A review of the new system for providing out-of-hours primary medical care has warned that some primary care trusts (PCTs) are failing to provide a satisfactory standard of service.
Although GP practices are no longer responsible for providing out-of-hours care, commentators say this is an area they need to keep a handle on because it is in everybody's interests that patients receive an effective service.
The scrutiny of out-of-hours care in England was launched by the National Audit Office (NAO) to examine how the new services have fared since they were handed over to PCTs when the new General Medical Services (GMS) contract was introduced in 2004.
Most GPs handed over responsibilty for out-of-hours services during the period from April to December 2004. By April 2005, 75% of out-of-hours provision was being carried out by PCTs or through cooperatives, with the remaining 25% provided by commercial providers, ambulance trusts and others, and with NHS Direct supplying initial call-handling for many providers.
NAO report's findings
The NAO found that there were shortcomings in the process of setting up many of the new services, but there was no evidence that patient safety was ever compromised.
One major problem initially encountered by PCTs was their lack of knowledge and experience in providing out-of-hours care. They did not even have access to reliable management data, including such fundamental factors as demand and cost.
However, a survey of patients found that most felt they were receiving a good service, with six out of 10 rating it as
excellent or good.
The report says that, despite the teething problems, the service is gradually beginning to reach a satisfactory standard, although fewer than 10% of PCTs are meeting the speed of response targets. It also recommends that a clinical assessment should be started within 20 minutes of a call for urgent cases and within 60 minutes of a call for nonurgent cases. No providers are meeting all the requirements.
The NAO reveals that the actual costs of providing out-of-hours care under the new system are considerably higher than the amount calculated by the Department of Health (DH), and that there is scope to reduce costs – at least £134m a year – without compromising quality. The total cost for the first full financial year of the new system was £392m – 22% more than the £322m allocated by the DH.
PCTs are also criticised for making limited progress in integrating out-of-hours care with other emergency care networks. An elderly housebound patient requiring care at night, for example, could be visited by representatives from a large number of different services, including an out-of-hours doctor, nurse or emergency care practitioner, an intermediate care team, a district nurse, or a paramedic team from the local ambulance service.
Need for greater integration
Rick Stern, former Chief Executive of Bexhill and Rother PCT, and now Primary Care Provider Network Lead for the NHS Alliance, agrees with many of the key issues highlighted by the NAO. These are that commissioners need to understand the sector better, to concentrate on the potential to make savings, and to improve integration of out-of-hours with other urgent care services.
But the good news is that providers of out-of-hours services have matured in the last few years, often developing from co-ops into mutuals or businesses, and are now more sophisticated organisations. The advantage of the mutual structure is that the company is owned by staff and its community, rather than existing for profit. This creates stronger leadership and better management, argues Mr Stern.
Another key theme is the need for PCTs to obtain better information and better quality indicators so that they can improve benchmarking, and thus improve performance and drive up standards of care.
Practices still have a key role to play in improving the emergency care they provide. Some are already making big strides forward by working together using practice-based commissioning (PbC), not just to look at elective care but also to look at new and more effective ways of handling emergency care. One example is where several practices arrange as a group to have one doctor on-call specifically to deal with emergency call-outs, so that they can see patients quickly and efficiently. This has dramatically reduced the level of emergency admissions.
The Provider Network is currently working with PCTs in looking at the data for emergency admissions in each practice across a certain period. After standardising the data for most factors, they have found in some areas a 600% variation over a whole year in the level of emergency admissions.
Mr Stern comments: "There may be all sorts of reasons for that, but some of it must be how practices are managing the care of those patients. We are working to find out more about what those at the top spread of variation are doing and what those at the bottom are doing. There must be some key issues about managing it better."
Opportunity for change
For the future, Mr Stern says that there is an opportunity genuinely to change the way out-of-hours services are delivered and to integrate them better into 24-hour primary care.
"There hasn't been much attention so far on what general practice can do to manage itself differently. We need to look at whether we need more community nursing teams, more diversion teams, or need to put more GPs in Accident & Emergency departments. All these roles have a part to play, but to date most people have underestimated what can be done within and across general practice, particularly the notion of working in clusters, which is what PbC is all about."
He adds: "It is in everybody's interest to have an effective out-of-hours service that is managed well and connects with all other parts of the system, otherwise it will inevitably rebound on general practice."
Jo Webber, Deputy Director of Policy at the NHS Confederation, says the NAO report has flagged how variable performance has been across the country.
She says it is important to remember that, at a time of change and reorganisation, PCTs have built an out-of-hours service that 80% of patients are satisfied with and 60% rate as excellent or good. Many have accomplished this in less than 18 months, which is a huge achievement.
In some places, out-of-hours services have been working well. One example is SELDOC, the South East London Doctors Co-operative, where a longstanding relationship between a collaborative and consortia of GPs and PCTs has been built up. When the PCTs took charge in 2004, the upheaval had been minimal and had been mostly about formalising the connections. However, in other places services had not been so well developed.
"But it's early days yet," says Ms Webber. "People will have learned from this year's experience and will be looking at the best performance that has been achieved and seeing how they can improve things in their own areas."
She adds that there are issues in the report that GPs need to be aware of because both sides will need to play a part if their services are going to work. "Everybody wants patients to have a good out-of-hours service," she remarks.
Demand management issues
Dr James Kingsland, Chairman of the National Association of Primary Care, says his concern is that now services are run by PCTs the driving force to manage demand has been lost. When GPs provided services, he explains, they had a vested interest in keeping numbers down by doing more triage or spending time explaining to the patient why they did not need treatment in the middle of the night. This meant that services were used more appropriately and effectively.
Now, he says, the culture has changed and there is no longer a personal vested interest in demand management. He adds there is anecdotal evidence that more patients are using the PCT-managed services. "I have mixed feelings about the changes – if you asked me if I would ever go back to doing my own on-call myself, I would say no. But if you asked, 'Has there been a compromise in demand management?', most people would say yes – that is the quid pro quo of it."
Like Rick Stern, Dr Kingsland agrees that PbC provides the opportunity to improve services. He believes that some practices may even consider working together and taking back responsibility for providing out-of-hours services because they could make savings from the resources currently being squandered through poor demand management, which could be invested back into improving their own services. He says his practice in Wallasey is currently revisiting the idea of opening again on Saturday mornings and until 8pm at night.
Patient reception mixed
Diana Kirk, joint practice manager of Lombard Street Surgeries in Newark, Nottinghamshire, says initially it was a big culture shock for their 17,500 patients when they suddenly stopped opening on a Saturday morning. Despite extensive advertising, a number still turned up, although after a few grumbles most have now accepted the new arrangements.
"The new system has eased the burden for GPs. It was a tremendous responsibility to be on-call 24 hours a day. Our practice is very satisfied with our local provider, and one of our GPs is involved and sits on the out-of-hours executive," she comments.
Dr Paul Roblin, Chief Executive of Thames Valley Local Medical Committee, says in his area services have been patchy, with about 50% having a good reputation and 50% logging increased complaints from patients, particularly concerning delays in treatment.
In the area where there has been general satisfaction, the new arrangements have not been too dissimilar from the old co-op type of system. But where there have been problems, services have been provided by third-party private organisations. The contract volume has been low, so they have had to cut corners, and that has meant employing either doctors from abroad or more nurses.
Ambivalence over care
Dr Roblin says that for years the government got the out-of-hours service on the cheap because the true cost of providing it when it was the responsibility of GPs was never recognised. GPs are also critical of a drop in quality standards that has been sanctioned by the government – the time allowed for phoning back a patient for a routine complaint has gone up to six hours.
Dr Roblin also worries about the future of out-of-hours services that have to be provided in an environment where PCTs need to make draconian cuts to address the NHS deficit.
"GPs are ambivalent about the changes – they are happy they are no longer having to do it because the quality of their work–life balance has improved, but on the other hand they do see the consequence that in some places patients are getting a worse deal," he concludes.
Sheila Williams, a former practice manager and now Director of Liaison and Development at Wessex LMC, says services have been variable across their area, which covers 500 practices.
Following a top-level review, work has been undertaken to centralise call-hand-ling and reduce duplication across three different services. There have been many – sometimes heated – discussions in which the local medical committee (LMC) has been included. There have been complex issues to weigh up about workforce skill mix, how quickly a doctor or a nurse takes to triage calls and how long it takes a patient to be treated.
"We have been encouraging doctors to take an interest and become involved in shaping the service," says Ms Williams. "Once the whole unscheduled care service is rolled out and PbC starts to impact, if patients are not managed correctly and if, for example, doctors do not understand the costs of operating at night, then we are going to get friction between out-of-hours services and GPs."
But she concludes: "The system isn't perfect, but people are genuinely working together to make it better. I am optimistic for the future".
The Provision of Out-of-Hours Care in England can be downloaded from: