Memorandum by the BMA (GP21)
INTRODUCTION—WHY
THE NEW
GP CONTRACT IMPACTS
UPON THE
PROVISION OF
OUT-OF-HOURS
SERVICES
1. The BMA's General Practitioners Committee's
National Survey of GP Opinion in 2001 dramatically confirmed endemic
low morale amongst general practitioners. That survey found that
96% of family doctors believed that too much was being asked of
general practice and 83.8% believed that it should be possible
for individual doctors to choose whether to opt out of out-of-hours
responsibility.
2. The Government and NHS managers, as well
as leaders of the profession, all agreed that the existing default
responsibility for all GPs to provide 24-hour care for their patients
made general practice unattractive for many prospective and current
general practitioners. As part of the early negotiations on the
new General Medical Services contract, the three negotiating parties
(the General Practitioners Committee, the NHS Confederation and
the four Departments of Health) agreed that GPs should have a
choice whether to provide out-of-hours services for their patients
and that where they chose not to, the provision of out-of-hours
services would be the responsibility of the local Primary Care
Organisation (PCO).
3. The contract documentation, "The
New GMS Contract 2003: Investing in General Practice", published
in February 2003, provided further information about the arrangements
for transferring responsibility.
4. "These arrangements may take time
to put in place in certain areas. They will be implemented on
a phased basis to allow PCOs, practices and new providers sufficient
time to manage the change effectively without detriment to patient
care:
(i)
until April 2004 out-of-hours will remain the responsibility
of the individual GP. The existing ability to transfer responsibility
to an accredited provider will remain and PCOs will be encouraged
to facilitate this;
(ii)
between April 2004 and December 2004, out-of-hours
will be a unique type of additional service. Individual practice
opt-out will be considered and implemented in the context of a
PCO-wide strategy; and
(iii)
by 31 December 2004, all PCOs should have put in
place effective alternative provision and, as a result, should
have taken full responsibility for out-of-hours. Strategic Health
Authorities (or their equivalents) will performance-manage this
process. In certain exceptional circumstances, eg remote and isolated
areas, there may be no alternative to the practice provision."
(Paragraph 2.23)
5. Under the new arrangements, PMS practices
(other than specialist PMS providers of out-of-hours services)
will also be able to opt out of providing mandatory out-of-hours
services.
6. In England, this policy development took
place in the context of "Shifting the Balance of Power"
and the devolution of responsibility for the provision of local
health services to Primary Care Trusts. The continued development
and growth of other initiatives, for example NHS Direct, signalled
the Government's policy direction towards further integration
of out-of-hours services and a plurality of providers.
FINANCIAL IMPLICATIONS
7. Historically, the costs of and rewards
for the provision of out-of-hours services have not been fully
recognised in GPs' remuneration. Much GP out-of-hours work has
been completed either at a discounted rate or for a notional charge
and, with the use of locums, deputising services and the development
of GP co-operatives, as well as private providers, it is impossible
to identify the full market cost of the historic provision of
this work.
8. As part of the new GMS contract negotiations
the parties negotiated an opt-out cost of £6,000 per GP with
an average practice weighted population. This value had to be
acceptable to all GPs, to incentivise both those wishing to transfer
responsibility and those wishing to retain responsibility. This
value does not represent the true cost of service provision; instead
this figure was negotiated as part of complex changes to the calculation
of GP income.
9. However, given the traditional underfunding
and undervaluing of these services, in many areas there may now
be a considerable potential funding shortfall. PCOs will not be
able simply to recommission the present medical model of services
but will have to consider strategic and more integrated and creative
solutions for service provision. The new arrangements for the
provision of out-of-hours services should allow PCOs to build
on existing local arrangements and allow for greater efficiency
of service provision across the PCO area through both economies
of scale and a more strategic use of skill-mix and local resources.
POTENTIAL IMPLICATIONS
FOR QUALITY
OF OUT-OF-HOURS
SERVICES, INCLUDING
RAPIDITY OF
RESPONSE, PROVISION
OF BACKUP
AND QUALITY
OF PATIENT
CARE
10. The transfer of responsibility for out-of-hours
care to PCOs should mean that high quality standards of out-of-hours
care will be maintained. All out-of-hours services commissioned
by PCOs will need to meet National Quality Standards and from
1 January 2005, all out-of-hours services included in GMS contracts
must meet these same standards.
11. A focused out-of-hours strategy across
a PCO area or PCO areas should ensure a high quality service for
patients. A greater and more integrated use of skill-mix could
mean that patients would be able to access the most appropriate
health care professional for their requirements. This would be
improved where out-of-hours urgent care resources were used to
facilitate capacity management and more rational care so that
resources could be directed in the most appropriate manner. Although
the majority of practices will be transferring out-of-hours responsibility
to their PCO, many GPs will continue to be involved in delivering
out-of-hours services, depending on the PCO strategy. They may
no longer have 24-hour responsibility for their patients, but
many are keen to perform these services under separate arrangements
dependent on the rewards and working arrangements.
12. The quality improvements arising from
the transfer of responsibility are not confined to out-of-hours
services. GPs providing in-hours services will be less tired and
more able to focus on delivering better quality of services in-hours
and recruitment will be encouraged. At present, there is a danger
of in-hours services breaking down due to a failure to attract
GPs.
SKILL-MIX
WITHIN OUT-OF-HOURS
SERVICES
13. Although many GPs will continue to deliver
out-of-hours care to patients, more use will be made of the skills
of other health care professionals including paramedics, emergency
care practitioners, nurse practitioners, nurses and pharmacists.
14. The use of skill-mix has been used in
a number of creative ways throughout the UK. In Derbyshire, for
example, nurse practitioners, based at local community hospitals,
are used in a triage role for out-of-hours care. GPs are available
to see patients when required. This service operates in tandem
with local paramedic services, and some local ambulance units
are also located at the community hospitals. Investing in General
Practice: Supporting Documentation published other examples
of innovative out-of-hours schemes, which are appended to this
evidence.
15. The BMA does have concerns that a greater
use of skill-mix in the out-of-hours period may generate inappropriate
demand during regular surgery hours if skill-mix is solely viewed
as a cost-cutting mechanism. An understanding of appropriate provision
is important in order to ensure that skill-mix is used as a vehicle
for efficient and effective patient care.
ARRANGEMENTS FOR
MONITORING OUT-OF-HOURS
SERVICES
16. PCOs will be required to undertake regular
monitoring and quality control of out-of-hours services. Each
PCO's out-of-hours planning and commissioning processes will be
performance managed by Strategic Health Authorities (or their
equivalents). It is vital that out-of-hours service provision
is also monitored at national level.
IMPLICATIONS FOR
URBAN AND
RURAL POPULATIONS
17. With appropriate and innovative strategic
planning and adequate resources there should be no reason for
a PCO to be unable to accept responsibility for the provision
of local out-of-hours services.
18. There has been an unfortunate assumption
that it is more straightforward to provide out-of-hours services
in urban areas and this has resulted in differential funding to
the disadvantage of some urban areas. In inner cities, PCOs, with
often large financial pressures to fund secondary care, may rely
on accident and emergency (A&E) departments to pick up any
underfunded activity. PCOs should aim to co-ordinate A&E,
community nursing and ambulance services, walk-in centres (where
they exist) and out-of-hours GP facilities and run these as an
integrated service which would bring the resources of all to address
the demands on all. In urban areas there are many opportunities
for such creative resource-sharing.
19. Significant issues for the provision
of out-of-hours services in rural areas include access for dispersed
populations, alternatives to GP provision, transport issues and
cover for community hospitals.
20. It was always envisaged that it might
not be possible for some practices in very remote areas of Scotland
to opt out of providing 24-hour services. These practices must
be compensated for retaining out-of-hours responsibility.
THE ROLE
OF GP CO
-OPERATIVES
21. It had been assumed that GP co-operatives
would play a vital role in the provision of out-of-hours services
under the new arrangements. Some GP co-operatives will continue
as not-for-profit providers of commissioned services to PCOs and
these will move from a purely medical to a multidisciplinary model.
However, many co-operatives could become destabilised if their
members opt out of service provision.
22. It is vital that PCOs do not assume
that current co-operative arrangements will continue without support.
THE ROLE
OF COMMERCIAL
ORGANISATIONS
23. There is currently one major commercial
deputising service: Primecare. Primecare is reported to have gained
fewer contracts than expected and its continuing stability is
a matter of concern.
THE ROLE
OF NHS DIRECT
24. The new arrangements should ensure that
NHS Direct (and NHS24 in Scotland) are able to be used as an integral
part of out-of-hours triage. However, it is possible that NHS
Direct may increase the demand on primary care services (both
in and out-of-hours) because of high levels of referrals. Furthermore,
there are serious concerns about the ability of NHS Direct and
NHS24 to cope with the increased demand in the short to medium
term without very significant additional investment. This could
have adverse affects on both the staff and financial resources
in other parts of the health service. We welcome the increasing
moves to use NHS Direct differently in different areas in accordance
with local views on how it can make the most appropriate contribution
to local health care.
THE POTENTIAL
IMPACT ON
OTHER NHS SERVICES
25. Demand not addressed by out-of-hours
services is likely to present elsewhere, especially other direct
access services such as A&E, walk-in services and 999.
Community hospitals
26. The BMA has particular concerns about
the impact of the transfer of responsibility for out-of-hours
services upon the provision of care in community hospitals. The
framework document about the new contract, "Your contract
Your future," published in April 2002, suggested that the
scope and responsibility for reviewing the remuneration structures
for such work would be considered by the negotiating parties.
To date the Department of Health in England has refused to undertake
this work. The BMA believes it is essential that the negotiating
parties urgently seek to agree at national level a national framework
for GPs working in community hospitals with local flexibility
to respond to the specific needs and circumstances of individual
community hospitals. Otherwise, the impact on out-of-hours services
will be two-fold. GPs will walk away from providing out-of-hours
services in community hospitals if the rewards are not sufficient,
given that they no longer will be obliged to provide out-of-hours
primary medical services through their GMS or PMS contracts. Indeed,
if they choose not to continue to provide out-of-hours services,
it is likely they will cease all services to the community hospital
as the current rewards are generally very poor, particularly compared
to the new earning opportunities in the GMS and PMS contracts.
Furthermore, if they do walk away this would seriously affect
the opportunities available to PCOs in developing an out-of-hours
service strategy, particularly in rural areas. Alternative provision
will be more expensive than securing fairer rewards to retain
GPs to provide the service.
A&E services
27. A small percentage transfer of activity
from GP out-of-hours services to A&E would have a significant
impact on A&E flows and waiting times. However, the new arrangements
offer PCOs the opportunity to examine resources across budgets
and tailor requirements according to any specific local issues.
A co-ordinated out-of-hours strategy which includes A&E services
and takes account of the Hospital at Night strategy is imperative
in order to ensure that these services do not become overburdened.
THE IMPACT
ON PATIENTS
28. Even before the transfer of out-of-hours
responsibility to PCOs, very few patients were able to see their
own doctor during the out-of-hours period as the majority of practices
have been using co-operatives, deputising services or a shared
rota with other practices to provide cover for the past decade.
Under the new arrangements, patients will notice a change in the
range of healthcare professionals providing care. There is evidence
that patients are happy to see a nurse or alternative healthcare
professional in particular circumstances but will continue to
expect attention from a doctor in other circumstances. Patients
should have access to a GP when they need one.
29. The BMA believes that the changes and
the monitoring of adherence to mandatory national accreditation
standards will be beneficial to patients, and that the changes
will improve GPs' quality of life. Patients will be seen by a
health care professional who is fresh and alert and will make
the appropriate response in the circumstances.
THE GENERAL
READINESS OF
PRIMARY CARE
ORGANISATIONS TO
UNDERTAKE THEIR
RESPONSIBILITIES WITH
REGARD TO
OUT-OF-HOURS
SERVICES
30. The BMA does have a number of concerns
about the readiness and capacity of many PCOs to undertake their
responsibilities for out-of-hours services. This capacity is largely
dependent on PCO strategic thinking and forward planning; those
that commenced planning over a year ago are well advanced or have
already taken over responsibility.
31. The most advanced areas generally tend
to be those where PCOs made an early decision to run the service
and have been most advanced in their planning. They have generally
involved and made use of other out-of-hours services to support
GP provision. Those PCOs which plan to commission out-of-hours
services from external providers appear to be less advanced and
will move more gradually toward integration. This means that the
current medical model (which is more costly to run) will be maintained.
32. Some PCOs have delegated out-of-hours
issues to managers who do not have the authority to make decisions.
This has resulted in a disengagement of stakeholders. It is vital
that all stakeholders, including GPs, are involved with the planning
of any new services. While some Strategic Heath Authorities have
become involved in strategic planning of out-of-hours services,
many PCOs have not looked beyond their own boundaries and so some
out-of-hours services have had to deal with multiple PCOs with
inconsistent approaches.
CONCLUSION
33. The new arrangements for out-of-hours
services offer PCOs great opportunities to use resources strategically
and efficiently in order to provide an integrated out-of-hours
service for patients. The benefits to the GP workforce, and potentially
to recruitment to general practice, resulting from the ability
to opt out of 24-hour provision of services, should not be underestimated.
Those GPs that are involved in the provision of out-of-hours services,
and particularly those who have been involved in the management
of services, should be involved in the planning of such services
and supported in doing so.
34. The BMA has concerns about the readiness
of some PCOs to take on out-of-hours responsibility. However,
there should be no justification for any PCO not accepting responsibility
by the end of December 2004.
The BMA is a voluntary, professional association
that represents all doctors from all branches of medicine across
the UK. About 80% of practising doctors are members.
June 2004
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