APPENDIX 11
Memorandum by KernowDoc (GP13)
BACKGROUND
These remarks are submitted from KernowDoc,
which is the GP Co-operative, which has provided GP out-of-hours
services for the whole of mainland Cornwall since March 1996.
The Co-operative consists of 329 GP members (300 WTEs) and covers
a resident population of 530,000. It covers all the practices
on the mainland, including two practices on the Devon border)
and takes approx. 110,000 calls from patients each year, ie, our
infrastructure is based on an expected call rate of 20% per head
of population—a figure which has remained constant since
KernowDoc's inception. An average of 10% of our total calls are
for Temporary Residents, although that percentage varies up to
20% at peak times and in the summer. KernowDoc is the only accredited
out-of-hours provider in the area.
Cornwall covers 1,370 square miles. It is 82
miles in length and 45 miles wide at its widest point; 5 miles
wide at the narrowest. Cornwall has 433 miles of coastline, the
longest of any English county. There are no motorways and many
of the roads are minor roads, lanes and tracks.
The area is mainly rural and sparsely populated.
There are a number of towns, most of which have populations of
less than 20,000. Some of the towns have very deprived populations.
The county has Objective One status.
In order to cover the patients, and meet the
quality standards required for accreditation, we provide 13 Emergency
Clinics (one Clinic per 40,000 population). Similarly, in order
to provide an appropriate response to patients who need to be
visited at home for clinically urgent conditions, we run 8 cars,
7 of which are operational overnight, except at peak holiday times
when all 8 run 24 hours per day (one car per 65,000 population,
or one car per 75,000 population overnight).
The service is well regarded by the public,
the Primary Care organisations and the wider healthcare community
in the county.
We employ 141 staff, most of which are part
time. Doctors are self-employed.
KernowDoc has a close working relationship with
the PCTs, with whom we share a long term vision for out-of-hours
and unscheduled care. KernowDoc proposes to work with the PCTs
to develop a model of out-of-hours service delivery that will
not only address any inherent inefficiencies in the current systems
but also the requirement to develop arrangements that will not
be so heavily reliant upon doctors.
Currently there are a large number of providers
each dealing independently with their own "segment"
of out-of-hours delivery. For example, doctors deal with patients
that would be more appropriately seen by a nurse; nurses sometimes
see patients that would be more appropriately seen by a doctor,
ambulance crews respond to 999 calls that would be more appropriately
seen by another professional.
KernowDoc and the out-of-hours mental health
team run an integrated service for people presenting with mental
health problems out-of-hours. This means that patients calling
the GP out-of-hours service can have contact with a CPN and if
the CPN requires the support of a doctor this can be arranged
by direct discussion. KernowDoc proposes that this operational
integration that is currently so successful should be built on
with all the other out-of-hours providers to ensure that the appropriate
professional deals with the patient, first time. However, it is
felt that this is a long term aim, and that it may take some time
to reach that goal. We believe the key element to the success
of this working relationship is co-location.
FINANCIAL ISSUES
The current cost of the KernowDoc organisation,
including the nominal payments that the GPs make to each other,
is £4,620,369 pa. Of this £1,608,040 relates to the
cost of the infrastructure (ie the staff costs, (excluding the
cost of any clinical shifts), the cost of IT, cars, etc). These
figures do not include any costs relating to the extended hours
required under the new contract.
The current Development (Quality) Fund allocation
is £605,000 pa. In addition Temporary Resident (TR) fees
for patients seen during the out-of-hours period have also been
paid by the GPs into the organisation to reduce their out of pocket
costs. In summary 87% of the current cost of the service has been
funded by the GPs personally.
TR fees contributed £110,000 per annum
towards the service cost. Under the new GMS contract TR fees are
no longer payable, which means that the additional cost of providing
a service at peak times will have to be funded by the PCTs.
Initial calculations for the service after 1
October, the date agreed by the PCTs for allowing the GPs to opt-out,
taking into account a shift pattern to cover Saturday mornings
and the extended hours of 18.30-08.00, using £50 per hour
as a rate of payment for the doctors when working basic (pre midnight)
shifts, estimate that the cost will rise from our current cost
of just over £4.5 million to approximately £8.5 million.
This includes the increased cost of the organisation employing
the doctors, such as National Insurance and pension payments,
sickness and holiday cover, which we currently do not incur.
Currently doctors are self-employed, and therefore
there are no employment "on costs" now. It is probable
that at least some of the doctor workforce will be classified
as employed in future, and therefore "on costs" will
have to be paid in relation to the clinical workforce after the
opt out, which, including the employers NHS pension contribution
of 14%, will add an additional 40% or so to the cost of the shifts.
Whilst "on costs" are currently payable for the non-clinical
staff, for any clinical staff "replacing" doctors this
is an additional cost which is not currently in the system.
The cost per doctor, if they opt out of their
out-of-hours responsibility, is £6,000 pa. This together
with the £3,000 increased Development Fund that has been
agreed will make £2,700,000 available to the PCTs to contribute
towards an OOH service if all GPs in mainland Cornwall opt out
as expected. There have been some further allocations from The
Department of Health to take account of rurality, however, it
is not expected that these further allocations will amount to
more than £500,000 for Cornwall, leaving a financial gap
of £5.3 million—a significant shortfall, even if some
can be made up by skill-mix changes (see also below).
Some of the shortfall will be able to be made
up by reconfiguring services, but this is not possible within
the time scale for the opt-out. The PCTs will therefore either
have to reduce the quality of the service, or find the difference
from their base line, which is likely to affect other services.
They are already under significant financial pressure.
IMPLICATIONS FOR
QUALITY
The financial concerns outlined above are causing
the PCTs to consider reductions in service, which may result in
reduced access for patients. Currently the number of out-of-hours
Clinics provided mean that most patients will have a maximum journey
time so see a health care professional of 40 minutes. If the number
of clinics were to be reduced, journey times would be longer.
At present, KernowDoc has received 12 months' Accreditation as
we do not currently meet all of the existing standards although
we have plans to do so. It is very likely that reductions in service
will seriously jeopardise the organisation's ability to maintain
our existing performance against the standards we meet, whilst
working towards achieving the quality required against those we
do not.
It is expected that many patients will not be
willing to make a longer journey, and may instead call 999 to
be taken to A & E. Cornwall has only one major Acute Hospital,
in Truro, which struggles to cope with existing levels of emergency
admissions, particularly through the winter months and at peak
holiday periods. Clearly, any increase in admissions as a result
of reductions in primary care out-of-hours services will have
a significant impact on the Acute Sector as well as the already
stretched Westcounty Ambulance Service.
SKILL-MIX
IN RURAL
AREAS
Evidence from our own trials and also from other
areas indicates that nurses can complete up to 47% of cases presenting
in clinics out-of-hours. That leaves 53% of patients who need
GP contact out-of-hours.
It must be recognised that opportunities for
skill mix are limited in rural areas, where a clinician is in
place in order to allow reasonable access for patients, even though
often there is not enough work to keep that one clinician busy.
If only one clinician is required, it probably has to be a doctor,
since only a doctor can cover all the workload. The alternative
would be for patients who have been seen, for example by a nurse
or paramedic, but still require doctor contact, to travel probably
30 miles/40 minutes to another location or wait possibly an hour
or more for a mobile unit to arrive.
Finally, alternative clinical staff currently
do not exist—there is no out-of-hours nursing service in
Cornwall for example. MIU nurses have received some minor illness
training, but this is not expected to enable them to complete
a high proportion of out-of-hours calls. Nurse practitioners/prescribers
are felt to be the most appropriate clinicians to be able, realistically,
to relieve a high proportion of the doctor workload out-of-hours,
however only a very small number of these nurses exist in Cornwall
at present and they all have fulfilling day jobs.
NHS Direct have advised the Cornwall PCTs that
they will not have the capacity to triage out-of-hours calls from
Cornwall in the foreseeable future. However, nurse triagers working
alongside doctor triagers are seen as a priority for the future.
SUMMARY
There are significant challenges for the PCTs
in commissioning a quality out-of-hours service in Cornwall. This
is mainly due to the difficult geography, which requires a high
level of infrastructure to ensure that the quality standards are
met. Patients currently benefit from a high quality service, funded
by the GPs. Unfortunately the PCTs are not able to afford the
same level of service.
June 2004
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