1 Introduction
1. Every year, approximately nine million patients
receive urgent primary care out of hours.[1]
The 'out-of-hours' period, as it is now defined, accounts for
two-thirds of every week.[2]
Not only do GP out-of-hours services provide essential medical
cover during the larger part of the week, they also act as a vital
means of managing demand on the rest of the health service, since
in the absence of accessible GP out-of-hours services, patients
may seek care by attending the Accident and Emergency (A&E)
Department of their local acute hospital, or by dialling 999.
The National Association of GP Co-operatives (NAGPC) argued in
evidence to us that "the numbers are such that a small percentage
transfer from GP out-of-hours services to A&E would have a
significant impact on A&E flows and therefore waiting times".[3]
2. However, despite the indispensable round-the-clock
provision they offer, GP out-of-hours services tend to be largely
invisible, without high-profile political targets or initiatives
to draw attention to their work. The lack of priority afforded
to GP out-of-hours services was emphasised to us by the Rt Hon
John Hutton MP, the Minister with responsibility for this area:
If you were to look critically at the development
of out-of-hours, it is not an unreasonable conclusion to say that
out-of-hours services, although there have been tremendous amounts
of change in out-of-hours, has not had the same focus certainly
in comparison to other parts of the health service.[4]
3. The changes to which the Minister referred include
the move towards greater use of GP out-of-hours co-operatives
during the mid 1990s. GPs currently have a responsibility to care
for their patients 24 hours a day. Historically, if a patient
who was registered with a GP required urgent medical care outside
their GP's surgery hours, that patient could expect out-of-hours
care, either in the form of a telephone call or a home visit,
from his or her GP. If GPs were single-handed they would provide
all of their own out-of-hours cover, or, if they worked in a partnership,
might provide cover in a rotation with their partners, or sometimes
through an extended rotation with a couple of other local practices.
Although there have long been alternatives to these intense working
patterns, including commercial deputising services and GP co-operatives,
according to the British Medical Association (BMA) it was not
until the mid-1990s that there was a major trend towards care
delivered by organisations above the level of the individual practice.
This also led to a shift towards more premises-based care, where
patients could be seen out of hours at a primary care centre rather
than having a home visit.[5]
Department of Health figures show that at the beginning of 2004,
approximately 70% of GPs had delegated the responsibility to a
GP co-operative, and around 25% to a commercial provider, leaving
only 5% of GPs providing their own out-of-hours services.[6]
4. Following concerns raised by the Health Services
Ombudsman, a review of arrangements for GP out-of-hours cover
was commissioned by the Department of Health and published in
October 2000 (the Carson Report). The report identified a future
model of out-of-hours care in which Primary Care Trusts (PCTs)
would develop an integrated network of unscheduled care provision,
bringing together providers of out-of-hours services to work collaboratively
with other health and social care providers such as A&E and
ambulance services. The report identified the core quality standards
to which all out-of-hours services should be delivered in the
future.
5. In addition to questions being raised over the
quality of out-of-hours provision, there was growing concern within
the medical profession that the requirement to provide out-of-hours
care was contributing to low morale amongst GPs, and 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 GPs. The BMA's General Practitioners
Committee's National Survey of GP Opinion in 2001 found that 83.8%
of family doctors believed that it should be possible for individual
doctors to choose whether to opt out of out-of-hours responsibility.[7]
6. Under the terms of the new General Medical Services
(GMS) contract, which was agreed in 2003, GPs are now able to
opt out of the obligation to provide out-of-hours care for their
patients. Until 31 December 2004, GPs may opt out with the agreement
of their PCT. After 1 January 2005, GPs will have a right to opt
out in all but exceptional circumstances (including, for example,
GPs working in remote and isolated areas). Where practices opt
out, responsibility for securing out-of-hours services for their
patients transfers to the PCT. In financial terms, providing 24-hour
out-of-hours cover for all their patients will earn the average
GP approximately £6,000 per year. This funding will default
back to the PCT if GPs opt out. According to the BMA, approximately
90% of GPs are expected to opt out of providing out-of-hours services.[8]
7. Several of our witnesses have argued that the
shift in responsibility for GP out-of-hours services from individual
GPs to PCTs should not, if all goes to plan, impact upon patients
at all. The greatest cultural shift for patients, they suggested,
in fact occurred in the mid-1990s, when instead of being visited
by their own GP, patients had to adapt to receiving out-of-hours
care from a GP employed by a co-operative or commercial company
who was probably unknown to them.[9]
8. However, adopting responsibility for commissioning
and in some cases providing GP out-of-hours services is clearly
a huge undertaking for PCTs, many of which are still relatively
new organisations simultaneously grappling with numerous other
changes in the NHS. We chose to undertake this brief inquiry to
investigate how ready PCTs are for this new responsibility; whether
opportunities to improve services are being exploited fully; and
whether risks to the delivery of a high quality GP out-of-hours
service are being properly managed.
9. We launched this inquiry on 11 May 2004 with the
following terms of reference:
The Committee will undertake a short inquiry into
the potential impact of the GP contract on the provision of out-of-hours
services. In particular, this will include consideration of:
- The general readiness of
PCTs to undertake their responsibilities with regard to out-of-hours
services
- The role of GP co-operatives
- The role of NHS Direct
- The potential impact on other NHS services
- Potential financial implications
- Potential implications for quality of out-of-hours
services
- Skill mix within out-of-hours services
- Arrangements for monitoring out-of-hours services
- Implications for urban and rural populations.
10. During the course of this inquiry, we took oral
evidence from: the Rt Hon John Hutton MP, Minister of State for
Health, with officials from the Department of Health (the Department);
the BMA; the NHS Alliance; the Royal College of General Practitioners;
the NAGPC; the British Association for Emergency Medicine (BAEM);
Primecare, a commercial out-of-hours provider; NHS Direct; West
Hull PCT; and East Anglian Ambulance NHS Trust. In addition to
our oral evidence, we also received over 30 written memoranda
from NHS agencies, PCTs, ambulance trusts, patient groups, Royal
Colleges, charities, medical advisory bodies, GP co-operatives,
private GP out-of-hours service providers and individuals. We
are extremely grateful to all those who supplied evidence to our
inquiry. We are also particularly indebted to the NHS Alliance
who at very short notice undertook a snapshot survey of their
members' views on this issue. This is published in an anonymised
version in Volume II. Before taking oral evidence we had a discussion
about out-of-hours services with representatives from BMA Scotland,
which proved a very informative introduction to the subject for
us.
1 Ev 58 Back
2
Q17; the out-of-hours period is defined in the GP contract as
from 6:30 pm to 8:00 am on weekdays, and also the whole of weekends,
Bank holidays and public holidays (Investing in General Practice;
the new General Medical Services contract, para 2.18). Back
3
Ev 12 Back
4
Q141 Back
5
Q5 Back
6
Ev 58 Back
7
Ev 1 Back
8
Q61 Back
9
Q7; Q147 Back
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