Memorandum by the Royal College of General
Practitioners (GP10)
HEALTH COMMITTEE
INQUIRY—GP OUT-OF-HOURS
SERVICES
The College welcomes the opportunity to submit
written evidence to the Health Committee's inquiry into GP Out-of-Hours
Services. We are also willing to give oral evidence to the inquiry.
The Royal College of General Practitioners is
the largest membership organisation in the United Kingdom solely
for GPs. It aims to encourage and maintain the highest standards
of general medical practice and to act as the "voice"
of GPs on issues concerned with education; training; research;
and clinical standards. Founded in 1952, the RCGP has over 21,000
members who are committed to improving patient care, developing
their own skills and promoting general practice as a discipline.
1. The general readiness of Primary Care
Trusts to undertake their responsibilities with regard to Out-of-Hours
services
From recent experience, most PCTs display a
lack of understanding of OOHs issues and, in general, are not
in readiness for this responsibility. In particular, PCTs lack
understanding of GP OOHs issues generally. This may be less of
an issue in areas where good GP co-operatives have been long established.
Where PCTs have clear arrangements in place, they will need to
turn their attention to modernising, rationalising and building
a sustainable service.
PCTs are also seen as reactive rather that proactive
organisations thus far, that underestimate risks, true costs and
practicalities of the OOH issue. They also generally fail to have
an appreciation of the good work done by GPs up to now.
There is a fear that PCTs hold false perceptions
that there is no real need for GPs to work OOHs and that GPs can
be replaced by nurses and other healthcare professionals. Although
we would welcome greater involvement of other professionals, the
College does not agree that GPs can safely be replaced. Our view
is that the skills of the generalist physician are an essential
element within the skill-mix for provision of safe OOH care. We
also question whether an adequate workforce to provide effective
skill-mix for OOH cover can be found.
We suspect that senior leadership within many
PCTs could be improved. Currently many junior managers and inexperienced
Directors within PCTs are left to lead on this critical issue.
In our view, PCTs often often demonstrate a
lack of strategic capacity, possessing a poor view of the whole
system and being currently preoccupied with targets, such as the
A&E 4hr target. PCTs can also display a lack of understanding
of the consequences of their actions and in general, suffer from
a lack of effective negotiation skills. They tend to act as single
units, working in a diverse way, rather than delivering a cohesive
approach for a whole city or area. They also tend to epitomise
an NHS as being an "organisation without a memory".
Many PCT Chief Executive Officers do not give
the impression of being fully engaged with, or having a full understanding
of, the implications of the new GMS contract (nGMS). Nor are many
PCTs working positively with GP Co-operatives, often being adversarial
and generating conflict.
It is our view that many Strategic Health Authorities
(SHAs) in fact lack strategic capacity and are not being proactive
in pushing PCTs.
We regret that generally there is little patient
or user involvement in discussions and where it exists, it is
often reactive.
2. The role of GP co-operatives
Co-operatives are in transition and some feel
under threat. The larger ones are more in tune with what is needed
for the transition period and for new models of service delivery.
Urban & inner city co-operatives are more
likely to advise GP members to remain opted in to OOH responsibilities
as most of these co-operatives are in a state of readiness with
experienced and established workforces.
There are uncertainties around the new role
in GP Registrar (GPR) training and in the role and performance
of Primecare, although contingencies are being worked through.
3. The role of NHS Direct
There are doubts in the system about the ability
of NHSD to cope with volumes of calls in the integrated model
and questions are arising around the clinical sorting of NHSD
(very risk averse) with high levels of urgent dispositions to
999/A&E/GP four hours.
At present, transitional arrangements are in
place with NHS Direct taking on the full role of accepting all
calls to OOHs services by the end of 2006. This approach will
put at risk many of the existing GP OOHs providers and in any
case, we question whether NHS Direct will ever have the capacity
to handle that volume of calls.
4. The potential impact on other NHS services,
including community hospitals, minor injury units, GP clinics,
and A&E services
The potential impact has not been fully thought
through by PCTs or local health economies. They are slow to respond
and lack a strategic view. There is merit in recommissioning OOHs
General Practice and nurse clinician support on the basis of providing
a quality response. It is inadvisable to allow OOHs providers
to carry out additional layers of triage, particularly as when
they are busy there is anecdotal evidence that work bounces back
to the Emergency Services.
PCTs and local health economies are not working
as cohesively as they could, with too much time and resource placed
on A&E targets in isolation.
Although the mutual model (community benefit
societies) proposed by DH/NAGPC appears, at this stage, not to
be popular, we suggest that consideration is given to the appointment
of a Care Co-Ordination Centre in each area (cf also the French
SAMU model) to ensure that General Practice, Ambulance Services,
Nursing and Social Care work more closely together.
The point of first patient contact with a clinician
is key. Previously, a patient was more likely to see a GP in the
home, who would then refer the patient directly to the appropriate
destination. This has changed and currently an ambulance or a
response unit is sent, the patient is taken to A&E and the
decision about treatment or admission is now made by a front-line
Senior House Officer with limited skills.
5. Potential financial implications
We perceive a general underestimation of costs
of providing OOHs services with little recall of the good will
displayed by GPs who have been performing the OOH services until
now. Attention is drawn to the resourcefulness of GP co-operatives
in keeping costs down to members, thereby masking the true cost
of GP OOHs service.
Most PCTs do not display the strategic perspective
to make funding shifts for "whole system" considerations;
most PCTs do not appear to have considered the potential of whole
system redesign with funding shifts post-December 2004.
6. Potential implications for quality of
Out-of-Hours services, including rapidity of response, provision
of backup and quality of patient care
Individual organisation risk only is being considered
rather than the whole system presenting the risk of a lack of
an integrated approach.
It is our view that GP co-operatives have been,
and are, working towards Carson standards with little support
from PCTs.
NHSD is working towards Carson standards—but
the system needs a new approach for faster and more appropriate
responses to maintain and improve quality of patient care. We
also have concerns regarding inconsistent approaches by PCTs and
GP co-operatives to appraisal of GPs working OOHs and the implications
of GPR training in the OOHs role.
7. Skill-mix within Out-of-Hours services
There is a general acceptance that a mix of
skills is needed but alternatives to GPs are scarce. Thus the
main professional during OOHs is expected to be the GP in the
foreseeable future. Deaneries and Workforce Confederations are
seen as very slow to respond in providing a workforce fit for
purpose.
8. Arrangements for monitoring Out-of-Hours
services
Where SHAs have got PCTs around the table a
process is developing—but this is patchy. There is a perceived
lack of timely guidance from DH in the post accreditation era
for OOHs standards.
9. Implications for urban and rural populations
In urban areas GPs are more likely to remain
and opt in but service re-design by PCTs may be challenged where
problems are encountered, especially over funding from PCTs. Unless
primary care OOHs services are as easy and convenient to access
as A&E services, patients will tend to go to the latter which
places an unfair burden on the A&E services.
Rural areas are likely to experience a much
greater opting out of OOHs services by GPs. While some contingencies
have been made, PCTs are not perceived as sufficiently innovative.
OTHER ISSUES
Children
The College draws the attention of the Committee
to the specific needs of children, particularly around issues
of access, environment and clinical care.
Access Issues: current OOH arrangements tend
to discriminate against children and young people, particularly
in relation to access such as difficulties in travelling to out
of hours centres with an ill child, especially in the situation
ofof a single parent with more than one child and limited social
support. Although "low users", teenagers are also unlikely
to be able to access OOH care easily, without parental involvement
because of travel issues.
Environmental Issues: it is not clear how "child
friendly" out of hours centres are and whether there are
any national standards on this. Centres should have child centred
facilities and staff that would enable appropriate observation
over a short period of time (eg to monitor response to anti-pyretic),
or such monitoring should be available within the home.
Clinical Care: concerns have been aired about
the adequacy of training of general practitioners to deal with
acute medical problems in children. This should be a core skill
but this is not necessarily the case.
The College also suggests that there is a need
to avoid the current trend for more children to be seen in A&E
out of hours, and assessed by paediatricians.
Access to Defibrillators
We are supportive of the Resuscitation Council
(UK)'s view that all those covering OOHs should carry and have
access to defibrillators. Approximately 5% of all patients with
acute infarction arrest in the presence of their GP and if the
GP has access to a defibrillator more than 60% survive.
At present, the British Heart Foundation statistics
show that around 75% of patients who arrest in a GP surgery also
survive, provided the practice has a defibrillator on the premises.
Community Pharmacies
The Committee may wish to consider an issue
that seems not to have been covered in their considerations so
far, that is the potential role of community pharmacy outside
normal surgery hours.
The compilation of these comments has been assisted
by a number of contributions, including those from Dr Tina Ambury,
Professor Tony Avery, Dr Dick Churchill and Dr Angelo Fernandes.
June 2004
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