Conclusions and recommendations
1. Our
evidence suggests that while PCTs across the country are in varying
states of readiness for taking on responsibility for providing
GP out-of-hours services, forward planning is taking place and
support systems are available. However, we were concerned at reports
that this critical transition was in some circumstances being
managed at too junior a level within PCTs, and also that some
PCTs were failing to think about more integrated approaches within
their wider local health economies. We urge the Department to
consider these concerns raised in our evidence in their support
and management of PCTs, and also to encourage, where possible,
a greater degree of public consultation and involvement around
the redesigning of GP out-of-hours services, as our evidence suggests
that this has so far been largely lacking. (Paragraph 21)
2. 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. (Paragraph 32)
3. 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. (Paragraph 40)
4. In our view, existing
GPs, including those who work in co-operatives, will continue
to form the backbone of future provision of out-of-hours services.
They are also the NHS's main source of expertise in this complex
area, and yet the availability of the GP workforce for out-of-hours
cover still remains uncertain. It is therefore vital that they
do not become disengaged from the process of redesigning GP out-of-hours
services during this critical transition phase, and their expertise
and local knowledge lost. We recommend that the Government should
take all reasonable steps to encourage PCTs to work collaboratively
with GPs, including those in co-operatives, and to encourage PCTs
to provide the flexibility and support, as well as the financial
incentives, necessary to retain a motivated GP workforce. (Paragraph
53)
5. We strongly support
the better use of skill mix to deliver out-of-hours care, not
only for its potential to relieve pressure on GPs and deliver
cost savings, but also, more importantly, for its potential to
deliver a better quality of service to patients. However, out-of-hours
care is a complex service to provide, and health professionals
other than doctors will need appropriate training if they are
to deliver it to a high standard. Our evidence suggests that those
working in the NHS are well aware of the difficulties attendant
upon recruiting and training this new workforce, and we urge the
Government to ensure that PCT forward planning allows sufficient
time for this to take place, and takes account of the view that
triage by the most experienced clinician available, who may or
may not be a doctor, is the most effective use of resources.
(Paragraph 62)
6. We accept the value
of a single telephone access point for patients for all out-of-hours
services. However, NHS Direct will have substantially to increase
its capacity in order to cope with this burden. We remain concerned
that full integration of NHS Direct and GP out-of-hours services
could introduce unnecessary delay and increase referrals to other
parts of the NHS. We recommend that alongside their work to develop
capacity, NHS Direct should work collaboratively with others,
including GPs, involved in delivering nurse telephone triage services
for out-of-hours care to develop and refine their referral protocols
to ensure this does not happen. (Paragraph 78)
7. GP out-of-hours
services provide only one of many routes for people needing urgent
care. Out-of-hours services are part of a larger network of 'unscheduled'
care providers, which can include emergency ambulances and A&E
departments, as well as GP emergency clinics run during the day.
If one of these services is withdrawn or changed, or access becomes
more difficult, demand for urgent care will simply increase in
other parts of the system. It is not surprising, therefore, that
A&E departments are anxious that changes in the provision
of GP out-of-hours services may impact on already rising attendance
rates. (Paragraph 86)
8. We deplore the
loss of GP Saturday morning surgeries which will limit access
to their GP for many working people, and we recommend that PCTs
should provide such clinics in primary care centres or co-located
emergency departments. (Paragraph 87)
9. Accessing healthcare
outside normal working hours can currently involve negotiating
a maze of different services and telephone numbers. We agree that
in the long term, services should be designed around patients,
taking account of where local patients are most likely to access
healthcare. We are encouraged to see this already happening in
certain places, through, for example, the co-location of primary
care centres and A&E departments. However, we also believe
that there is a place for patient information campaigns in order
better to equip patients to play an active role in their own healthcare.
Clear information should be available to everyone who needs it,
setting out what local NHS services are available where, in order
to help patients make informed choices on how to access out-of-hours
healthcare. We recommend that the Government takes steps to ensure
PCTs proactively provide information on NHS services to their
local populations on a regular basis, paying particular attention
to the need to keep people informed of any changes that may occur
as a result of the handover of responsibility for out-of-hours
care. (Paragraph 88)
10. Although providing
services to community hospitals is a separate issue from GP out-of-hours
services, it certainly seems possible from the evidence that we
have heard that the handover of responsibility for GP out-of-hours
services from GPs to PCTs will prompt some GPs to re-evaluate
and perhaps to withdraw the services they currently provide to
community hospitals, as part of their on-call duties. In our view
it is regrettable that this vital subset of GPs' work has not
been addressed more swiftly, and we urge the Government to ensure
that this is resolved as a matter of urgency to ensure that the
extremely valuable service provided by community hospitals is
not jeopardised. (Paragraph 94)
11. While we do not
feel that we are in an appropriate position to make recommendations
on the necessary funding levels for GP out-of-hours services and
how this should sit with PCTs' other spending priorities, it is
clear from our evidence that there is anxiety in many quarters
about securing adequate funding for GP out-of-hours services.
Furthermore, with the true cost of GP out-of-hours services having
been largely disguised until now by GPs' previous practice, this
is essentially a 'new' cost for the NHS, and one for which there
are few precedents for commissioning or providing. In the light
of this, we recommend that the Department monitor closely the
financial arrangements for funding GP out-of-hours services. We
will continue to investigate this in future years as part of our
annual Public Expenditure Inquiry. (Paragraph 107)
12. We support the
introduction of quality standards for all providers of GP out-of-hours
services, and we hope that these will be rigorously audited. Providers
should also be encouraged, through incentives, to exceed quality
standards and work towards continuous improvement. We are concerned
by reports that financial pressures may adversely affect the quality
of services some providers are able to offer, and we recommend
that a broad-brush assessment against current quality standards
is conducted prior to the handover of responsibility to PCTs,
in order to provide a baseline against which performance under
the new system can be measured. (Paragraph 111)
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