Memorandum by the NHS Alliance (GP26)
1. The NHS Alliance welcomes the opportunity
to comment on the principle and application of GP Out-of-Hours
services and would be pleased to give oral and/or oral evidence
should the Committee determine that this is appropriate.
2. The NHS Alliance is a national membership
organisation rooted in primary care and draws its membership from
both primary care organisations in the UK and individuals working
in primary care. In particular it reflects the critical partnership
between lay people, managers and clinicians in planning, securing
and evaluating effort to improve the health of local populations.
3. The NHS Alliance is committed to values
of fairness, equity and collaborative working within a structure
that is mutually supportive and accountable. Both national and
local organisations have an important role to play in delivering
those values.
4. In keeping with the guide to preparing
written evidence to the Health Committee, this evidence is a summary
and is therefore concise and in the form of a self contained memorandum
that addresses the terms of reference set out by the Committee.
5. In order to produce this memorandum,
the NHS Alliance has canvassed its members and the following represents
nearly 50 responses or 20% of all Primary Care Trusts in England.
This has been achieved at short notice and within a seven day
period.
a. | The general readiness of Primary Care Trusts to undertake their responsibilities with regard to Out-of-Hours services
| The majority of Primary Care Trusts are satisfied that they have plans in place that will provide for a replacement service to be in place by agreed target dates in the Autumn 2004. A small minority have already commenced alternate service provision. Of nearly 40 respondents, only three cited major reservations about their prepardness to be able to provide out of hours services.
In one PCT area, there is expected to be no change, as over 90% of GPs intend to continue to provide OOH cover. In the majority, practices are withdrawing from OOH arrangements. In these areas, services are being planned either:
— as directly managed services led by one PCT on behalf of others; or
— are being tendered and will be provided on an outsourced basis.
b.
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The role of GP
co-operatives
| Many co-operatives are evolving into mutual service providers which will take over responsibility for service delivery. Co-operatives are and have been key in managing the transition period.
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c. | The role of NHS Direct
| Is seen as critical in being the front end of replacement services. Key concerns include the need to harmonise procedures, software and treatment protocols to produce a single coherent service—see below.
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d. | The potential impact on other NHS services, including community hospitals, minor injury units, GP clinics, and A&E services
| Most PCTs recognise that the key issue is integrating unscheduled care and not just replacing GP OOH cover. In approximately a third of PCTs amongst those responding, the process has provided a valuable opportunity to bring stakeholders together to collaborate on service provision. The most significant problem is seen as uncontrolled variety of access points for patients with an absence of assessment and triage procedures. It is considered that it will take a number of years to achieve full integration and that there is a significant challenge in educating and informing the public as to how to access unscheduled care appropriately—especially given the variation in local circumstances.
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e. | Potential financial implications
| Almost all PCTs see the "new" services as costing more than the historic service and a significant number anticipate that this will restrict their ability to develop services in other areas. Increased costs will result from:
— Market pressures exerted by new providers.
— NHS Superannuation costs.
— Costs associated with rurality.
Many PCTs feel that the increased cost of providing alternate OOH provision will threaten their financial stability in the current year.
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f. | Potential implications for quality of Out-of-Hours services, including rapidity of response, provision of backup and quality of patient care
| Most PCTs see this is an opportunity to improve and harmonise service provision and to manage public expectation. A number of concerns have been raised which are significant in terms of quality:
— The requirement to trim service quality and quantity to match funding availability.
— An inability to recruit appropriate clinical staff.
— Uncertainty over accreditation arrangements (one or three years).
— The general impact of loss of experience (particularly for training and development purposes) previously gained by participation in OOH cover.
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g. | Skill-mix within Out-of-Hours services
| Almost all PCTs are putting in place arrangements that provide for an appropriate clinician to be available to patients out of hours. This includes:
— Ambulance Trust employed paramedics.
— Nurses.
— Pharmacists.
— Doctors.
— Appropriate support staff.
The multi-disciplinary nature of this provision is a feature of many alternative arrangements but has increased the complexity of service planning and delivery.
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h. | Arrangements for monitoring Out-of-Hours services
| Those with contracted out arrangements have developed service specifications against which service provision will be measured. The NHS Alliance believes more attention should be paid to the development of appropriate monitoring and evaluative mechanisms, particularly concerning clinical quality.
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| i. | Implications for urban and rural populations
| The balance appears to be that service provision is proving more difficult to secure in rural settings because of:
— Increased costs of services.
— Increased travel times.
— Poor transport infrastructure.
— Cross-boundary complexities.
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CONCLUSION
— Planning for the replacement service has placed
a severe burden on Primary Care Trusts and other primary care
professionals at a time when there is a large, fast-moving agenda.
— The NHS Alliance believes that most Primary Care
Trusts have the replacement of GP OOH traditional arrangements
in hand and are confident in alternative service provision.
— These new arrangements are more likely to integrate
unscheduled care. This is welcome and will improve patient experience
in the medium to long term, but will present short-term difficulties
around transitions as new arrangements "bed down".
— The new services will cost more than those replaced
and this will place many PCTs under significant budget pressures.
— Recruitment is a major challenge in many areas,
but new services will be successful only if provided on a multi-disciplinary
basis and there are clear benefits to be gained where an integrated
service across the community and hospitals can be provided.
— Public engagement and education about replacement
services has not yet begun in earnest. This is critical to the
smooth transition of care arrangements and must be undertaken
at national and local levels to allow for geographical variation.
— Arrangements for service monitoring are in their
infancy.
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