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GP Out of Hours Services

12th May 2007

A Public Accounts Committee report in March slammed the way in which out of hours arrangements have been changed across the NHS. Here we look at the committee’s conclusions, and what further changes are in the pipeline.

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What happened to Out of Hours services?

Nine million patients use primary care services out of hours each year. In 2004 GPs were given the option of dropping their work commitments outside normal surgery hours as part of the new General Medical Services (GMS) contract. As long as they were willing to give up £6k of their income, they were no longer obliged to provide surgeries in the evenings, weekends or bank holidays, or to be on call.

90% of GPs took up the offer and opted out. Out of hours services were left to PCTs to provide without them, using a range of alternative providers including private firms, social enterprise companies, GP co-operatives and ambulance trusts. NHS Direct has been widely used to provide initial call handling to local out of hours services.

The change was made because of growing concerns that the existing system was unsustainable. GP recruitment and retention was in crisis, and out of hours commitments were a major contributing factor to making the job particularly undesirable. The plan was that the tide of GP retention would be turned by a combination of offering less onerous working hours and the new pay deal under GMS.

Why has it cost so much?

To put it simply, the £6k relinquished by each GP opting out in no way covers the additional cost to the PCTs of providing out of hours services. Within the first year, costs of out of hours services were £70m more than predicted. Some have put the excess cost at nearer £100m. When GPs were providing the service for themselves, there was an incentive to keep costs to a minimum as they could keep the difference because of their self employed status and pay structure. This incentive is now gone and costs have escalated.

PCTs have tried to drive costs down by negotiating hard with new providers, and by using a higher ratio of non-medical staff (ie nurses) to provide the new services. But there are still reports of GPs providing out of hours cover charging up to £100 per hour. Minimised costs on out of hours contracts may also lead to unforeseen additional costs in other parts of the system. If out of hours costs are controlled tightly by the new provider, patients may end up finding other, more expensive parts of the urgent healthcare system more accessible, including A&E and 999 services.

What did the Public Accounts Committee have to say about new arrangements?

The PAC, reporting in March, was damning of the way in which the new system of out of hours was conceived and put in place. Amongst other conclusions it found that:

  • Preparations for the transfer to PCTs were ‘shambolic’. PCTs were inexperienced and poorly prepared for the transfer in 2004/05. They had very poor information about the existing out of hours workload.
  • The Department of Health were insufficiently involved in negotiating new arrangements, being only an observer in new GMS contract negotiations. The PAC said the Department should have been ‘principle’ in the negotiations, ensuring a good deal for patients and the tax payer.
  • Deals with alternative out of hours providers were left to local negotiation by unprepared PCTs and costs now vary widely across the country. This approach contrasts with other areas of NHS service which have been tendered out (eg ISTCs) where the Department of Health Commercial Directorate has retained control of negotiations centrally to achieve value for money. The PAC has concluded that there is scope for significant savings if all PCTs secured deals as good as the best.
  • New service providers are still not meeting standards for things such as initial call answering and advice response times.
  • Only GPs have done well out of the new arrangements for out of hours.

The PAC report followed a report by the National Audit Office in May 2006 which had identified similar shortcomings.

What is being done to improve things?

In January 2005 standards for out of hours services were published by the government to try and regain some of the initiative and make sure services all performed to the same levels. As the PAC highlighted, achievement against these targets remains patchy, and the government now proposes random spot checks to improve services in under-performing areas. But the HSJ reported last month that there is still no central monitoring of performance against out of hours standards. This is making it hard to see whether things are getting better at all.

The Royal College of General Practitioners has launched an out of hours Audit Toolkit to help PCTs and practitioners monitor service quality.

More recently, the Department of Health has announced a full review of all NHS urgent care services to make the most of the resource that is going into services such as out of hours. It ran a consultation into its initial proposals through the end of last year. In Direction of Travel for Urgent Care it sets out a vision for an urgent care system which:

  • Moves care out of hospitals, and particularly A&E departments.
  • Makes use of new technology.
  • Minimises confusion for patients about where in the system to present with an urgent need – whether out of hours services, Walk In Centres, Minor Injuries Units etc.
  • Ensures patients receive a consistent assessment of their condition, whichever entry point to the urgent care system they present to.
  • Includes social care as an integral part of urgent care.
  • Encourages co-location of urgent care facilities to streamline pathways and achieve value for money eg out of hours services alongside A&E Departments.

There are some reports that GPs may soon be offered new incentives to return to out of hours provision as part of their on-going pay negotiations with the centre.

For more information on out of hours services, go to:

http://www.publications.parliament.uk/pa/cm200607/cmselect/cmpubacc/360/360.pdf

http://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Primarycare/Out-of-hours/index.htm

http://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Primarycare/Urgentcare/index.htm

http://www.hsj.co.uk/healthservicejournal/Search.do?
dispatch=showPage&pageId=11767&page=0

 

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