Different models of service provision
29. We have received evidence of a number of different,
innovative models of service provision. We were impressed by the
positive experiences in areas such as West Hull and East Anglia
where GP out-of-hours services have been successfully integrated
with ambulance services. We also took evidence from Primecare,
England's largest commercial provider of GP out-of-hours services,
who were keen to adapt and respond to local needs.
30. The evidence we received from organisations developing
new services demonstrated the crucial importance of building on
existing local expertise by working collaboratively with existing
GP out-of-hours providers, with an example of this being provided
by East Anglian Ambulance NHS Trust:
Within Norfolk, all six GP co-operatives collectively
agreed to dissolve and worked with East Anglian Ambulance NHS
Trust to amalgamate the current systems into the newly formed
service called Anglian Medical Care. The service proposal that
was put forward to the six PCTs was supported by all six GP co-operatives,
the acute trusts and the Local Medical Committee. Each of the
GP co-operatives was involved from the beginning and had input
in the planning and the submission of the proposal.[36]
31. However, this level of co-operation with existing
GP out-of-hours services again does not seem to be uniform across
the country. The evidence given by East Anglian Ambulance NHS
Trust contrasts starkly with the reports made by North Yorkshire
Emergency Doctors, a GP co-operative, who stated that two of the
PCTs whose area they currently cover initially selected the local
ambulance service as their preferred out-of-hours provider without
even consulting them.[37]
32. We are impressed
with the potential of some models of GP out-of-hours service provision,
including integration with ambulance services and creative use
of skill mix. However, some of the models we have seen seem to
be predicated on well developed collaborative working relationships
with successful existing local out-of-hours service providers,
and we urge the Department to encourage such collaborative working
wherever possible.
33. In future, it is planned that NHS Direct will
play an increasingly important role in the delivery of GP out-of-hours
services. NHS Direct was first established as a stand-alone helpline,
with calls to NHS Direct being answered by call-handlers who receive
two weeks induction training, but are not clinically qualified.
Calls are then returned by NHS Direct nurses who will give patients
advice, which may include their administering self-treatment,
making an appointment to see their GP, calling their GP out-of-hours
service, going to their local A&E department, or, in emergencies,
calling an ambulance.
34. The Carson report set out a central role for
NHS Direct in the implementation of an integrated model of out-of-hours
care. Under this model, patients accessing out-of-hours primary
care would be transferred through a single telephone call to an
assessment of clinical need conducted by NHS Direct. The patient
or carer would either be given health information or advice on
self-care or, where necessary, be referred to the point in the
local network of out-of-hours care best able to meet that patient's
needs.
35. The NHS Plan was published mid-way through the
Carson review, and was informed by that report's preliminary findings.
It included the aim that "by 2004 a single phone call to
NHS Direct will be a one-stop gateway to out-of-hours healthcare,
passing on calls, where necessary, to the appropriate GP co-operative
or deputising service".[38]
This aim was affirmed in the Priorities and Planning Framework
2003/06, Improvement, expansion and reform: the next three years.
Ed Lester, the Chief Executive of NHS Direct, explained to us
that NHS Direct was currently able to provide two distinct 'products'—call
handling, and nurse triage. The key service models for NHS Direct
are:
- Full clinical integration:
calls are diverted from GP surgeries during out-of-hours to NHS
Direct—providing single call access—where callers
are assessed, given advice or information by NHS Direct and/or
referred on as appropriate.
- Call handling only: calls are diverted from GP
surgeries out-of-hours to NHS Direct—still providing single
call access. Life-threatening emergencies are passed onto 999
and all other calls passed onto the out-of-hours provider. This
may be particularly useful as an interim service until full clinical
integration is achieved.
- Full clinical integration where staff are co-located
with out-of-hours providers: this model is based on the full clinical
integration model outlined above with the addition of nurses being
co-located with out-of-hours providers. This is likely to be more
expensive, although PCTs may be prepared to pay a premium to support
this level of close working. In this model, nurses could be employed
to carry out a dual role, providing telephone triage and face-to-face
care.
- Nurse assessment only: in this model calls would
be handled, and in the future possibly streamed, by an out-of-hours
provider and only those calls that could benefit from nurse assessment
would be passed onto NHS Direct. The out-of-hours provider would
need to use the NHS Direct software to support call transfer,
audit and support seamless single call access.[39]
36. By December 2006, NHS Direct aim to be able to
provide a clinically integrated out-of-hours service to 100% of
the population, although local needs and choices will dictate
which type of service is provided. The Department and NHS Direct
confirmed in their memoranda that by December 2004 technical links
will be in place to enable NHS Direct to transfer calls, where
appropriate, to local GP out-of-hours services.[40]
NHS Direct is currently working with the Department and SHAs to
identify those areas that might benefit most from clinical integration
with NHS Direct, to achieve early PCT-funded integration with
the service by April 2005. NHS Direct will be able, if required,
to take on the full role of accepting all calls to GP out-of-hours
services by the end of 2006.
Quality
37. In its memorandum the Department pointed out
that national quality standards for out-of-hours services now
exist, and will apply to all providers of GP out-of-hours services:
The national quality standards are currently being
reviewed to ensure that they take account of the changing realities
of service provision, where a wider variety of organisations and
health professionals will provide the service. Although the new
standards will have a sharper focus on clinical outcomes and the
audit of patient satisfaction, they will closely follow the existing
standards for access and clinical assessment. These set out the
maximum duration for episodes of care, including the maximum permissible
times patients should wait for a telephone or face-to-face consultation.
The new standards will come into effect on 1 January
2005, and from this date all providers of out-of-hours services
(including GP practices who choose not to opt out) will have to
meet the quality standards as a contractual obligation.
The revised quality standards will include requirements
that patients must be able to see a GP out-of-hours where necessary.
Work is under way to frame a suitable standard through a small
project team that consults with an expert reference group. The
aim is to have a standard which requires PCTs to make arrangements
for appropriate levels of GP cover, but without being prescriptive
about what that level should be. [41]
38. The Department stated that it had made it clear
to PCTs that they should have in place a contingency plan which
could be put into immediate operation should an out-of-hours provider
fail. They also argue that the greater role for PCTs in commissioning
out-of-hours services should provide new opportunities to improve
arrangements for the supply of medicines out of hours. The Carson
Review recommended that, other than in exceptional circumstances,
patients should be able to receive the medication they needed
at the same time and in the same place as the out-of-hours consultation.
A guide for PCTs and providers is in preparation and will be issued
in Summer 2004, setting out approaches for PCTs to achieve this
recommendation. The guide will include a new national formulary,
which identifies those medicines which should be available to
meet patients' urgent medical needs during the out-of-hours period.
39. The NHS Confederation suggested that the quality
of the existing system was "variable", and pointed out
that under the new system all providers, including those who continued
to provide their own out-of-hours services, would be expected
to meet the national standards.[42]
40. We look
forward to the publication of the guide for PCTs and providers
to be issued in Summer 2004, and recommend that it makes mandatory
scope for the provision of medication, where necessary, at the
same time and place as out-of-hours consultation.
29 Appendix 18 Back
30
Ev 62-63 Back
31
Triage is a system of classifying patients according to their
clinical need to determine the most appropriate type and place
of care. Back
32
Ev 2 Back
33
Ev 41 Back
34
Appendix 18 Back
35
Appendix 22 Back
36
Ev 42 Back
37
Appendix 9 Back
38
The NHS Plan, Department of Health, 2000; paragraph 12.4 Back
39
http://www.dh.gov.uk/assetRoot/04/07/50/42/04075042.pdf Back
40
Ev 62; Ev 45 Back
41
Ev 63 Back
42
Appendix 18 Back
