside them, but there are also many specialist outpatient clinics that can be delivered in primary care settings, so long as the facilities are there. We hope that the £1 billion infrastructure fund that we have announced will deliver better facilities closer to where people live.

We have a lot to be proud of but we are inclined to dwell on areas where we are failing and forget sometimes where we are achieving great success. The workforce is a serious issue. We are committed to finding 10,000 new GPs or GP equivalents in general practice by 2020 and we have increased the number of training places by 3,500 from this year and going forwards. To be honest, there is a risk around whether we will be able to get that number of people into general practice. However, without that kind of workforce commitment it will be difficult to deliver our ambitions.

So, it is a combination of technology, workforce and infrastructure. The five-year forward view is behind the thrust of the comments made by noble Lords and, if I am still here in 2021, I hope that I will be able to say that we have spread the best practice that exists in large parts of the country on a much wider basis. However, I am afraid that we will not have eliminated all variation.

Sitting suspended.