One of the principal policy goals with regards to access has been to increase the numbers of appointments available in primary care. In England, since 2013, this has been done mainly through extended access covering evenings and weekends. More recently, there has been a move towards on-the-day hubs for patients to access when their practice has no urgent appointments remaining.
Extended-hours GP services were introduced in October 2013 by then Prime Minister David Cameron. He established a £50m ‘Prime Minister’s Challenge Fund’ to pilot methods of providing evening and weekend appointments. At the time, he said ‘millions of people… find it hard to get an appointment to see their GP at a time that fits in with their work and family life.’
According to the first evaluation of the pilot schemes, the aims were: to provide additional hours of GP appointment time; to improve patient and staff satisfaction with access to general practice; and to increase the range of contact modes. The evaluation also looked at: how the initiative contributed to reducing wider NHS demand; tackling health inequalities; identifying replicable delivery models; delivering value for money; and establishing sustainable and transformational change in the primary care sector.
In October 2018, clinical commissioning groups (CCGs) were mandated to offer extended access to their whole populations - brought forward from the original 2019 deadline. By 2022, this responsibility had shifted to PCNs. The PCN contract (directed enhanced service), mandates the provision of 60 minutes of enhanced-access appointments per 1,000 patients between 6.30pm and 8pm on weekdays and between 9am and 5pm on Saturdays. The requirement for Sunday opening under the CCG schemes was removed.
So, how successful has the concept of extended hours been? According to NHS Digital data, in July 2025, around 367,000 appointments were provided through extended access, making up some 1.1% of all appointments in general practice. Funded at £8.52 per patient per year – based on current general practice populations, this comes out at around £535 million. In other words, around £120 per appointment, or the same as the total global sum practices receive per patient for a year. Again, there needs to be caution with these figures. NHS Digital suggests extended access appointments could be underreported.
In terms of patient satisfaction, numerous studies have looked at the impact. Researchers from the University of Manchester and the University of Liverpool said their analyses ‘did not identify significant linear associations between extended access services and patient experience measures’. They also found ‘some evidence suggested that the frequency of seeing or speaking to a preferred GP (a measure of continuity of care) was negatively associated with extended access services, although not linearly’.
The study did note that ‘a small positive effect was observed on satisfaction with appointment times for patients in full-time employment’. It concluded: ‘The provision of extended access services by GPs at scale may provide additional capacity and choice of care for patients, but care continuity could be threatened.’
Another study from the same authors at the University of Manchester found: ‘Supra-practice access models can provide effective care for most patients with straightforward issues. When ongoing management of complex problems is required, this model of patient care can be problematic.’
What primary care staff think of extended access
Despite these findings, on the whole, the majority of survey respondents said evening and weekend appointments had been a success where set up – although more people chose ‘quite successful’ than ‘very successful’.
This is reflected in the comments, some of which were very much in favour of the schemes, while others offered a more cautious backing.
The Manchester and Liverpool universities’ study found that ‘greater cooperation between GPs positively impacted patient experience but might compromise continuity of care’, and those who found extended hours to be very successful tended to reference good working within the PCN.
Tanya O’Brien, a practice manager in north west London, says: ‘Extended access has significantly improved service provision for patients registered across our local practices. One contributing factor is the strategic location of our extended access clinic, which sits centrally among the six member practices – making it geographically accessible for a broad patient base. Feedback from our ANP, who delivers sessions at the hub, indicates that member practices are actively booking their patients into the extended access offer. This has been particularly beneficial for patients who work or study during standard hours, as it provides flexible appointment options that better align with their schedules.’ Interestingly, she adds: ‘Overall, the hub model is helping to reduce barriers and enhance continuity of care across our PCN.’
Other commentors described the increased access as an overall help at a time of limited appointments. One practice manager in Bristol says: ‘I would say access is at a premium and whilst evening or early morning appointments do help, a lot of patients will come at whatever time offered.’ Another, from Leeds, says: ‘Saturday appointments for smears and learning disability reviews has been a real success for working people and parents.’
Criticisms of extended hours
But opinions were mixed among other respondents, with criticisms focused around certain themes:
- The effect on continuity and a duplication of work
- Low take-up, and high numbers of ‘did not attends’
- A reluctance from patients to travel
- Conversely, low availability of appointments
- A lack of cost effectiveness.
Effect on continuity and duplication of work
Echoing researchers’ findings, a number of respondents were concerned about the effect of extended hours on continuity. One GP in Greater Manchester says his PCN provides extra GP appointments and an overflow hub that runs through the winter. ‘Both these services have contributed to reduced waiting times but don't really help with continuity – we often end up with referrals to make on their behalf and need to arrange additional tests as they are unable to send routine referrals and don't seem to be able to request bloods/MSUs.’ This ‘does generate a fair amount of additional work for us’, he adds.
A Leicestershire GP says the configuration of the workforce in extended hours has an effect on continuity: ‘Extended hours clinicians are mostly not GPs or, if they are, they are external staff. So they offer no continuity of care or the access to the GP the patient wants – they can at best just help sort out acute issues, like you would get from an urgent care centre or emergency department.’
Other GPs agree. ‘Extended hours are good at soaking up acute conditions but less so for chronic conditions patients tend to rebook with their practices,’ says one GP in Luton. Another in north east England says: ‘Patients are often referred back to “own GP” causing work duplication. Or tests ordered uncovering incidentalomas, causing more work without benefit to the patient.’
Hertfordshire GP Dr David Turner is scathing: ‘Extended hours after 6:30 pm and at weekends are in my opinion little more than a gimmick and a soundbite for politicians. If we see a patient out of hours often the pharmacy is closed so they have to go the next day to pick up medications. Samples such as urine are only collected once a day and never at weekends so patients end up having to come back to the surgery in normal working hours in any case. The commissioners just do not understand having GP surgeries open is fairly pointless unless all the allied support services are also working at the same time.’
Lack of take-up
There is little information about the take-up of evening and weekend appointments. An investigation from sister title Pulse from 2018 – before extended access had been rolled out across the whole of England – suggested that 25% of appointments were unfilled. Anecdotally, practices suggest there are still a high number of appointments unfilled. Dr Nicola Bignall, a GP partner in south west London, says: ‘We moved our extended access to within our PCN. We simply struggle to fill the face-to-face appointments on Saturdays for both doctor and nurse appointments, and all telephone calls.’
A number of other respondents agreed, with one saying the most high-use patients ‘prefer to see us during working hours – they don’t work, buses or lifts are easier, it’s daylight, etc’. One GP in Somerset says they ‘fill evening appointments with people who don’t need evening appointments. It’s a farce. Then it looks successful and necessary, but it is neither’.
This lack of take-up can often be seen through increased DNAs, practices say. The GP in Manchester says all extended hours appointments are with GPs and are face to face – which we’ve seen are drivers of patient satisfaction – but that DNA rates seem to be ‘pretty high’. A practice manager in Bristol says: ‘Like all PCNs we offer enhanced access appointments in the evenings and at weekends. The majority of people booking them are not working people, and the DNA rates are massively higher.’
Patients unwilling to travel
A potential cause of this – but one that deserves its own analysis – is that patients are unwilling to travel. When appointments are provided at PCN level, patients often have further to travel. Dozens of respondents referenced this, especially in rural areas. One GP in Shropshire says: ‘None of our patients have ever used extended access appointments at other surgeries. Our PCN weekend extended-access appointments are at a surgery that is 20 miles away.’
One practice manager in south east London says: ‘Our patients will not go to another practice even within our PCN if they want a GP, even when advised it is a doctor from our surgery.’
Lack of availability
Conversely, appointments in some areas can be hard to come by, many primary care staff say. Some respondents said another problem with the PCN model was that the host surgery would often secure the bulk of available slots. Some practices also game the system, according to a practice manager in south west London: ‘We were finding that some practices were having a monopoly on the appointments and starting with a list of patients ready to book into as soon as the appointments were available. That was very frustrating as lots of the slots would be taken up and also the practice often hadn't spoken to the patient yet, which meant lots of DNAs. Frustrating all round.’
A problem with increasing the number of appointments is that there is no guarantee they will be used by those most in need. One GP in Berkshire says: ‘At first it helps, but before long, all the space gets filled, or worse, the gaps are filled with even more trivial nonsense. Our shopping mall walk-in centre recently closed as it led to no reduction in A&E or GP attendance; it just meant more trivial issues were consulted for.’
A lack of cost effectiveness
Many referenced the idea that providing extended-access appointments had not proved a good use of limited NHS resources.
A GP in West Yorkshire says ‘so few appointments and so expensive per appointment – better use of the money would be to do in house’. Another in Cornwall agrees: ‘So few hub appointments that it doesn’t make an impact – highly paid for the amount seen. It would be money better spent in practice.’ Another GP in Herefordshire says: ‘These appointments are a faff to organise, probably not cost effective and reduce 8am to 6.30pm Monday to Friday capacity.’
Hub working
On-the-day hubs are not as common as extended hours. Only around a third of respondents who answered the question said that there was a local on-the-day hub in their area.
Around 363 acute respiratory infection (ARI) hubs were set up across England in the winter of 2022-23, with national funding to relieve pressure on other parts of the system. The hubs were recommended by NICE due to rise of ARIs following the Covid pandemic, including 220,000 people being diagnosed with pneumonia in England and Wales every year, causing significant winter pressures. In an NHS England seminar on the ARRIs, it said that 83% of providers agreed that ARI hubs ‘reduced pressures on primary care’ and that without the hubs, about 360,000 patients would have gone to their GP instead. Despite this, NHS England discontinued the funding the following winter.’
Survey respondents in areas where similar on-the-day hubs had been set up felt they had been successful, although at slightly lower rates than for extended access – 77% who had hubs in their area said they had been ‘very successful’ or ‘successful’ compared with 83% for weekends and 82% for evening appointments.
However, qualitatively, there were more positive comments about the hubs (see case study). Many came from respondents who were upset about not having a local hub, or because the funding had been pulled. One GP in Lancashire says: ‘We did have an ARI hub which was incredibly successful last winter. However, it was only temporary and no other on the day hub provision being discussed due to extreme financial difficulties for our ICB.’ A practice manager in Lancashire says: ‘The respiratory hub through autumn and winter was fantastic but the funding for this has now been stopped.’ Meanwhile, a GP in Scotland says: ‘Wish we had hubs, nobody does in Scotland, extended hours service is an irritating drag.’
But they weren’t the only positive comments. A number of GPs and practice managers referenced how helpful they had been, especially during the winter. As one practice manager in Worcestershire put it: ‘The overflow hub has helped with access and relieved pressure especially winter and when a clinician is ill, it helps create capacity.’
How hub and extended hours working can help
One of the places we get support from is the hub our PCN runs Surrey Heath practices. They provide a mixture of skill sets: GP, paramedics, paediatric nurse, advanced nurse practitioner, and they work quite centrally for the seven practices. It gives options for patients. It’s not masses of appointments, but it appears to be working for some.
Saturday working with phlebotomists also working has really supported the Friday ‘rush’ as people go into the weekends. The Saturday help has meant we have gone from a partner working a Saturday possibly every few weeks, to only having to do one every year or so, which is totally manageable.
The PCN have also been piloting extended hours on a Friday evening for the surgeries. I know this is work that we all did historically (18.30 – 20.00), but we haven’t been receiving complaints that patients can’t see us at our own place of work on that evening since the pilot has been in place.
This in turn has supported health and wellbeing of GPs and staff getting home reasonably early on a Friday.
Wendy Foster, practice manager, Frimley
Familiar criticisms
That said, many comments offered similar criticisms to those about weekend and evening working. General practice staff referenced issues with travel, lack of continuity and some practices hogging appointments. However, there were no comments around a lack of take-up.
The criticisms were summed up by Richard Langthorp, a practice manager in Humber and North Yorkshire: ‘In our experience patients are likely to find an unfamiliar setting, an unfamiliar clinician and the clinician is unlikely to access full patient records. Follow-up action (for example blood tests, referrals or follow-up reviews) are unlikely to be delivered with first class continuity of care. Experience tells us that patients are not reviewed thoroughly and tend to be passed back to their own practice to perhaps review and provide the care they should have been provided with in the first place.’
SURVEY METHODOLOGY
GP partners and practice manager respondents were asked to input their practice code, their practice name and their post code. Where this wasn’t clear, we correlated this information with data from NHS England (epraccur document – and epcn for PCNs), uploaded 30 May 2025), OpenData Scotland (GP Practices and List sizes July 2025), NHS Information Centre for Health and Social Care (Information from the General Medical Services Census Statistics in Wales) and HSC Business Services Organisation (Northern Ireland practice list). Where this still wasn’t clear, we searched practice websites. All those without the required information after this research were removed.
For duplicate practice codes – more than one respondent from a single practice – we remove duplicates in the following order:
- Those who provided fuller information (ie, fewer blank answers and ‘don’t knows’) were prioritised;
- After this, GP partners were prioritised over practice managers;
- After this, those who answered first were prioritised.
This left a remaining 797 distinct practices, represented by 471 GP partners and 326 practice managers.
Respondents were asked: ‘Have the following measures been set up in your area (through ICBs, PCNs, health boards or trusts), and how successful have they been? Extra appointments offered at evenings (including through PCN); Extra appointments offered at weekends (including through PCN); An on-the-day hub being formed locally.’ They were given the options of: ‘Yes, and it has been very successful; Yes, and it has been quite successful; Yes, but it hasn't been successful; Yes, but I don't know if it has been successful; No, this measure hasn't been introduced; I don't know whether this measure has been introduced.’ To present the results, we aggravated all those who said yes for the first chart, and for the second chart, we only used those who answered ‘yes’, but didn’t include those who answered they didn’t know whether the measure had been successful.
You can find all the data and the methodology in the full report. Click here to download the full report.
Commercial partner of this white paper: General Practice Solutions
