Seven-day access to NHS primary care: how does England compare with Europe?

This article is one of a series on healthcare policy

Introduction

Healthcare systems globally are facing an increasing demand for care under stable or decreasing resources. It is often assumed that providing easier access to community-based general practice during evenings and weekends can reduce demand for emergency and other unscheduled care services, promoting more appropriate care and reducing the costs associated with expensive hospital-based treatment. However, evidence for this is mixed.^1–3 In England’s NHS there is political pressure to expand general practice surgeries’ opening hours to progress towards a ‘seven-day NHS’. ⁴

When considering extension of primary care opening hours in England, it is useful to compare primary care access across other countries in the European Union. Despite differences in healthcare commissioning and funding, European countries face comparable challenges such as ageing populations and increases in chronic conditions and mental health problems, all of particular relevance to primary care. ⁵ This paper examines England’s current in-hours general practice services relative to those of European countries in order to better contextualise the debate on extending general practice opening hours.

Access to general practitioner provision in England and the European Union

English general practices are required to be open between the core hours of 8 am to 6:30 pm, Monday to Friday, a total of 52.5 h per week, ⁶ although 46% of practices are closed to patients during some of those hours, with 18% closing by 3 pm at least once per week. ⁷ In January 2017, the Prime Minister reaffirmed the Government’s pledge to provide patients in England with access to a general practitioner between 8 am and 8 pm, seven days per week. ⁸ As of April 2017, 20% of Clinical Commissioning Groups in England were providing some seven-day 8 am–8 pm routine general practitioner appointments. ⁹ Eighty-five percent of Clinical Commissioning Groups were meeting a target of having 60% of additional evening appointments booked; 71% were meeting the same target for Saturday appointments and 68% for Sundays. However, this varied widely by location, with some areas seeing only modest uptake of weekend appointments (8% and 2%, respectively). ⁹

Despite a lack of uniform data on general practice opening hours in European countries, some information is available (Table 1). Of 31 countries, obligatory minimum weekly opening hours for primary care practices exist for all but nine countries, varying from 20 hours in Austria to 52.5 hours in England. ⁶ General practice opening hours in other European countries vary depending on region and local demand. In Finland and Greece, urban practices offer extended opening hours compared with those in rural locations, while in other countries, such as Spain, some rural practices are open 24 hours per day. Countries without a statutory requirement for minimum opening hours may have standard or customary opening times; most of these data were unavailable.

Table 1.

Minimum general practice opening hours in European Union countries.^6,10

Country	Obligatory minimum hours	Notes
Belgium	No
Cyprus	Yes	7:30 am–2:30 pm, with opening to 6 pm one night per week
Estonia	Yes	8 h/day, Monday to Friday
Finland	No	Typically, health centres are open 8 am–3 pm or 4 pm; centres in cities are usually open until 8 pm
France	No
Germany	No
Greece	Yes	Practices are open for a minimum number of hours; rural and semi-urban practices open 8 am–3 pm
Hungary	Yes	2–4 h/day
Iceland	Yes	8 am–5 pm, Monday to Friday; 9 am–12 pm Saturday
Italy	Yes	Hours vary based on number of patients (5–15 h per week, depending on practice size), with one day until 7 pm for group practices
Ireland	No
Lithuania	Yes	Minimum of 6 h, depending on municipality
Luxembourg	No
Malta	Yes	Hours vary; some 8 am–8 pm (family medicine services stop at 5 pm) and others are open for 24 h
Norway	Yes	Requirements vary locally
Portugal	Yes	Typically open 8 am–8 pm
Slovakia	No
Spain	Yes	Rural practices are open 24 h per day; urban practices vary (most common is 8 am–8 pm)
Sweden	No
Switzerland	No
England	Yes	8 am–6:30 pm, Monday to Friday

Perceptions of access in England compared with Europe

Patients in the United Kingdom generally had good access compared to other European countries (Table 2). England compares well with other European countries on measures of patient-reported access to care. More than 80% of English respondents surveyed in 2017 were able to make an appointment they found convenient when they last tried, ¹¹ with 80% satisfied with the opening hours of their general practice. ¹² General practice participation in NHS England’s extended-hours access scheme, where practices were incentivised to offer additional appointments per week, was associated with a slight statistically significant increase in patient satisfaction. ¹² However, an extended-hours pilot scheme in one area of the UK has ended because of a lack of patient interest in weekend appointments. ¹³

Table 2.

Access for United Kingdom patients compared with European countries.^6,14,15

Metric	UK (%)	Range
Easy access to after-hours care without going to emergency department	71	37% (Sweden) to 77% (Netherlands)
Able to get appointment on the same or next day	65	53% (Sweden) to 83% (France)
Visited emergency department for a condition that could have been treated by primary care had it been available	4	3% (Germany) to 10% (Sweden)
Satisfaction with primary care access	86	60% (Turkey) to 97% (Belgium)

Doctors’ perception of access is more mixed. Although 89% of UK general practitioners stated that their practice had an arrangement where patients could see a doctor or nurse if needed after-hours without going to the emergency department, only 37% stated that almost all their patients could get an appointment on the same or next day. ¹⁶ In Europe, this varied from 19% in Sweden to 64% in Germany. ¹⁶

Association between primary care opening hours and emergency department use

A number of cross-sectional observational studies in the UK have found an association between increased primary care access and decreased emergency department visits, but it is difficult to claim that this association is causal. ³ General practices with restricted hours were associated with an increased chance of emergency department visits, ¹⁷ while extending general practice access to a seven-day service was associated with a reduction in emergency department visits in one city in the UK. ¹⁸ Similarly, patients from practices with seven-day general practice pilot schemes went to the emergency department less often, with greater reduction at weekends. ¹⁹ However, another UK study did not find significant association between access to primary care and avoidable emergency department visits across general practices. ² Evidence of this association from other European countries is limited, but one study did demonstrate that increasing primary care practice hours in Italy reduced the use of emergency department services. ²⁰ A systematic review found no significant relationship between the introduction of general practitioner cooperatives to provide out-of-hours service with emergency department attendance. ¹

Conclusions

European countries provide important benchmarks in the context of discussion about expansion of general practice opening hours in England. While there are insufficient data on obligatory or customary opening times to establish any reliable correlation between standard in-hours primary care provision and emergency department use either in England or elsewhere, the position of England relative to other European countries in terms of standard opening hours and patient satisfaction with access is instructive. More high-quality data are needed to determine if expanding general practice opening hours is worth the investment. Stakeholders should prioritise obtaining such data before a final determination is made.

Standard opening hours in England already exceed those of most other European countries, and patients in the UK are satisfied with out-of-hours access to general practice, compared with other European countries. Achieving easier access to primary care services seven days per week would require significant investment, and must compete with other NHS priorities; politically attractive priorities should not to have an undue influence in shaping resource allocation. The existence of true patient demand for extension of general practice opening hours in England is not yet fully established and evidence for a correlation between increasing in-hours provision and decreased emergency department use is inconclusive. Furthermore, the demand for services likely varies based on local demographics and disease burden; if general practice opening hours were to be extended, those regions with the highest demand for care should be prioritised.

More research is needed, especially on the results of pilot programs that expand general practice access, as well as further work to understand the effects of changes to in- and out-of-hours primary care provision on access and emergency use in England and other European Union countries.