Memorandum by by Primecare (GP17)
1. SUMMARY
— Primecare is the largest provider
of GP out of hours care in the UK.
— It serves more than a quarter of
the population.
— It has invested considerable resources
over the last 18 months to deliver standards set by the Department
of Health.
— Primecare's national infrastructure
offers a resilient and cost-effective service, providing an outstanding
service to patients and minimising cost to the public purse.
— Primecare is working with many PCTs
to deliver out of hours solutions in the new GP contract era.
2. INTRODUCTION
TO PRIMECARE
2.1 Primecare currently provides out-of-hours
services for over 7,000 GPs, or around 15 million people. It is
the biggest single provider of out-of-hours primary care in the
UK, predominantly serving urban centres, often with high deprivation
indices and challenging provision of in-hours services. The service
deals with some 60,000 calls a week.
2.2 Primecare is part of the Nestor Healthcare
Group, a publicly quoted company on the London Stock Exchange.
3. CLINICAL QUALITY
AND IMPROVED
PATIENT CARE
3.1 A substantial programme of investment
to improve clinical quality has been undertaken to ensure that
standards reach those set out in the October 2000 Department of
Health Review (the Carson Report) and that the patient experience
is an increasingly positive one.
3.2 Primecare has developed clinical governance
processes and structures to improve quality, manage risk, monitor
performance, and provide systems of accountability and responsibilities.
Our standards for responding to complaints exceed those of the
NHS, and we have national review and analysis to enable closure
of the quality improvement cycle.
3.3 Carson Access Targets are challenging.
We have invested £12 million over the last 18 months in the
development of a clinical network centred around two Clinical
Response Centres, set up to ensure that telephone answering and
clinical triage advice standards set by the Department of Health
can be met in the most resilient and cost-effective manner. The
success of these centres has been shown by consistently high and
improving standards for telephony and triage over the past six
months (see Appendix 1).
3.4 Impressive levels of telephone triage
and clinical consultations have been achieved via the use of a
pooled national resource (our "Central Triage Pool"),
meaning that calls are dealt with on the basis of assessed clinical
need, rather than by location. Assisted by sophisticated resource
planning software, triage performance has almost doubled in 6
months. This achievement means that Primecare will answer patient
calls in an average of 12 seconds. If patients require clinical
advice they will be called back by a doctor or a nurse in an average
of 11 minutes mid-week, and 18 minutes at weekends when the service
is at its busiest. The UK wide Central Triage Pool also allows
a balancing of local peaks and troughs in demand and supply.
4. CLINICAL STAFF
AND SKILL
MIX
There are problems in attracting clinicians to
work in the out-of-hours period, and an urgent need to optimise
their use
4.1 Primecare has invested over £1
million in a programme of "Home Teleconsultation", enabling
clinicians to work from home using the modern communications software,
clinical decision support and telephony that would be found in
a branch or Clinical Response Centre. This has increased recruitment,
flexibility, quality and the geographical area from which clinical
staff can be drawn.
4.2 Skill mix is important, but recruitment
can be difficult.
4.3 More than 200 nurses now provide care
for the patients served by Primecare. Though predominantly providing
telephone consultation to date, increasingly nurses are able to
play a major part in face-to-face consultation, assisted by a
comprehensive, externally accredited (University of Greenwich)
training and development plan. Emergency care practitioners, and
pharmacists, also form part of the Primecare multi-disciplinary
approach to care, which marks the company's endorsement of the
need to move away from the traditional doctor only model of out
of hours services.
4.4 Doctors will, however, continue to form
a key element of out-of-hours care. The new GP contract has removed
the contractual obligation for 24-hour care, raising doubts about
the desire of GPs to continue to be involved in such provision.
Historically, Primecare, and its commercial predecessors, has
by definition provided care in areas where GPs have elected to
purchase such services rather than provide them themselves. The
company thus has considerable experience of providing medical
services in the absence of contractual obligation.
5. PARTNERSHIP
Primecare works closely with all parts of the
NHS
5.1 From local PCTs and acute hospitals
through to the national organisations such as General Medical
Council, Nursing and Midwifery Council, NHS Direct and the Department
of Health, successful out of hours service provision requires
strong partnership working with commissioners and other providers.
This should be based on open information-sharing, consistent procedures
and policies, and a shared commitment to audit and review.
5.2 Primecare is committed to partnership
with the NHS in all areas and for example has been praised for
its partnership working with Leicester Royal Infirmary and its
joint working in North Tees (see Appendix 3).
5.3 We recognise that high quality in-hours
and out-of-hours care are interdependent. In a number of areas
Primecare is working with other agencies to enhance in-hours services,
including special allocation schemes for vulnerable patients excluded
from GPs lists and the provision of day time clinics to ensure
48-hour access.
6. POTENTIAL
FINANCIAL IMPLICATIONS
Cost is a key issue in the implementation of the
Out-of-Hours Review, and the new GMS contract
6.1 The traditional inclusion of out-of-hours
care within the 24-hour responsibility of GPs has contained clinical
resource costs, though they have still formed the most significant
element of out of hours primary care expense. Loss of this contractual
obligation has already led to fears of cost inflation. Primecare
is well placed to control such escalation, with its ability to
draw on staff from across the UK, rapidly introduce other health
professionals to broaden the skill mix, attract staff working
from home and the resource planning capability to ensure the shift
patterns of clinicians on duty closely matches patient demand.
7. IMPLEMENTATION
OF THE
OUT-OF-HOURS
REVIEW—NOW
AND THE
FUTURE
Primecare supports the development of robust access
and quality standards for out of hours care
7.1 Primecare has invested to ensure that
it has the technology, infrastructure and capacity to achieve
these standards for up to 20 million people, in a resilient and
cost-effective manner. Quality data demonstrate the progress made.
We are well placed to work with PCTs to meet the remaining challenges
of the Carson review.
7.2 In 2004 to date, however, a number of
primary care organisations have commissioned their out of hours
services "in-house", or from other new providers, whose
services are untried, particularly at times of peak demand, and
may lack resilience.
7.3 Failure to secure a reasonable proportion
of new contracts has lowered the population covered by Primecare.
Nestor issued a trading statement to this effect in mid-May 2004,
and is now undertaking a review of its cost base. Primecare currently
has spare capacity, and is willing and able to work with all parts
of the National Health Service to ensure high quality out-of-hours
and in-hours care throughout the UK. We seek to harness our strengths
of experience, resilience, and high quality, efficient telephony
and triage, with the knowledge, flexibility and vision of local
NHS services.
8. ORAL EVIDENCE
8.1 Primecare would be delighted to offer
oral evidence to the Committee, to expand on its written submission,
and to share with the Committee its expertise and thinking, if
the Committee would find this helpful.
June 2004
APPENDIX 1
PRIMECARE'S QUALITY PERFORMANCE
APPENDIX 2
CLINICAL QUALITY
BETTER RECOGNITION
OF MENINGITIS
A fundamental challenge in providing out-of-hours
care is to deal efficiently with patients' problems: to provide
appropriate care and to make best use of scarce resources. This
has to be done without overlooking rare and serious conditions,
even when they present with common symptoms. We have to optimise
referrals to Accident & Emergency Departments and hospital—neither
overloading Accident & Emergency Departments with self-limiting
illness, nor delaying transfer of patients who need specialist
care.
Perhaps the best example of this is the problem
of meningitis, which particularly in the early phases of the disease
can present with few specific symptoms.
Call handlers collect basic information, and
arrange for callers to receive clinical advice from appropriately
trained staff. We consider an important part of their job is be
aware of "alarm" symptoms, which may suggest more serious
conditions, and require accelerated attention. Call Handlers are
lay people, and we have sought to improve their understanding
of meningitis, its typical symptoms, and the actions to be taken.
This has been done through extensive training and the development
of a comprehensive set of guidelines drawing from the work of
the Meningitis Trust.
APPENDIX 3
PARTNERSHIP WORKING
3.1 LEICESTER
ROYAL INFIRMARY
PRIMARY CARE
CENTRE
Primecare moved its Primary Care Centre to the
Leicester Royal Infirmary in March 2003 as part of the Leicestershire
Emergency Services Collaborative initiative to reduce trolley
waits in the Accident & Emergency Department and provide more
appropriate treatment of primary care cases within University
Hospitals of Leicester.
The facility is located in an outpatient clinic
immediately adjacent to the A&E Dept and comprises of reception
facilities and access to 12 consulting rooms. Primecare currently
use up to six of these at any one time, but are able to expand
in emergency situations such as epidemics. This centre serves
the inner city and surrounding area, and transport to the hospital
site is good.
The Centre opens for a total of 114 hours per
week as shown below:
| Mon/Tues/Wed/Fri | 19.00 to 08.00
|
| |
| Thursday | 18.00 to 08.00 |
| |
| Saturday | 08.00 through to
|
| |
| Monday | 08.00 |
The centre accepts referrals from the Accident & Emergency
Department during all operational hours following protocols devised
by the Local Primecare Medical Director and the Senior A&E
Consultant. The referral process is well used by the department,
with for example 228 referrals in April 2004 and 217 in May 2004.
In addition to these patients Primecare see some 3,000 patients
per month seeking the normal out of hours primary care service.
This service:
— provides a better and more appropriate patient
experience;
— reduces pressure on the A&E department allowing
them to focus on trauma and acute secondary care patients; and
— demonstrates Primecare's integration with local
NHS Services.
3.2 CASE STUDY
OF WORKING
WITH PCTS—NORTH
TEES
The following are press items from national and local press
concerning Primecare's work in North Tees, a mixed urban and rural
population of some 750,000.
"GPs bid early farewell to out of hours—A Case Study"
Source: General Practitioner
Monday 22 March 2004
GPs within Middlesbrough, Lanbaurgh, North Tees, Hartlepool
and Darlington PCTs will be able to opt out of 24-hour responsibility
from 1 April, thanks to the PCTs contracting commercial provider
Primecare to take over.
Martin Phillips, head of primary care at Middlesbrough PCT,
explains that allowing GPs to opt out was something the PCTs had
been looking at well before the new GMS contract.
"We have been doing a lot of work since the Carson report
in 2000 trying to link GPs' out-of-hours work with our unplanned
and emergency care agenda. The new contract has provided another
mechanism to make sure that this happens," he says. "In
Middlesbrough we had been planning to allow GPs to opt out from
1 April for some time."
Primecare was identified as the preferred provider after
a competitive tender process. The company then spent three months
working with the PCTs to ensure they had the right service in
place. Primecare will link in with NHS Direct, A&E departments,
emergency care practitioners (ECPs) and the PCT emergency care
network. The service plans to expand the roles of nurses and other
clinicians, while maintaining doctor involvement where appropriate.
"Middlesbrough PCT has requested a requirement in our
contract with Primecare that our clinical services will eventually
take over the treatment element of the service," says Mr
Phillips. "Primecare will run the triage system and we will
have one clinical rota across the whole area that will enable
our clinicians to provide the face-to-face aspect of the service.
However, before we do this we have to have the infrastructure
up and running."
Dr Edward Summers, a GP in Redcar, East Cleveland, thinks
that the service will work well. Although his practice is opting
out, Dr Summers plans to continue to work for Primecare on a regular
basis.
"I have always done out-of-hours and worked for deputising
services," he explains. "I think if you don't do it,
there is a risk of becoming deskilled to a certain extent in emergency
care. I thought it was quite important to carry on doing the work."
Dr Summers' sessions are currently based in a primary care
centre or on the road in a mobile unit doing home visits, and
under the new arrangements this will continue.
Docs hail care "out of hours"
Source: Evening Gazette (in North Tees)
28 May 2004
New out-of-hours medical care arrangements have been hailed
a huge success across the Tees Valley.
The scheme has worked smoothly since its introduction on
1 April.
Around 50,000 letters were sent to patients in Darlington
alone, explaining the new system which asks them to call a single
helpline number.
And Darlington Primary Care Trust's public health director,
Dr Nonnie Crawford, said feedback from GPs had proved very positive.
Dr Richard Harker, chairman of the PCT's professional executive
committee and a GP, said: "From the point of view of my own
practice it's going very smoothly. I don't think the majority
of patients even realise there has been a change, which implies
the introduction has been seamless."
The introduction of the service followed a new GP contract
negotiated by doctors with the Government, which allowed them
to opt out of providing out-of-hours services.
The new system means patients who give their details are
called back by a trained healthcare professional who will assess
their needs.
They can then be advised over the phone or may be asked to
visit an out-of-hours care centre where they may be seen by a
nurse, an emergency care practitioner or a doctor.
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