APPENDIX 21
Letter from the Minister of State Rt Hon
John Hutton MP, Department of Health, to the Chairman of the Committee
(GP1A)
HEALTH SELECT
COMMITTEE ON
GP OUT-OF-HOURS
SERVICES
During my appearance before the Committee on
Thursday 8 July, I undertook to provide the committee with further
information on several areas relating to out-of-hours services.
The evidence, provided as attachments, covers:
1.
Evidence of the ability of NHS Direct to reduce demand
for out-of-hours services (in response to question 149);
2.
Information on A&E attendances which makes an
effective comparison with previous years (in response to question
154);
3.
A response to the evidence received by the Committee
from the GP co-operative Kernowdoc, on potential under-funding
of out-of-hours services in Cornwall (in response to question
183).
I also undertook to provide the Committee with
the evaluation of the NHS Exemplar sites (question 163). The independent
report is being completed by the University of Southampton team,
and will be available at the end of July (or shortly afterwards).
I will send you a copy as soon as it is available.
I would also like to take this opportunity to
correct an error in my response to Mr Bradley's question whether
or not I was confident that PCTs have enough money (question 178).
In reply, I referred to £30 million in capital incentives
as being additional to the £316 million available to fund
out-of-hours services, when in fact the latter sum included these
incentives.
20 July 2004
1. NHS DIRECT
NHS Direct was set up to improve patient access
to advice and information, However, evaluation by the School of
Health and Related Research at Sheffield University has indicated
that even without the clinical integration of NHS Direct and out-of-hours
providers, NHS Direct still has an impact in reducing demand for
out-of-hours services. The evaluation involved a longitudinal
study of activity data from a range of current care services in
areas covered by NHS Direct sites.
In the case of A&E Departments and Ambulance
Services the impact of NHS Direct has been harder to detect. However
Sheffield University saw no evidence for NHS Direct increasing
demand. This was confirmed by the representative of the British
Association for Emergency Medicine who gave evidence to the Committee
to the first session of the Committee.
The NAO report on NHS Direct in England in 2002
similarly found evidence to indicate "that NHS Direct can
reduce demands on health services provided outside normal working
hours". It estimated that NHS Direct is off-setting around
half of its running costs by encouraging more appropriate use
of other services.
An additional report by the Commission for Health
Improvement records how highly NHS Direct is valued by patients.
The reports are attached,[10]
but can also be viewed at:
www.shef.ac.uk/sharr/mcru/reports/nhsd3.pdf
www.nao.gov.uk/publications/nao_reports/01-02/0102505es.pdf
www.chi.nhs.uk/eng/cgr/nhs_direct/nhsd_report03.pdf
2. A&E
This note responds to the HSC request for data
on actual growth over the last few years ie with growth from the
collection change and new services stripped out, It also sets
out background information on the reported rise in demand.
I promised the Committee data on attendances
with the effects of collection changes removed.
The increase in total attendances[11]including
new services reported (MIUs and WICs) is 17.3% between 2002-03
and 2003-04. The reported increase in major A&E department
total attendances 2003-04 over 2002-03 is 6%[12]This
suggests new services contributed about 70% of the headline growth.
There is a further factor to consider in the
major A&E figure. The focus on the A&E target has incentivised
trusts to record every attender at all A&Es. Some of the growth
even at major departments is likely therefore to have been contributed
due to the general improved recording of attendances.
This data therefore still comes with caveats
and needs to be treated with some caution at this stage. We continue
to work with trusts to interpret the figures and strip out remaining
data artefacts on an individual basis.
There is no current evidence to support the
anecdotal view that the reported A&E growth is linked to changes
in GP out-of-hours (OOH) arrangements. For instance, in the five
SHAs where there were significant GP opt-outs from OOH provision
in April, A&E attendances in the first 10 weeks of the financial
year rose by a very similar percentage as in the rest of the country.
We are, however, continuing to closely monitor PCT OOH plans to
ensure provision of good quality alternative arrangements.
3. KERNOWDOC
MEMORANDUM
Kernowdoc provides out-of-hours services to
the three Cornwall PCTs (West, Central, and North and East) and
in addition, covers a single practice in North Devon PCT and a
single-handed practice in South Hams, and West Devon PCT.
Kernowdoc has provided an excellent out-of-hours
service in Cornwall, and the three Cornish PCTs, commissioning
as a consortium, are currently in the process of developing with
Kernowdoc the specifications of a new out-of-hours service, provided
by a range of practitioners. Around 70% of GPs in Cornwall will
continue to work out-of-hours through Kernowdoc.
Kernowdoc and NHS Direct have an excellent working
relationship (Kernowdoc was the first provider to have a successful
Technical Link to NHS Direct, for single-call access to out-of-hours
services), and are working with the PCTs to explore new ways of
working for future out-of-hours provision.
Local research into case mix, in which Kernowdoc
was involved, has suggested that approximately 40% of out-of-hours
work currently done by GPs could be handled by nurses working
in Minor Injury Units. Local training of these nurses is underway,
and their induction into out-of-hours work, will take place over
the autumn. KernowDoc are actively involved in the clinical placements.
Kernowdoc will continue to provide its existing
service during this time. From 9 January 2005, a new service will
begin, which will combine GPs working through Kernowdoc, with
Minor Injury (or Illness) Units largely staffed by nurses. This
will reduce the costs of the service, and represents the first
step in the longer term aim of integrating all aspects of the
out-of-hours services, including social services, mental health,
pharmacy, the ambulance service, and acute trusts. Cornwall is
also in the process of appointing a lead healthcare practitioner,
who will be defining care pathways, writing protocols and devising
a training package for out-of-hours care practitioners, who will
be integrated into the service during 2005.
Pensions contributions, and the need to incentivise
GPs to continue to work out-of-hours will increase costs. The
Cornish PCTs are committed to providing a service which meets
the national quality standards, and in addition to the extra investment
received through the ring-fenced development fund, rurality money,
capital incentives and global sum, intend to use their combined
unified budgets to cover the additional costs of establishing
the first stages of integrated unscheduled care, in a geographically
unique area.
Payments for temporary residents are included
within a practice's global sum. The amount included for temporary
residents is calculated as the average annual amount claimed by
a practice over the previous five years, up-rated for inflation.
In addition the weighted registered population
of a practice, on which the global sum is based, is adjusted quarterly.
Any temporary residents who appear on a practice's list on the
date when the adjustment is calculated will be included in a practice's
revised global sum for that quarter.
10 Not printed. Back
11
Data source: KHO9 annual return /QMAE quarterly returns. Back
12
Data source: Based on QMAE quarterly returns for Q2-Q4 period. Back
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