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Monday 26 September 2016
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Out-of-hours: A tarnished past? A golden future?

Focus on ... out-of-hours

STEVE AINSWORTH

Medical Journalist

Steve is a well-known writer specialising in the history of medicine, the NHS and primary care. He qualified as a member of both the Institute of Chartered Secretaries and Administrators and of the Institute of Healthcare Management. He has been the chairman of independent review panels dealing with complaints about the NHS and a lay panel member for the Healthcare Commission. He is currently a lay reviewer for the Royal College of Surgeons

Shelagh Eggo, practice manager at the York Street Practice in Cambridge, is in no doubt that patients preferred it when GPs did all their own night visits.

Out-of-hours (OOH) services used to be called “GP out of hours services”, but these days it seems anyone can get a contract to provide healthcare outside the normal working day. Gone is that golden age when every GP would happily come out in the middle of the night to provide patients with personal care and attention.

Alas, that all changed in the 21st century.

Earlier this year, the coroner for North and East Cambridgeshire, William Morris, was widely quoted in the media when, during a 10-day inquest, he described one OOH medic brought over from the continent as “incompetent and not of an acceptable standard”.(1)

German locum Dr Daniel Ubani had mistakenly injected 70-year-old David Gray with 100mg of diamorphine. The Cambridgeshire inquest heard that Dr Ubani was working his first shift in the UK when he administered the fatal dose to Mr Gray. Dr Ubani had been employed by the private OOH service provider SuffDoc, later Take Care Now, when he injected Mr Gray in February 2008.(2)

What has gone wrong with our OOH service? And can it be improved?

Myth-creating nostalgia?
First, however, was there ever really a golden age for OOH services, a time when every GP provided a perfect personal service? And was that now-lost 24-hour, 365-days-a-year GP cover really as good as people remember? If so, should GP practices be forced to revert to providing their own night and weekend cover?

Despite the widespread belief of many commentators, family doctors invariably did not provide OOH cover in years gone by. In reality, deputising services of various kinds have existed for as long as GPs. Almost all family doctors were members of local rotas – an arrangement that was invaluable in the days when the majority of GPs were single-handed, rather than working in group practices.

In the 1950s, more than half a century ago, GPs were already organising themselves into deputising co-ops, as well as engaging commercial services to whom they were subcontracting their OOH responsibilities.

However, the NHS was strangely uninformed, even incurious, about what GPs were actually up to. According to the minister of health in response to a parliamentary question in 1960:

“I regret there is no centrally available information regarding the number and types of deputising service, but I have no reason to suppose that such services are operating on a commercial basis in more than a very few areas.” (3)

Under the radar, however, large numbers of GPs were pursuing a covert, decades-long policy of trying to invisibly opt out of personally providing night and weekend cover. Thousands of GPs were only too happy to discreetly pay someone else to take on the task of providing cover during “antisocial hours”.

In the past, demand for OOH visits was not as high as today – but by the 1960s the percentage carried out by deputising services was ever-increasing. By 1969, though, GPs were on average making only 13 or 14 night visits annually, and two thirds of all such attendances were being carried out by deputies.(4)

Patient demand rose alongside the use of deputising services. Those who didn’t like to bother their own GP felt no similar constraint if they knew it was “only a locum” they were calling out. A decade later the number of call-outs had doubled.

Similarly, patients who felt little reluctance to call out a deputy felt even less inhibition about complaining if the service they got did not meet their expectations.

Complaints are nothing new, and those that were received in the 1970s may sound familiar today: deputies arrived late or not at all; the deputy couldn’t find the address; the deputy couldn’t speak English; or the apparently tired and incompetent deputy made a disastrous decision and the patient died. Nothing changes.

Of course, attempts were inevitably made to address the problem.

Changing face of general practice
In 1978, a Code of Practice for Deputising Services came into force. In future, all deputies were to have experience as GPs and pass suitable selection arrangements approved by new local “Professional Advisory Committees” (PACs).

In reality, this made little real difference other than to fuel an increase in both the use of deputising services and patient demand. Over a period of 20 years, the number of night visits doubled again. And, unsurprisingly, the number of complaints increased accordingly.

The PACs were by now morphed into the Joint Doctors’ Deputising Services Subcommittees of Family Practitioners’ Committees. These predecessors of family health service authorities and PCTs set the arena for a cat and mouse game. In one camp were GPs, who naturally wanted the cheapest deputising services possible and unrestricted usage. In the other camp was the NHS, which wanted the best service and limited usage.

With decades of experience of fending off NHS attempts to manage them, GPs tended to win the game – maintaining their coveted independent contractor status while simultaneously subcontracting at will.

Meanwhile, commercial pressure maintained a delicate balance: GPs wanting to pay the least they could get away with, while simultaneously needing to pay deputies enough to ensure cover was always available. When that balance failed to produce quality, as it often did, complaints became inevitable.

Such a situation might have lasted forever if general practice had not begun to evolve and change. Many one-time deputising co-operatives were by now commercial companies, often with current or former GPs as shareholders.

Meanwhile, by the early 1990s, the long-defended status of independent contractor had eroded. One of the biggest changes had been the huge number of female doctors qualifying (now around half of all new doctors). Many women doctors saw nothing wrong in being more an employee than a contractor, not least when seeking part-time rather than full-time contracts.

Many other young GPs knew nothing of earlier conflicts. For them, the ancient contractual clause, which made them personally responsible for the acts and omissions of any deputies, was not a public safeguard but a personal burden. When the opportunity for change came, large numbers of GPs jumped at the chance.

Fallout of the 2004 contract changes
Schedule 3 of the NHS (GMS) regulations 2004 ushered in a new contract era in which most GPs could opt out of OOH cover. In future, PCTs could take the responsibility – and the blame. And blame there is aplenty. PCTs find it no easier to engage good-quality OOH providers than GPs ever did.

By a curious coincidence, at almost the same moment that the Cambridgeshire coroner was delivering his highly critical pronouncements, the Department of Health (DH) issued a report into GP OOH care that makes a number of recommendations for improving OOH services.

The report, General practice out of hours services, followed a review by Dr David Colin-Thomé, National Clinical Director for Primary Care at the DH, and Professor Steve Field, Chairman of Council, Royal College of GPs.(5)

The review looked at current arrangements for OOH services. It noted that robust requirements are already in place to ensure the commissioning and delivery of safe, high-quality OOH services, but that there is unacceptable variation in how these are implemented and monitored by individual PCTs.

According to the report, PCTs should review the performance management arrangements in place for their OOH services, and ensure they are robust and fit for purpose. The DH should issue guidance to PCTs to assist them in making decisions about whether or not a doctor has the necessary knowledge of English. The DH should also develop and introduce an improvement programme for PCTs to support their commissioning and performance management of OOH services.(5)

OOH providers themselves should consider the recruitment and selection processes in place for clinical staff to ensure they are robust and that they are following best practice. Strategic health authorities should consider how they monitor action taken by PCTs in response to the report, and in carrying out appropriate performance management of OOH providers. Providers, meanwhile, should co-operate with other local and regional providers (both in and out of hours) to share any concerns over staff working excessive hours for their respective services.(5)

“Unacceptable variation”
According to Dr Colin-Thomé, one of the report authors: “‘The quality of OOH care for most people is better than it was in 2004, but there is unacceptable variation in how services are implemented and monitored around the country. However, I am confident that by implementing the recommendations from our report, the system can be strengthened and vastly improved.”

In Cambridgeshire, at least, heads had already rolled. The NHS in the county stopped using Take Care Now’s weekend and evening GP services in Fenland and East Cambridgeshire four months before its contract was due to end.

Next door, the NHS Suffolk Board named another nationwide service provider, Harmoni HS Ltd, as its preferred provider for its new OOH GP and dental contract. The newly commissioned service went live on 1 April.

As for Take Care Now, it appears to have been taken care of for good. Following consultation with those PCTs in contract with Take Care Now, Harmoni went out and bought a controlling interest in the company – and its contracts.

Unsurprisingly, if not entirely logically, corporate “contract transfers”, such as a similar one in Lancashire in which Assura sold its primary care business to Virgin, have caused protests from smaller potential providers. Dr John Horrocks, for example, the chief executive of social enterprise provider Urgent UK, would like to see legislation to prevent commercial entities from selling on OOH contracts with the “passive permission” of their PCT commissioners.

One of the most curious aspects about the OOH debate has been both the promotion and criticism of commercial entities. For decades, successive governments have tried to turn what were genuinely self-employed independent contractors – GPs – into quasi-NHS employees. Paradoxically, it’s some of these original “subcontractors” who are now the most critical of the  private sector.

A brighter future?
What do practice managers think? Shelagh Eggo says that even though her local not-for-profit GP-run service is satisfactory, she is concerned that its widening geographical range may lead to difficulties for both doctors and patients.

One of the biggest challenges is the difficulty of employing sufficient staff. Despite this problem, Mrs Eggo believes the best method of providing OOH services is by GP-run organisations, not by commercial companies.

However, David Channon, manager of the Wandsworth Medical Centre in London, an area where Harmoni has the OOH contract, has no complaints about the service. He suggests that GP-run co-operatives are actually likely to be “a bit of a pain, with too many people trying to chip in”.

Meanwhile, what of the immediate future? With OOH services such a perennial source of mischief, it was surprising to see that in the run-up to the general election neither Labour nor the Conservatives’ manifesto on the NHS made any direct mention of the subject.

Andrew Lansley, then Shadow Secretary of State for Health, did at least have some comment, however. He said: “GPs should be put back in charge of OOH services and should be collectively responsible for commissioning it. They are best placed to ensure patients get the care they need, when they need it.”

Whatever politicians think, it would be hard to return a genie to a bottle it was seldom honestly in. The supposedly golden past of general practice was always a tarnished myth. The true history of OOH cover in modern history is a story of provision by a plethora of providers. And it is a tale scarred by the chronic failure of both GPs and NHS authorities properly to manage and monitor them.

Can that tarnished past become a brighter future? Yes, but only if PCTs or any future commissioning agencies manage and monitor contracts with real determination. Commissioners who forget the past are surely doomed to repeat it.

Can a practice “take back” OOH provision?
In the meantime, many practices may be tempted to consider taking OOH care back “inhouse”, though to do so at the moment is far from straightforward. Any practice that has handed over responsibility for OOH is not automatically entitled to provide the service if it wishes to move back at a later date.

Practices that have transferred responsibility, or new practices that want to provide OOH services, “will be considered alongside other potential providers”. And in any competition, all potential providers will have to show that they meet the relevant accreditation standards.

From 1 January 2005, any contractor providing OOH services was required to meet quality standards established in 2002.6 These standards were followed up by national quality requirements published in 2006.(7)

Meeting such standards may not be easy, but doing so will almost certainly be easier than presenting a business case and competing directly against large commercial organisations for a contract.

Practices contemplating making such a bid should not only ensure that they can meet the standards required, but also seek the advice of their LMC and local NHS managers before entering any competition.

References
1. Triggle N, Wilkinson E. Patient killed unlawfully by overseas doctor. BBC News 4 February 2010. Available from: http://news.bbc.co.uk/1/hi/8497911.stm
2. See www.managementinpractice.com/article_20345
3. Executive Council Journal 1960;11:171.
4. Executive Council Journal 1969;20:188.
5. Department of Health. General practice out of hours services. London: DH; 2010. Available from: http://www.dh.gov.uk/en/MediaCentre/Pressreleasesarchive/DH_111900
6. Department of Health. Quality standards in the delivery of GP out-of-hours services. London: DH; 2002. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
7. Department of Health. National quality requirements in the delivery of out-of-hours services. London: DH; 2006. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...