APPENDIX 18
Memorandum by the NHS Confederation (GP24)
INTRODUCTION
1. The NHS Confederation welcomes the Committee's
inquiry into GP out-of-hours (OOH) services in England and the
opportunity to present evidence.
2. The NHS Confederation is the independent
membership body for the full range of organisations that make
up the NHS across the UK. We work to improve health and health
services by influencing policy and the wider public debate, promoting
management excellence and supporting members through networking
and information exchange.
3. From 2001, on behalf of the UK Health
Departments, the NHS Confederation led the negotiations with the
British Medical Association for a new General Medical Services
(GMS) contract. A key element of these new arrangements was the
ability for GPs to transfer the responsibility for providing OOH
care to their Primary Care Organisations (PCOs).
4. OOH provision had already moved away
from the traditional model as many GPs were providing OOH cover
through a GP co-operative or private commercial organisation,
with only a minority providing their own OOH cover.
5. Part of the reason for these changes
was the significant disquiet in the profession about continuing
to be responsible for the provision of a 24-hour service. It was
believed, from a number of surveys, that this was one factor leading
to a decline in the number of doctors choosing a career in general
practice and to the high proportion seeking early retirement.
In recent years there have been significant changes in the hours
worked within hospitals and GPs expect this change to be mirrored
within primary care. In addition, younger doctors expect a better
balance between work and personal commitments and are less prepared
to accept historical working patterns. The increase in public
expectations, the ageing population and changes in behaviour have
made OOH work increasingly onerous. The system as configured also
offered a variable quality of service and as a whole was deemed
to be an uneconomical way of providing OOH.
6. The changes give PCOs the opportunity
to build a more integrated OOH service that will maximise the
skills of the wider health team, including nurses, pharmacists,
mental health professionals and paramedics and will ensure that
patients see the most appropriate health care professional.
7. The changes will be introduced between
April and December 2004 where there is agreement between a practice
and the PCO. From 1 January 2005, all PCOs will automatically
assume responsibility for OOH care.
8. The NHS Confederation's continuing responsibility
is to negotiate matters of outstanding policy with the BMA and
to ensure that the contract is implemented in the spirit in which
it was negotiated. Responsibility for implementation lies with
the Department of Health and the Devolved Administrations. Given
the difficulties arising from organisational change within the
Department of Health, we believe that their central structures
need to be strengthened in anticipation of the crucial months
ahead.
PCT READINESS TO
UNDERTAKE OOH RESPONSIBILITY
9. We are confident that all PCOs in England,
Scotland, Wales and Northern Ireland will secure a safe and effective
service by the deadline of 1 January 2005. There are no official
figures as to when Primary Care Trusts (PCTs) in England will
assume responsibility for OOH however we believe that the majority
will do so in the late autumn of 2004.
10. Currently our members are in a variable
state of readiness. Planning and implementation at a local level
takes many months. PCTs which had already embarked upon the reconfiguration
process before final contract agreement will assume OOH responsibility
with relative ease. A minority have been less prepared for the
transformation and will experience significant pressure in the
run-up to the January 2005 deadline.
11. PCTs are considering a number of models
of re-provision. The most conservative approach is to renew the
OOH contract with an existing GP co-operative. This will provide
a traditional doctor-based service albeit at significant extra
cost. We have concerns about this approach over the longer term
because it is clinically unnecessary, may be financially unviable
and goes against the grain of systems integration.
12. More significantly many PCTs are taking
the opportunity to re-design services around the needs and patterns
of usage of the communities they serve. The most effective models
are those that integrate all the providers of unscheduled care
in the primary, community and acute sectors into a first contact
service for a community, overseen by the PCT. This is commensurate
with the policy goal of basing more services in primary care and
planning across whole healthcare delivery systems rather than
focusing on individual components of care.
13. There are, however, risks for PCTs,
both financially and in terms of accountability, in being responsible
for the provision of OOH services. Those PCTs who have both the
Chief Executive and the Professional Executive Committee fully
engaged will be the best prepared. All PCTs have already identified
a member of staff to be responsible for OOH re-provision and the
most effective services will be implemented where these leads
are senior enough to deliver the radical solutions necessary and
are given a sufficiently strong mandate.
14. Networks have been established in some
Strategic Health Authority (SHA) areas to encourage the sharing
of information and experience between PCTs. We would strongly
support their further development to both spread good practice
and to set benchmark tariffs for the commissioned services. This
will help to maintain a stable environment across the patch and
avoid OOH providers escalating costs. The benefits will be augmented
if these networks are integrated with the unscheduled care networks
already in operation across the country.
15. Whilst PCT readiness is not consistent
across England we believe that the necessary structures and the
support are available. The most successful PCTs will be those
who have both the vision and the leadership to deliver a whole
systems solution.
THE ROLE
OF GP CO
-OPERATIVES
16. We see an important role for traditional
co-operatives in the short term. In the longer term, the expansion
of the primary and community sectors, the development of a multi-skilled
workforce, the potential entry of new commercial providers and
the opportunities for PCTs to provide services directly will result
in traditional co-operatives having a diminishing hold on the
market.
17. Co-operatives are therefore considering
a number of business models in order to continue in the new world.
Those who capitalise on their pre-existing knowledge of the local
health economy and change their skill mix will be able to contribute
as partners in a whole systems approach.
THE ROLE
OF NHS DIRECT
18. HS Direct currently has capacity problems
and it is unclear when key milestones will be delivered. The service
offered is also perceived to be expensive compared with alternatives.
This means that there is a limit to what PCTs can expect at present
and, as a consequence, many PCTs are not taking account of NHS
Direct in their re-provision plans. This is disappointing given
the potential of such a service.
19. HS Direct has recently been established
as a Special Health Authority. This will give an enhanced focus
but, as it is distant from local debates, could make it more complicated
to get full engagement at a local level, particularly if the Board
expects standard, NHS Direct solutions. We believe it is important
that NHS Direct is positively engaged in the system redesign process
at an individual PCT level and that it is prepared to accept variation
where this best suits the needs of local communities. If this
can be delivered, then NHS Direct could offer a good and cost-effective
service as it expands and could develop into the biggest and cheapest
provider of call-handling services given economies of scale. There
is significant attraction in having a single number for patients
to access the service and NHS Direct could deliver this. Achieving
this aspiration will need close co-operation between the Department
of Health, NHS Direct and individual PCTs.
THE POTENTIAL
IMPACT ON
OTHER NHS SERVICES,
INCLUDING COMMUNITY
HOSPITALS, MINOR
INJURY UNITS,
GP CLINICS AND
A&E SERVICES
20. There is still a myth that patients
receive OOH cover from their own GP. In fact, a large majority
of GPs use co-operatives or private commercial organisations.
Thus, only a fraction of patients currently have access to their
doctor in the traditional way.
21. The change in responsibility now gives
PCTs the opportunity to achieve greater integration as a result
of the OOH changes. Previously, parts of the NHS have operated
in isolation and the patient's journey between these sectors has
been incoherent. Service integration will now allow the patient
journey to be planned efficiently. If this is achieved it could
help A&E meet public expectations for reduced waiting times.
22. One of the biggest potential risks and
fears is that the changes will have an adverse impact on other
NHS services. In reality, where services are well planned, well
implemented and effectively communicated with the public, the
potential risks will be minimised and the service improved.
23. As part of the planning process, PCTs
need to ensure that contingency arrangements are in place to ensure
that the health economy is not destabilised during the transition
period. These plans need to be communicated to all NHS services
at an early stage in order to reassure the system. Planned changes
need to be communicated to service users in a simple manner; this
will be helped by the single number when it comes on stream.
24. Community Hospitals: Community
hospitals are not normally involved in OOH provision unless they
are a primary care centre. If so, the continuing arrangements
will be covered by the GMS contract. If they provide hospital
services, separate remuneration applies. Community hospitals will
therefore only be affected if they are part of planned change.
There is however opportunity for them to develop their roles in
the integrated service model.
25. Minor Injury Units: MIU's tend
to be funded from a separate budget. Where this continues there
will be a minimum impact on them. However, there is opportunity
for integration and for funding streams to be rationalised.
26. GP Clinics: many practices expect
to be adversely affected in the short-term, with patients inundating
clinics on Monday mornings rather than use an evening or weekend
service they have no confidence in. However, the history of implementation
of co-operatives in 1996 showed that where the change was well
planned and communicated, there was no adverse impact on practices
at all. We believe that an essential part of the planning process
is to ensure that patients are told at an early stage about the
changes to the arrangements.
27. A&E: A&E centres are
extremely nervous about the impact of the OOH changes on them
especially since they will also be meeting their waiting time
targets and managing winter pressures. There is anecdotal evidence
of increased attendance at A&E, especially on Saturday's where
GP surgeries are now closed. Some members in the acute sector
believe that they will be expected to shore up the system if it
fails at the point of provision. We believe that it is essential
that planning for OOH at a local level, whilst led by the PCT,
must engage all elements of the health, social care and voluntary
sectors. A&E and the ambulance service should, in turn, monitor
patient activity, especially if there is increased attendance,
so that the cycle of improvement is informed by quantitative data.
28. Ambulance Service: Similarly,
the Ambulance Service expects to be adversely impacted by the
change. Anecdotal evidence is that, where the OOH changes have
already happened, workload for the ambulance service and 999 has
increased. Again, we believe that any evidence of increased workload
to the ambulance service should be collected to inform the planning
process and to ensure that the redesign process responds appropriately.
POTENTIAL FINANCIAL
IMPLICATIONS
29. The financial model of the OOH change
assumes that there are currently too many GPs providing OOH and
this is not cost efficient to the NHS. GP input could be reduced
by triaging the majority of calls, with only a small minority
remaining needing medical input. This model assumes that the labour
cost of the GP will double but that only half the number will
be needed.
30. Substantial resources have been made
available in this current year to PCTs in order to re-provide
OOH service but initial estimates suggest that this is not enough
to cover the cost of the reconfiguring the entire system. It is
difficult to predict what effect market forces will have on GP's
hourly rates, especially in under-doctored areas. There is no
firm estimate of the additional costs which will be dependent
on the state of readiness and the maturity of the delivery system.
31. This is a heavy burden on PCTs who are
experiencing conflicting financial priorities. However, we expect
that the risk from OOH re-provision will decrease as the system
matures and as economies of scale are sought.
32. One means of nurturing sophistication
within the system is by bringing all unscheduled care budgets
(ie GP OOH, GP in-hours, A&E, emergency care, Walk in Centres,
Minor Injury Units, Community Hospitals etc) into one global fund.
This could be managed by a senior, PCT-based steering group representing
all sectors with powers to make financial decisions based on the
whole system approach.
POTENTIAL IMPLICATIONS
FOR QUALITY
OF OOH SERVICES,
INCLUDING RAPIDITY
OF RESPONSE,
PROVISION OF
BACKUP AND
QUALITY OF
PATIENT CARE
33. The quality of the existing system is
variable. Under the new system, all providers, including those
who continue to provide their own OOH, will be expected to meet
the "Carson" standards as set by the Department of Health.
These standards directly relate to rapidity of response, provision
of back-up and the quality of patient care. PCTs will also have
the opportunity to include additional standards in response to
local circumstances.
34. The economies of scale under the new
arrangements will also ensure that quality is standardised across
wider areas and that clinical governance is guaranteed. Moreover,
PCTs as accountable bodies will ensure that all providers meet
a minimum level of quality.
SKILL-MIX
WITHIN OOH SERVICES
35. The NHS Confederation is very clear
that the only way in which OOH services can be re-provided effectively
is by maximising the skills of the wider health team. This involves
engaging the full range of organisations involved in emergency
care, with the emphasis on ensuring that patients see the most
appropriate health care professional for their condition. Therefore,
emergency care practitioners, paramedics, mental health professionals,
nurses and others will have a vital role in an integrated OOH
service.
36. Workforce planning should focus, as
a matter of urgency, on the training of first contact clinicians
from a range of backgrounds. Timely implementation of a financially
viable and sustainable system needs early investment in this training.
37. Communication with patients is essential,
not only about how they should access the system but also about
which health care professional they will be seeing and why. There
is evidence that when explained to, patients are happy to be seen
by other clinicians. This is true of the NHS as a whole and in
the future, OOH provision could provide a model for imaginative
thinking about provision across the service.
ARRANGEMENTS FOR
MONITORING OOH SERVICES
38. The NHS has a well-established performance
management structure and OOH services fall comfortably within
this remit. PCTs will agree appropriate performance management
and contractual monitoring arrangements with providers.
IMPLICATIONS FOR
URBAN AND
RURAL POPULATIONS
39. Provision models in rural areas will
necessarily be different given their special geographic circumstances.
To ensure that they are not penalised, we believe that this should
be considered as part of the overall review of the way in which
resources are allocated to rural populations.
40. In urban areas currently, there is evidence
that the quality of service in areas of deprivation is poorer.
The change to the system is therefore an opportunity for PCTs
to tackle this inequality by providing better services to those
communities.
CONCLUSION
41. The NHS Confederation does not underestimate
the challenge ahead for PCTs in providing an integrated, effective
and safe OOH service. This is just one of the issues on the primary
care agenda, albeit an important one. However, we would like to
emphasise that we are confident that PCTs will be sufficiently
prepared to take control of the system from 1 January 2005 and
that they are best placed to effect the wholesale changes necessary.
42. It is also worth emphasising that communication
to both patients and other sectors of the NHS is vital during
the transition period. We strongly support both national and local
campaigns at an early stage and any recommendations that the Committee
can make to encourage this.
43. We welcome the opportunity to provide
oral evidence to the Committee to support our written submission.
June 2004
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