Jeremy Laurance: Why does it have to be so hard to see a doctor?

The NHS is still too inward looking and struggles to focus on its patients

Why, she complained, was it impossible to book an appointment with a GP more than two days in advance since the 48 hour target had been introduced? A baffled Mr Blair responded: "Surely they [GPs] are not saying you have to have an appointment quicker than you want it." But that is exactly what they were saying, as a vociferous section of the Question Time audience assured Mr Blair.

Welcome to the topsy turvy world of general practice. Just a few years ago, in many practices you were lucky to get a routine appointment inside a week. Today, so aggressive have family doctors become about insisting that patients turn up at the surgery the moment they have phoned for an appointment, that ministers are now ordering them to slow down.

How did we get here? The turnaround from long wait to almost instant access was achieved by the now discredited mechanism of targets. GPs were told in 2003 that if they saw all patients who requested an urgent appointment within 48 hours they would receive payments totalling £11,000 per practice.

Many set about the task with alacrity though not, it has to be said, without a certain grumpiness. Doctors dislike being pushed around, and some decided in response they would push their patients around. They abandoned all appointments in favour of open-access surgeries where patients were expected to turn up and queue. You can hardly blame them; £11,000 buys a lot of cotton wool and bandages. But it is a good example of the distorting effect of targets . If you press the balloon in one place it will bulge in another.

The findings of a survey by the Healthcare Commission, carried out before the election, show that while more than 90 per cent of patients who want an urgent appointment are now seen in 48 hours, almost a third are unable to book an appointment more than three days ahead.

This is not what was envisaged by the NHS "patients choice" agenda so energetically promoted by Labour, and ministers were furious. The health department contacted journalists even before the survey had been released to declare that GPs would be ordered to offer advance appointments. The British Medical Association meanwhile has preserved the air of unreality over the row by claiming first, that the 48-hour target was unachievable, and then that offering instant access and advance booking at the same time was impractical.

In 2003, the association insisted 10,000 extra GPs would be required before every patient could be offered an appointment within 48 hours. But two years on, with barely an extra 2,000 GPs in post, 70 per cent of practices are managing to offer both advance appointments and 48- hour access for patients who want it. Which raises the question, if 70 per cent can do it why can't the other 30 per cent?

Dr Hamish Meldrum, chairman of the British Medical Association's GPs' committee, continued to insist yesterday that the only way to solve the problem was by having more doctors and nurses.

"If you skew the system by forcing doctors, or encouraging doctors, to keep a lot more appointments free to be booked on the day, then common sense tells you there are fewer appointments left to book ahead," he told the Today programme.

This is a peculiar argument. Each GP practice has a finite number of patients. Common sense tells you, therefore, that if more patients are booking ahead there will be fewer wanting to book on the day, and vice versa.

The truth is that getting to see a GP is less a capacity problem than an organisational problem. GPs have not, historically, organised themselves well to respond to patient demand. By the simple expedient of offering same day consultations over the telephone, ensuring investigations are co-ordinated with consultations, and providing more appointments with practice nurses, GPs have cut waiting times.

Without laying on any extra surgeries or working harder than before, they have discovered they only have to work differently to offer a better service.

It seems so simple yet it has proved so hard to achieve. It underlines a central truth about the NHS - that it is still too institutionalised and inward looking and still struggles to focus on its patients. These issues will be addressed in the coming white paper, expected in the autumn.

Unless the NHS can change its institutional culture and put patients first, its long-term survival will be imperilled.

j.laurance@independent.co.uk