APPENDIX 12
Memorandum by OOH Foundation, Mutuo, Cobbets
(GP14)
1. OVERVIEW
The new GP contract presents a significant opportunity
to continue the development and integration of OOH services outlined
in the original Out-of-Hours Review.
The contract formalises arrangements and trends
in service and workforce which have been developing over the last
10 years. For example Û of the GP workforce prior to the
contract development and noted at the time of the OOH review had
little or no active participation in delivering OOH care. This
group delegated either to a commercial deputising service or to
their colleagues in a GP co-op.
Other professional groups and staff have been
having an increasing role in the delivery of first contact primary
care for many years. The evidence both academic and operational
shows this trend is both safe and popular with the public.
The mechanism of care delivery has developed
with significant changes over the last 15 years. Greater use is
made of telephone advice, and premises-based as opposed to home-care
has been a key element of the GP co-op development. Again these
methods are effective and popular with the public. They allow
more effective access enabling more patients to access high quality
care in a timely fashion.
GP co-ops empowered their members to develop
innovative and effective care. The new model constitution for
a mutual OOH primary care provider broadens the basis of membership
to include other staff (clinical and non-clinical) and gives a
voice at strategic level to other NHS and local bodies which are
key to the delivery of the service. The continued development
of these new mutual organisations will empower and engage the
entire workforce and the wider community they serve to enable
the local workforce and the community to shape local services.
Empowered providers are more likely to be able
to create the joint operations and linkages with other providers
such as ambulance services to allow effective networks of providers
to work together allowing rapid access to the most effective care
for the patient's particular need delivered to consistent standards.
The new mutual organisational structure inherently facilitates
this type of joint provision.
As patients correctly expect high quality and
responsive services everywhere, providers will have to develop
more sophisticated clinical management and leadership systems.
These underpin effective networks which are the mechanism to ensure
patients achieve rapid access to the most effective service for
their need.
2. SPECIFIC COMMENT
ON ISSUES
RAISED IN
THE TERMS
OF REFERENCE
The general readiness of Primary Care Trusts to
undertake their responsibilities with regard to Out-of-Hours services
As in any large system there is variation in
approach and state of readiness. A number of PCTs could and should
ensure more effort is expended in ensuring existing capacity and
expertise is not lost to the system. The loss is occurring due
to empirical procurement processes which have the effect of setting
providers from all sectors (NHS, Mutual, Private) against each
other rather than encouraging cooperation which will result in
the networks envisaged in the original OOH review.
PCTs have yet to develop a mature and integrated
approach to commissioning which includes providers working together
and with the PCT to develop an integrated and long-term approach
to service development with attendant benefits for patient. In
some areas there is excessive localism by PCTs which is placing
unnecessary burdens on providers having to respond to individual
PCTs because the PCTs have failed to achieve any joint working.
SHAs should seek to provide some strategic leadership where PCTs
are not yet progressing developments, and in particular should
pay more attention to ensuring PCTs are enabled to work together
for the benefit of larger populations.
There is an urgent need for those who hold PCTs
to account to ensure short-term bureaucratic priorities are not
preventing proper integrated services being delivered to patients.
PCTs are acting both as commissioners and providers.
It remains to be seen if this model will achieve the necessary
leadership and sustainability to maintain high quality services
and attract staff as each PCT-sized service is in volume terms
small. PCTs may also find that the combined risks of being commissioner
and provider are more than their governance structures can readily
cope with. Over time we may see an increasing trend to pass on
the risk of delivery to a third party.
The role of GP co-operatives
GP co-operatives will continue to have a significant
place in service delivery. Their mutualism and commitment to quality
has been one the most successful parts of primary care development
in the last 10 years. The contract did threaten the mutuality
and existence of GP coops however we are now seeing the leaders
moving to develop existing co-ops into mutuals with a broader
membership. It is a key aim of the developing foundation to support
and encourage best practice in new MUTUAL development.
co-op providers based within local communities
are effective and responsive providers of care. Local co-ops networking
to share the development of quality and governance systems will
allow accelerate the pace of development.
The mutual model of governance has shown itself
to be a responsive and effective vehicle for service delivery.
Mutual organisations are well suited to the
delivery of public services as they combine the expertise of professional
front line managers with the necessary accountability derived
from the involvement of other staff and sometimes users in their
governance structures.
One example of this in a public sector environment
has been the successful conversation of over 60 local authority-run
leisure services departments to community mutual organisations.
The pioneer organisation for this model is Greenwich Leisure Limited
(GLL), which was formed as an employee-owned community mutual
in 1993.
Based on charitable objectives, GLL is a non-profit
distributing organisation, with profits generated reinvested into
the service and the community. It has a board consisting of elected
staff, council members, a trade union representative and customers.
Day to day management responsibility is devolved to an experienced
senior management team.
The existing seven Greenwich Council-run leisure
centres were transferred to the new organisation in July 1993.
Since then GLL has thrived, adding three new centres to its' portfolio
in Greenwich and has forged partnerships to run all the leisure
contracts in the London Boroughs of Waltham Forest, Merton, Newham
and Barnet and in Epsom and Ewell.
GP co-ops pioneered the development of new mechanisms
of care delivery. They were the forerunners for NHSD style services.
They will continue to have a positive role in ensuring the role
and operation of NHSD is developed in a style which achieves maximum
benefit for OOH services and local people.
The role of NHS Direct
The OOH review placed NHSD in a key role in
OOH care. We have no reason to suggest that this should change.
Experience of operating the system at scale suggests that while
NHSD has made significant progress in developing operations at
scale and has inherent resilience there should be more attention
paid to the link between national level services and local services.
The logistics of local health care systems is
complex. The demand from patients presents itself in a particularly
uneven pattern to OOH services. The joint system between NHSD
and local OOH providers must have the flexibility to enable NHSD
to operate more locally at peak periods and nationally at quiet
periods.
Attention is also required to the interface
governance and operational process between NHSD and local OOH
providers to ensure quality is maintained across organisational
interfaces. There is a need to explore further with NHSD and OOH
services best practice in the interface working as well as establishing
an intermediate tier of provision between national and local services.
Nurse advice has been shown to be effective
and safe and can meet the OOH needs of up to 40% of callers to
services. Continued attention needs to be paid to the outputs
to other services from NHSD. More effective local joint governance
will allow a feedback loop which will progress this area.
The potential impact on other NHS services, including
community hospitals, minor injury units, GP clinics, and A&E
services
If PCTs commission a service of adequate capacity,
responsiveness and quality which has been jointly developed between
providers of ambulance, A&E and GP OOH services there is no
reason for anything other than a positive impact on these other
services. As we have outlined above this is not yet happening
in all areas.
Reprovision of existing services to adequate
capacity will have a neutral effect on other services.
The biggest risk is that inaccurate public statements
about GPs or services not being available will place the perception
in the minds of users that they have no choice but to access ambulance
or other services.
Local mutual OOH providers who achieve long-term
joint operations with providers of these service will achieve
an integrated approach to the benefit of users. Indeed we have
examples of OOH services that are now responsible for providing
OOH, urgent care centres and ambulatory A&E care as an integrated
package.
The integrated approach will not be achieved
if PCTs continue to have a fragmented approach to commissioning
these services.
Potential financial implications
The financial implications are manageable if
the following occur:
— PCTs have a more integrated approach
to commissioning GP OOH services with other services such as OOH
community nursing, urgent care centres, A&E and ambulance
services at a minimum.
— Local providers of OOH care are enabled
to operate at sensible economies of scale.
— Local OOH providers take advantage
of joint development at regional and national level.
Potential implications for quality of Out-of-Hours
services, including rapidity of response, provision of backup
and quality of patient care
There is no reason for the quality of care to
deteriorate as a result of the changes. The standards in the original
review are still in place and must be the baseline for the planning
and commissioning of post-contract services.
Joint working and effective responsive local
providers with good clinical and operational governance systems
will actually improve quality of care.
The joint operation and governance systems which
were envisaged in the original review if put in place in the new
arrangements will ensure the whole patient experience is monitored.
The changing nature of the workforce and the
attendant need to have more structured clinical quality systems
will further extend existing quality measurements into clinical
quality benchmarking.
The overall quality of service and rapidity
of effective response should increase as the new structures bring
together various service providers, and provide an effective mechanism
for them to work together to optimise their endeavours.
Skill-mix within Out-of-Hours services
There is abundant evidence that staff other
than GPs can play a significant, safe and effective role in meeting
the needs of many patients.
There is a need to ensure the providers who
are developing a more mixed workforce pay adequate attention to
the workforce as a whole and not develop each new role in isolation.
This means effective clinical leaders are required in every service
and a culture of inter-professional cooperation rather than competition
is established. We believe the Mutual structure will facilitate
this development.
There is a lot of comment that staff are not
available. We do not subscribe to this view. Providers who offer
a good working environment, training and support for staff to
work together will attract staff of all types and enable them
to work together as an effective team.
In the past skill mix has been a metaphor for
substitution. We believe GPs will continue to play a significant
role alongside other staff. The evidence suggests that services
who allow staff with a narrower competency base to access GPs
during the decision making process are more secure in their extended
role and more effective.
Arrangements for monitoring Out-of-Hours services
The contract will require changes be made to
the existing arrangements. We would like to see maintenance of
the access standards amended to recognise the potential clinical
role of staff other than GPs.
There must be more emphasis placed on the clinical
quality of the care provided after access has been achieved.
Evidence from quality systems around the world
clearly points to self assessment and monitoring within a statutory
framework as being the most effective system.
Monitoring will be set against the contractual
process. Providers will have to demonstrate the capacity to operate
effective internal governance systems.
Mutual providers with dual accountability to
the commissioner, their members and local people will have a greater
incentive to maintain and improve quality.
Implications for urban and rural populations
The deployment of service in rural and urban
areas will be different. The original OOH review avoided suggesting
any facilities or service template to local systems.
Rural areas may have less economies of scale
than urban populations however resource allocation has recognised
this.
In rural areas it is very important the joint
provider working is rapidly developed as it is via this mechanism
the challenges will be met.
BIOGRAPHIES
David Carson
David Carson has a professional background in
General Practice.
David has recently moved from the Department
Of Health where he was National Clinical Lead in Access and Choice
Primary Care supporting the modernisation of Out-of-Hours Services
and Emergency Care.
He is now working with a number of Out-of-Hours
providers to establish and chair a new foundation for best practice
in out of hours, primary and emergency care.
He led the Review of GP Out-of-Hours Services
in England reporting to Ministers in October 2000 and was the
primary care lead in developing the national strategy for Reforming
Emergency Care.
Within an inner London Health Authority he has
previously developed local systems to assess and support doctors
who have problems with their performance, co-ordinated the development
of new approaches to Post Graduate Medical Education, led the
primary care development for the area and led the improvement
of prescribing practice.
As a General Practitioner in Scotland he has
chaired a GP Fundholding Group and led the local GP emergency
care support to the Ambulance Service.
Peter Hunt
Peter Hunt, aged 37, is the Director of Mutuo.
Since 1994, he has worked with the co-operative sector and in
2001, he established Mutuo as the first cross mutual sector project
to promote mutuality to opinion formers and decision makers.
Peter is particularly interested in mutuality
and has sought to engage the co-operative movement in work to
raise the profile of the co-operative and mutual sector.
He was one of the founders of Supporters Direct,
the football supporters trusts initiative, and has been instrumental
in the Parliamentary agenda to modernise Industrial and Provident
Society law.
Cliff Mills
Cliff is a Partner at Cobbetts, Solicitors in
Manchester and Leeds and is a leading expert in corporate governance
and industrial and provident society law.
After spending the first ten years of his career
at City law firm Ashurst Morris Crisp, Cliff moved to the North
West and has worked with co-operative societies since 1992.
He has advised the major retail societies on
constitutional and democratic issues and since June 2001 Cobbetts
have been legal adviser to Co-operatives UK.
Cliff is at the forefront of designing new corporate
constitutions for the ownership of public or community assets.
Projects include a constitution for a water utility company, the
Community Housing Mutual constitution for the National Assembly
for Wales and a childcare model for Mutuo and Social Enterprise
London.
He was adviser (with Ian Snaith) to Gareth Thomas
MP on his Industrial and Provident Societies Bill (now enacted),
and provided support and advice on industrial and provident society
law to the Strategy Unit of the Cabinet Office in their recent
report.
For the last 11 years, he has been responsible
for managing a team of lawyers dealing with the disqualification
of directors in the North West under the Company Directors Disqualification
Act for the Insolvency Service on behalf of the Secretary of State
for Trade and Industry.
June 2004
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