APPENDIX 22
Responses to Out of Hours Questionnaire—Compiled
by NHS Alliance from Responses Received from survey of the NHS
ALLiance (GP26A)
Four local PCTs will contract ***, currently
a GP co-operative, to start in early October. Planning going well
and to time. Primecare staying around the service to the 25% of
practices that still use them up until the handover. Negotiations
continue re: costs. Service will contain a Dr presence at all
times but will have increasing nurse input.
MAIN ISSUES
AROUND REPROVISION
OF OOH SERVICES
1. Finance—struggling in the short-term
despite the various non-recurring pump-priming resources announced,
and will definitely struggle long-term, especially if the going
rate for doctor time is higher than anticipated.
2. Integrating the service, both between
the four different PCTs in our locality and also across different
relevant professions (gps, community nurses, Macmillan services,
paramedics, social services etc). This is not due to a lack of
co-operation—indeed the level of joint working in this area
is refreshingly high, but is due to the complexity of the problem
in making sure the future model is an improvement on the existing
one and will deliver a better service to patients as a result
(ie the right professional dealing with the right person at the
right time).
3. Ensuring that the current gp-based OOH
service and NHS Direct use the same protocols/triage software
etc. NHS Direct are pretty restrictive about only being able to
use their software and there are concerns about how good it is
from other professionals.
4. Buying a new site and getting built the
building we will need to house the new service—again, good
progress but the timetable is tight and reliant on an overly bureaucratic
consultation process before we even get to being at the mercy
of the architects and builders!
Three PCTs are combining to provide a PCT led
service from 1 October. This is based on the old co-operative,
which has now been taken over by the PCTs.
The service will be hosted by *** PCT.
Primecare got the hump and pulled out of the
area in April!
PCT heading full speed for cliff edge with eyes
shut!
Reason for yes vote in GMS mainly for OOH opt
out at bargain 6K price.
PCT hopes loads of GPs will carry on working
at previous co-op rate.
Promises of paramedics and nurse practitioners
in team with GP but very few exist as yet.
Here all five PCTs have been ordered by Sir
Ian to scrap their plans and join pan-*** scheme, contract awarded
to floundering no star Ambulance Trust three days ago.
We await details of proposed pay and conditions
for GPs with interest. Worried that timescales have been left
deliberately tight so pressure can be applied to GPs to work at
low rates or risk Sir Ian refusing opt out notices.
And it is all going to be working by 1 October!!
INFO ON
OUR PLANS
AND PREPAREDNESS
Planning to reprovide the current GP co-op service
across 2 PCTs with mix of salaried GPs (have 6.5 wte recruited
to date but this is not adequate to run service and they are very
expensive, pay up to £110 per hour) and sessions provided
by GPs currently working in the system; main problem is being
sure we will have enough GPs to cover total hours.
Have set aside £4-5k funds in each LDP
in addition to expected claw back from GMS contract and also have
qualified for £50k each PCT of "preparedness" funding.
One practice from my PCT coming into co-op not
currently covered (currently their own practice still doing traditional
on-call)—patients in this area anxious as they perceive
deterioration in service, with them having to travel to centre
(even though transport provided) and also no Sat am surgery—public
consultation here is a challenge.
The co-op was originally set up and run by GPs
but recently has been handed over to PCT for management. PCT is
still contracting with GP company for provision of medical services
but directly employs receptionists, nurses etc. GPs don't pay
themselves, just do shifts according to number of patients per
practice—so when PCT takes over providing medical services
too will have to set up clinical governance systems etc which
are currently just responsibility of individual GPs; this is proving
a little bureaucratic.
Overall—complexities of PCT providing
the system are greater than when GPs ran it themselves; for PCTs
it's more difficult taking the risk of providing GP cover because
of the accountabilities—GPs individual responsibilities
were always met but the organisation's employees don't have the
same sense of accountability, interesting culture change. Plus
costs are higher to PCT to run a safe system compared with individual
GPs working together.
Starting 1 September across 2 PCTs. Rurality
is an issue but working with rapid response paramedics and 24
hour district nurses to provide a triage visiting service—they
will assess and call the OOHs centre to discuss with GP for best
course of action. Advertising for salaried doctors. 50% of GPs
say they will work on the rota. Looking good at the moment.
Nightmare!!
Transferring on 1 July 2004.
Went through tender process with three tenderers
with neighbouring pct resulted in own present co-op losing out
to major nearby player also a co-op this caused a stink!! although
the tender process was correct and backed by pct boards [there
was] loss of good . . .
Major headache for our chief exec—ongoing
meetings to try and keep every one on board by organising subcontracting
for the two co-ops during the next nine months—we will then
make arrangements for next april and beyond
ONGOING PROBLEMS
Termination of existing contracts with commercial
organisations and possible fees for early termination.
Different hours of cover—telephone answering/triage/calls.
Cross boundary/cross cover arrangements.
Confusion over accreditation for one or three
years?
Still confusion over how one town will offer
Sat and Sunday surgeries.
If the local co-op falls—unemployment
for 30 staff—drivers, sec, telephonists etc.
Imc then got involved (inappropriately) with
an unnecessary and wasteful vote.
It is all an unnecessary disruption which has
lost good will and almost destroyed a service—it should
have been a better process if any change really needed to happen
at all—what is wrong with the systems that works—if
it works why break it when all it needs is a little development.
So much of this new GMS contract which promises
so much is delivering so little and destroying general practice
along the way.
We can develop services by keeping everyone
on board as we have done for years we don't need this unnecessary
rigid interference.
Generally a disaster but thanks to our chief
executive hopefully all will be ok—many management hours
have been spent to achieve very little.
In the short term delivering doctor cover will
prove challenging. As the fruits of the new contract are delivered
I have doubts about the number of GPs willing to work ooh . .
. and this is in an area well served by GPs in the past. The other
key issue is cost. The available funds are inadequate and the
resulting deficit reduces our ability to deliver other plans .
. . ie practice based commissioning and care closer to home.
We are working across two PCTs to build on our
OOH Co-Op that already exists.
We have recruited 5.5 salaried Drs and will
be ready to take over OOH GPs from 1.11.04.
We are also working to integrate our service
with A&E and currently do the following:
1. Share reception with A&E.
2. Run an integrated transport service with
our Acute Trust, GP OOH and the Ambulance Trust.
3. Run a rapid response team and a hospice
at home scheme form the centre.
4. Provide 24 hour district nursing from
the centre.
5. Have started to skill mix with Nurse
Practitioners.
We have avoided using Emergency Care Practitioners
until we see how the pilots work out in our neighbouring PCTs.
We are part of the development of an Emergency
Care Directorate across General Medicine A+E and Primary Care
to run 24 hours a day.
We have sorted out our plans for our technical
links to NHS Direct and we already run a completely paperless
electronic medical record in the centre. We are about to pilot
the electronic transfer of records from our GPs to our OOHs centre
so that records are available 24 hours per day.
We have submitted our plans for OOH to the SHA
and have been told that we have been put forward to receive the
£50K funds for having successfully produced our implementation
plan.
We have access to pathology but not radiology
out of hours and have good relations with A+E. We have good access
to mental health services.
Funding is our main issue but as we have employed
salaried Drs on a salary of £110,000 each—the bulk
of the cost will be covered by the money recouped from Practices.
We have already invested heavily in services such as transport
and have looked after the Co-Op since being a PCG.
2 of our practices have decided to retain their
own On Call but we will call handle for them and already provide
district nursing cover.
We have 35 practices two are run by the PCT.
Two single handers have opted out—all other practices will
do their own on call as part. of a cooperative that currently
includes all practices in the PCT and which covers the PCT practices
and two from a neighbouring PCT.
OUR CURRENT
POSITION IS
AS FOLLOWS
On 1 April the PCT took responsibility for providing
OOH for one area of our PCT and from 1st June we took responsibility
for the whole PCT area (220,000 population).
We had many months ago canvassed GPs as to whether
they were going to opt out (99%), whether the existing three co-ops
wished to continue or expand to cover the whole PCT (no and no!)
and whether GPs would be willing to work in a new PCT led integrated
OOH service (60% yes).
Our new service has a single point of access
through the ambulance trust call handling, nurse triage of calls
(100% overnight, less in evenings/weekends but to be 100% in next
few months), transport with drivers for the doctors/nurses, multi-professional
provision with GPs and first contact nurses/nurse practitioners.
There is extended district nursing to 22.00 hours 365 days/year,
a new mental health crisis resolution team available 365 days/year
24hrs.
After midnight the service will be entirely
nurse delivered once the nurses have completed all the modules
in the first contact course with A+E doctor back-up for any queries
(The service runs adjacent to our local A+E dept).
Currently however we have volunteer GPs rota'd
to staff pink-eye shifts from midnight to 03.00 and an extra A+E
staff grade doctor to work with our OOH nurse from 03.00 to 08.00.
There is also a back-up for palliative care/nursing home etc.
visits of the on call GP police surgeon available if necessary
between 03.00-08.00.
The system currently requires 160 GP shifts/month
to populate the rota but we anticipate as the nurses complete
their training they will populate more of the shifts and ultimately
we will require around 100 GP shifts/month. This will reduce costs.
Filling 160 shifts/month with volunteers has been difficult. We
do not anticipate difficulties filling 100-120 shifts/month with
our volunteer GPs.
The monies recovered from our GP opt-out were
- £1 million and the service, as presently configured, is
costing £1.2 million annualised. When the balance of shifts
changes to more first contact nurse involvement the cost will
be less than £1 million.
There were undoubtedly some organisational difficulties
in pulling together all the strands that make the service work.
To date we still are behind in various things eg:
1. Signing off the Patient Group Directions
for our trainee first contact nurses to be able to dispense emergency
medicines to patients without them having to see a doctor.
2. Increasing our previous single triage
computer point to six (so far we have three up and running).
3. Our planned 24 hour nursing response
team to prevent unnecessary hospital admissions won't be up and
running until December.
4. Admission rights for our nurses are still
under negotiation.
Nevertheless we are up and running and to date
everything has gone well!
Our PCT took over responsibility for OOH 19
April, on behalf of all GPs in the city. From the start of the
year the existing GP co-op began working for all GPs (the rival
Primecare stopped) and the PCT has based the service initially
on the expanded co-op, using the local ambulance service to take
calls. The site is next to the existing Walk In Centre which operates
evenings and weekends. The plan is to introduce triage by nurse
and additionally trained ambulance paramedics by the end of this
year, for appropriate cases, and to develop an integrated service
for all OOH health needs.
CURRENT MODEL
Our PCT has had an Out of hours service up and
running since 1 April with the exception of Saturday mornings.
Saturday mornings done by practices as a LES
for 0.5% of the Global Sum.
Evenings and Weekends contracted to a consortium
of local GPs who guarantee to provide two GPs for each shift (one
at primary care centre base adjacent to A&E at local Horton
Hospital, and the other mobile in car with driver).
Red-eye shift (11 pm-8 am) contracted to Primecare
who provide mobile GP.
HOW IS
IT GOING?
Working very well with patients appreciative
of the input of local GPs. However it is costly for the PCT—an
additional cost pressure over funding of approx £400K. This
has been funded out of the Enhanced Services floor with only very
reluctant agreement of the LMC—this will need to be revisited
next year.
THE FUTURE
Currently negotiating with consortium of GPs
to alter shift times—increasing to three GPs on Sunday mornings
and reducing the hours of one of the GPs in the evenings.
Paramedics currently being trained and we hope
to integrate them into the model later in the year.
Also working on involving District Nurses.
A wider model is being worked on which may allow
some economies of scale.
Closer working with next-door A&E is happening
ad hoc but we are beginning to formalise these links which may
also allow some reduction in GP time in the future however we
do not envisage that we will ever be able to do entirely without
any GPs—not if we are going to be able to keep a lid on
our emergency admissions.
The key to our current model is that it is safe
with the local GPs and flexible enough to allow grafting on of
these other professionals and services as time goes on thus reducing
the input of GPs.
Our PCT went live on 5 April, initially taking
over the red-eye shifts entirely, and with a phased programme
to take over the other shifts during this Autumn. The regulations
did not allow us to operate a partial opt-out. Therefore, our
GPs have all officially opted-out from 5 April, although they
have agreed to maintain GP cover for shifts until the phased programme
kicks in.
Our red-eye shifts (11 pm-8 am) are now manned
entirely by nurses. We have two First Contact Practitioners (FCPs)
on duty, with a team of twilight and night-shift community nurses
and a health-care assistant who acts as driver and general helper.
They operate from an "emergency centre" which is located
next to A&E. They give telephone advice, see patients at the
centre, or do home visits as deemed necessary. They can assess,
diagnose, give advice, treat, refer onwards or admit. They currently
use Patient Group Directions to supply medication but are undergoing
training to become prescribers.
During this red-eye shift we have *no* GP on-call
or available. However, for the first few months we are paying
a distant GP co-op to provide telephone GP advice to our First
Contact Practitioners if needed (this is rarely used and has not
been helpful). Our local A&E departments have agreed to assess
patients in the department if our FCPs think further medical examination
and advice would be helpful (again, seems rarely used). We have
secured agreement from our two local hospitals that our FCPs can
have direct admission rights, following advice from staff on MAU,
SAU etc, to all the major acute admitting areas.
We are currently analysing the data from the
first six weeks. Initial results look promising with no evidence
of a surge in admissions and high patient satisfaction. Final
results due shortly and I have asked the team if we could produce
any interim results to inform the House of Commons Select Committee.
Background
Our teaching PCT covers 185,000 patients spread
over a wide geographical area in five market towns and surrounding
villages. We started work on OOH back in 2002 when we realised
we had a major problem looming. We had three small co-ops, none
of which were interested in providing a full integrated OOH service
across the PCT. Initial surveys of GPs attitudes flagged up that
any OOH provider(s) would have a problem covering shifts with
our existing GPs and there was virtually no interest by GPs in
covering overnight shifts. We collected extensive data from the
existing OOH services and used this data to inform our planning.
Being a teaching PCT we had the opportunity to train FCPs, and
we grasped this when we realised this could help solve our OOH
problem. We planned a "nurse-led, doctor-supervised"
model, operating from two "emergency care centres" during
the day and evening, and from one centre for the red-eye shift.
Consultation
We didn't go out to formal consultation, having
been advised we did not need to do this. However, we involved
everyone, GPs, Hospital Trusts, patients, ambulance, etc. in the
planning of our service. This doesn't mean, of course, that everyone
agrees with the model! But all views were heard and the final
model was kept fluid to accommodate emerging views and experience.
Publicity was extensive with all the local papers printing articles
and thousands of leaflets produced.
Finances:
The PCT took over the infrastructure of the
existing GP co-ops on 5 April. The GPs are still currently receiving
their full average 6K for OOH services. The red-eye shift has
been provided FOC by the PCT for the first two months. This month
(June) we will begin deducting amounts from that 6K for the red-eye
cover, based on pro rata per unit of time covered. As we phase
in other shifts, the amounts deducted will grow. From October,
GPs will be able to work paid shifts for the service.
Planned GP involvement in OOH service
We are planning to offer three hour shifts to
GPs, one shift per evening, three shifts per weekend (am, pm,
eve). By shortening the hours and concentrating the GPs work we
can (a) make the shifts less onerous time-wise to GPs and (b)
pay more per shift. The GPs will work alongside FCPs and nurses.
GPs will probably see booked patients in booked "surgeries"
during their shifts, but could, if they wish, choose to triage
or do visits. We are deliberately keeping this fluid until we
see how things work out.
Issues
Some problems caused by having no GPs over the
red-eye period: controlled drugs for palliative care, mental health
"sections", residual concerns by a few secondary care
clinicians. Retaining our First Contact Practitioners, who have
already had offers from other PCTs and co-ops! Recruiting enough
GPs to fill the shifts, despite the shortened hours and generous
pay and realisation that our "nurse-led, doctor-supervised"
model could turn into a "nurse-led, doctor-less" model.
(Based on our experience with the red-eye shifts, this model could
work—but is not what we originally planned.) Uncertainty
and fear that political interference could jeopardise our hard
work and planning.
Our PCT has worked with the other PCTs in the
Strategic Health Authority area to draw up a Service Specification
for a preferred OOH provider (attached). The next step is to hold
a selection process between the local contenders who are the existing
co-op and a commercial provider.
In our PCT 39 out of 40 practices have opted
to continue to provide OOH care; the PCT has arranged cover for
the single opting out practice through the existing co-op.
The big issue is not arranging OOH cover from
December using the existing model but developing, a new model.
Like most areas we wish to re-shape and integrate emergency and
OOH: Work on this has only just begun through the establishment
of an Urgent Care Network.
We are looking at a mutual organisation arising
out of the present co-op. Bit small population of 400,000 so exploring
risk sharing with another area to give over 1,000,000.
Task group making progress. Hoping to be sorted
and responsibility transferred by October. Issues around governance
of the organisation and availability/willingness for GPs to work,
training around other professionals and service redesign needing
public buy in (ie decreased doctor visiting etc)
We are generally on track and should be ready
to go live in December.
Our coops are linking up and we have a building
part of walk in centre planned.
Our PCT has tendered and selected. The successful
provider is a combination of the PCT and the local hospital trust
with a subcontract to *** to provide medical staff, call handling
and triage. They are providing a similar role for other local
areas. This will provide economies of scale and allow us to integrate
the service with existing services including community nursing,
A&E and walk in centre. This was never possible with the previous
provider—Primecare who have lost out in a big way in our
region.
Main issues are getting everything set up for
1 September particularly IT.
Doctor recruitment is underway and may be a
concern although a lot of interest in salaried posts.
Finance is obviously a concern and how much
of a problem this is will depend on doctor recruitment.
3PCTs locally have arranged with three OOHs
Coops a service to officially start 1 July 2004. Don't know population
size or total area-but must be large-nearly 500,000 people. They
have started to employ lots of nurses. Costing more than original
quote-due to redundancy costs and superannuation.
A few words re OOH. The OOH service covers 3PCT
areas. We have appointed the former Coops to run the new service
and they have formed a new mutual vehicle. The process has been
a lengthy one and working across three PCTs and former coops has
been complicated but eventually worthwhile, GPs essentially were
able to opt out from 1 April though we expect to sign formal 3
year contract in the next week or two.
The service is based on the existing but we
are moving to
3. integration with our new Emergency Care
Centre
Two big issues—finance and GP expectations.
Overall a very time consuming process-has enabled
us to engage with secondary care and other providers to look to
re-engineer the service.
As you are probably already aware, our four
local PCTs have developed a county wide plan for the OOH service.
The organisation of the new service is being lead by one PCT on
behalf of all four.
In brief this service is front ended by NHS
Direct who will filter calls to a "central" triaging
GP. This GP will then have the option of referring on calls to
local PCT based services—MIUs with enhanced nursing/paramedic
cover, mobile paramedic, GP in base surgeries or mobile GP. The
plan is to phase in the new service with the "red eye"
shift of the new service starting on 1 July. The remainder of
the service to start on 1 October all being well.
However there are still some outstanding issues—mainly
around funding. Despite "trimming" the service (including
reducing the "red eye" shift to three mobile GPs for
the whole county) there is still a funding gap of around £880k.
Quite rightly we have resisted pressure form
the SHA to trim the service further to reduce the cost of the
new service—any further changes could put patient care at
increase risk. A major challenge for us revolves around the rural
nature of our patch and the long distances to travel to see patients
+ poor transport infrastructure.
As with all PCTs we will be embarking on a PR
plan to inform the public of the changes—which it is hoped
will be viewed as an enhanced service rather than a reduced one.
Quick thoughts:
We have developed a new model to fit with the
new GMS provisions.
Main issue is likely to be availability of practitioners.
We are actively seeking views of GPs as to whether
and how much they are prepared to work. We are interviewing for
salaried GPs to cover some shifts.
We are piloting nurse/paramedic teams as part
of OOH provision.
We are appointing some extended scope nurse
practitioners to supplement and perhaps replace some of the GP
sessions.
We are considering taking in the Sat am sessions
to the OOH service in the summer and intend to have the new system
running by October.
We have been extremely lucky in that we had
a functioning GP co-op in situ. This had been doing 7-11pm week
days and weekends after 12.00 Saturdays for about seven years.
It took over the over night sessions in January 2002 and all OOH
inc Sat mornings in April 2004. We now cover the entire PCT population
with calls triaged through NHSd and operate out of refurbished
accommodation which we share with the Minor Injuries Unit -a nurse
practitioner led service, at our local hospital. (The PCT used
part of its 3 star bonus on this work). We have been designated
an Exemplar site. Plans are well advanced to further integrate
the service with the District Nursing team and to enhance the
service with the use of Nurse Practitioners and ECPs. All the
practices are enthusiastic about the levels of service which the
co-op provides—as are the patients, and there is a large
pool of GPs willing to work the required number of shifts. Registrar
OOH training is incorporated into the process and supervised by
the GP trainers on the rota. There is a real feeling of teamwork
across the district.
We seem to be on schedule to go live with OOH
opt out on 1 September. This has been an unhappy transition, mainly
because of the adherence of our PCTs to the edict to aim for OOH
organisations to cover approx 250,000 head of population.
This in turn has led to the need to merge two
adjacent (current) OOH organisations—who are very different
in many respects!
It seems that the new arrangement will be more
expensive than the one it replaces; a further irony. No doubt
it will all settle down with time.
We are in discussion with the local Co-Op. Hoping
to take over on 1 October 2004.
We have had an exemplar status GP Cooperative
which we hope to continue within the cost constraints and GP availability,
making working for it attractive. the hourly rate will vary according
to time of week and day/night. the telephone/ pcc base consultations
shifts are about to be lengthened from 3-4 hrs.
We will be commissioning the model as from October
1st. the GPs have elected to manage the service after quite a
bit of internal discussion around taking on the risks above. the
pcts have worked closely with the co-operative directorate through
a series of workshops to demonstrate a system wide [and regional]
view of possibilities and constraints. we will be working on a
transitional model up to March 05 engaging GPs in working with
A&E streams.
Our BIGGEST PROBLEM is uncontrolled variety
of access points for patients. about 25% emergency admissions
are 999, untriaged patients are using both the co-operative's
clinics and A&E as Walk in Centres.
Personally I am concerned about GPs retaining
and gaining OoH work experience and skills with the 24hr opt out.
Plans seem to be progressing well (touch wood)
for the launch of a region-wide scheme (ie, across 3PCTs) in October
2004. We are at the moment advertising for salaried GPs and other
healthcare workers. The "risk" which we are contemplating
is that, as indicated elsewhere in the country, hourly/sessional/weekly
fees may come in at higher-than-budget cost. This is why we are
trying to attract a range of people; not just GPs.
The PCT has signed up with a former deputising
service that has transformed itself into a mutual to provide a
service on the PCT's behalf from 1 July 2004. This agreement runs
until 31 March 2005 when it will be reviewed. The PCT has developed
a model of the way it eventually wishes to provide a full unscheduled
care service in the longer term and the co-operative have agreed
to facilitate the development of the new service. The new service
is expected to be fully implemented by 1 September 2005.
This arrangement is only affordable because
it is a part year cost and the PCT has carried forward some unspent
funding from 2003-04 that can be applied also. The new service
model is expected to be more cost-efficient in its use of skilled
manpower and reduce levels of secondary care activity.
Progressing steadily. Hope to outsource rather
than be run by the PCT. Local GP Co-op bidding and probably the
favorite. Aim will be to have more triage than currently. Hope
to better integrate with district nurses and other teams in order
to provide a more joined up service and have less attending A+E
( a big problem in this area). There has been some piloting of
nurse triage at the co-op already In middle distance will need
to work better with ambulance trust.
Hope to go live by 1 October or at latest 31
October.
We are working collaboratively to produce an
out of hours and emergency unscheduled care service by the end
of the year with some service up & running by 1 October. There
is much work to do and clearly there are major financial issues
to resolve well before then. We plan to advertise for "expressions
of interest" in working the service shortly and for a provider
to be appointed in due course.
We worked with the local co-operative and PCT
to arrange a revised OOH service wef 1 October 2003 and our GP's
have benefited from a virtual opt-out arrangement since that date.
This meant that the PCT invested in the revised service configuration
and ahead of formal opt-out in order to gain practical experience
of likely future market conditions re GP supply all cover slots
have been "sold". Up until 1 October 2004 GP's are obliged
to back-fill a slot if it cannot be covered but in practice this
has been a rare occurrence. This has been useful learning ahead
of the formal transfer of responsibilities to the PCT.
The PCT has also been working with partners
to look at the opportunities of moving away from traditional models
of service to broader unscheduled care and in particular looking
at how other professions can be skill mixed into the service.
We have looked in particular at how we can expand the role of
Minor Injury Unit nurses to train them in managing Minor Illness.
In this way we will have a range of skills available in or visiting
treatment centres—trying to balance rural access with cost
effectiveness.
An agreed plan for the development of the service
is in place and the PCT anticipate being in a position to formally
sign a contract for the new service shortly.
One of the early issues arising is Doctor availability
for particular shifts at weekends—we have addressed this
by working with ** to increase supply by jointly recruiting a
small number of GP's wanting portfolio careers and willing to
do 50%-60% OOH and the balance working for the PCT (either in
practices or as GPs with Special Interests). We have been pleased
to see that this type of arrangement is able to bring extra potential
recruits into the area.
Costs are significant—the additional rural
funding will help but the new service configuration is requiring
a greater level of investment that originally envisaged. Our priority
is to ensure a smooth hand-over and a safe and secure service
Over time we believe that costs will be able to be reduced a little
through skill mix and modernisation of the unscheduled care work-stream
This is however not a quick fix!
As a PCT we have had a joint OOH service in
place with our colleagues in the neighbouring PCT since April
2003. Originally, this was commissioned by individual practices
who each held contracts with the provider but this has been taken
over by the PCTs from April 2004 in line with the nGMS requirements
and covered under a SLA agreement.
In terms of issues there are no major concerns
except that of affordability, the 6% top slice from nGMS has been
way short of the figure required to commission a robust and efficient
service to patients out-of-hours. Naturally we expect to further
develop the service over the coming months and years but as it
stands we are confident that the service in place is in line with
nGMS.
We are working with the three local PCTs (our
nearest neighbours) to provide a service. In the short term this
will be not dissimilar to existing deputising services but will
eventually follow other models involving Paramedics, Emergency
Care Practitioners, Walk in Centres etc etc
We have put it out to tender and will be assessing
and interviewing in three weeks time, with the aim of having a
shadow service up and running by October to take over fully before
the deadline.
Of course finance is a problem.
Another problem may be with Practitioners who
are unwilling to let go but would struggle to meet required criteria.
All the GPs in our PCT area have opted into
out of hours dare. They will be providing out of hours care via
a well established co-op.
A few points:
— all GPs "opting out"—December
04.
— new arrangements based on further
cooperative plus local developing service, with county-wide visiting
service.
— establishment of PCCs a challenge,
both financially and staff, but proposals look workable.
We are taking over OOH from end July. Using
two providers—one an expanded and invested in local co-op—the
other via private OOH provider. One practice out of 44 has decided
to carry on itself. We are to date feeling confident re earlier
take over that is essential in the contract.
We have agreed to take over financial and legal
responsibility for OOH cover from 1 October 2004 by contracting
with our present GP co-operatives. We had originally intended
to take over from 1 April 2004 but the shortfall in funding caused
by the difference between global sums and MPIGs gave us a financial
gap we could not hope to cover—we still have a far wider
gap than we feel comfortable with. Unfortunately one of our co-operatives
covers across other three counties at present. In order to be
financially viable it requires input from the other PCTs. This
is at present hoped for and expected but not certain. We know
we will lose some GP workforce in October but hope that using
Nurse Practitioners (as we already do) will enable us to sustain
a service. However, a continuing service depends on the existing
GP workforce (we know of no other large source of Primary Care
trained doctors) and their continuance depends on working conditions
(they aren't going to work OOH if the conditions are onerous,
most of them don't need the money) reasonable rates of pay (they
already have fairly well paid day jobs) and continued goodwill
and a sense of belonging and responsibility to the organisation
and the population. The risks are that there will be a gradual
and continued reduction in the number off GPs prepared to work
for an OOH service (that I feel is certain, it is the rate of
loss that is uncertain) and that in order to maintain a workforce
we will have to provide rates of pay that we cannot afford. In
addition the EWTD will impact as although at the moment medical
staff can opt to work longer hours we understand that there will
be a duty on organisations not to knowingly employ staff who will
be exceeding the working time directive by working for you.
The local PCTs have been working together for
the last two years to implement the recommendations of the Carson
Report and move towards PCT commissioning of out-of-hours services.
One co-op is now the only organised provider
in the county and over the last two years their coverage has been
increased from c. 80% of the population of the county to 100%.
They are accredited until December 2004.
The eight PCTs have agreed to jointly commission
the co-op with effect from 1 October 2004 with one PCT as lead.
A contract is currently being drawn up and will be finalised within
the next two months. Meanwhile all PCT chief executives have written
letters of intent to commission the co-op. The co-op will become
a public interest "mutual" organisation in line with
Department of Health guidelines.
We have been piloting "virtual opt-outs"
in many parts of the county over the last year. These allow GPs
to choose when and whether to work before the actual opt-out date
and have given valuable information on the numbers of GPs who
are expected to work post October and on the expected market rates
for different sessions.
The new model of out-of-hours care makes much
more extensive use of other healthcare professionals, particularly
MIU nurses, WIC nurses and district nurses. We are also piloting
paramedic involvement but without a definite commitment to use
them as part of the service at this stage. These measures will
reduce the numbers of GPs required to work out-of-hours thereby
reducing the cost for the PCTs and the demands on GPs. Not all
PCTs will have the full complement of nurses in place and trained
by October.
In the four "urban" PCTs links are
being established with crisis resolution teams to streamline the
management of mental health issues.
The co-op is now linked to NHS Direct so that
patients who elect to telephone NHS Direct can have their details
passed seamlessly to the organised provider. Further integration
with NHS Direct may be implemented within the next two to three
years depending on funding flows under the PCT commissioning of
NHS Direct.
We are still waiting for the final version of
the DoH document "medicine supply out of hours" so that
we can implement its recommendations. However we have been implementing
or piloting the anticipated improvements wherever possible and
are well positioned to implement fully via the co-op once the
final document is published.
All primary care treatment centres are now set
up in their correct locations, co-located with either community
hospital MIUs or DGH A&E departments. One combined WIC and
out-of-hours treatment centre is operating on Saturdays only pending
the completion of an extension in October from which date the
integration will be complete.
The PCTs are concerned about the heavy cost
burden represented by this process. Even with some financial assistance
for rurality the costs of providing the new service are well in
excess of the revenue available to pay for it. In particular the
entitlement of all clinicians and staff to join the NHS pension
scheme creates a heavy burden on the PCTs.
In our area we have attempted to utilise the
4 providers that have historically been in place to continue to
provide the service. There are 3 Cooperatives (covering 600,000
population mainly around the suburbs and rural hinterland of the
city) and Primecare (covering approximately 350,000 mainly in
the city centre). The PCTs have worked with the Coops to encourage
them attain ubiquitous coverage and are working hard to keep Primecare
in place (not because we are happy with their quality—we
are not—but because the Coops cannot assimilate the "Primecare
practices" within the timescale required). Quite a number
of local practices are trying to leave Primecare, as the service
has been so poor, but the PCTs are not encouraging destabilisation
of Primecare in our local area for the reason above.
The Coops, which have been offering a very high
quality service, are changing. There is now a mixture of full
members and associate member practices. There is the ability of
groups of doctors to form syndicates and to offer to cover regular
sessions after the 1 October, our provisional OOH opt out date,
for the benefit of not only an hourly rate of pay but a retainer
for recognising the commitment undertaken. Doctors can also agree
to do occasional sessions where required, though regularly committed
doctors get priority in session allocation. The Coops have been
working on skill-mix, employing nurses to give advice and recently
to start to see some patients at the primary care bases (all located
on the acute hospital sites). For many of the week's sessions,
however, there is currently no nursing availability and the doctors
deal with all calls. Coops are also interested in diversifying
into in-hours services and have a number of ideas about this.
Most of their current energy though is being spent in trying to
get the service safe and sustainable beyond 1 October.
However, the hourly and retainer rates of pay
that will apply have still not been agreed. Sessions that are
not able to be covered by specific doctors now are currently starting
to attract higher and higher monetary values. Doctors are also
worried that as pay rates go up, the Coops will try to compensate
for this by increasing workloads to the extent that doing sessions
becomes increasingly unpalatable. No contracts have as yet been
signed between the PCTs and the Coops, though the PCTs have indicated
to the Coops that they wish this distribution of coverage to work.
Most doctors locally will exercise their right of opt-out. The
PCTs still seem to feel that they can run the OOH services on
the amount that was spent on OOH previously—I think this
is very unlikely. Also, until rates of pay are known, it is impossible
to know whether or not GPs will sign up to do sessions—and
unless rates of pay rise significantly, my informal soundings
from colleagues suggests that many of them will not.
So there's the makings of some sensible changes,
but there is still great risk and the PCTs do not seem to be aware
quite how fragile the situation still is.
We moved to a countywide structure for OOH care
earlier this year in line with a plan that predated the GMS contract.
Its structure is based on the previous cooperatives and their
coming together was facilitated by the PCTs. The organisation
of the new system is managed by one PCT on behalf of the 3 in
our county but the GPs remain responsible, in essence, for the
care of their patients and for the hands on provision of care
except during the redeye shift from 11 to 8.
The current situation is light on when responsibilities
lie as the system retains some of the ethos of a cooperative but
with PCT involvement and some management. However it is a transitional
phase which should facilitate a smooth change into the new world.
Under the opt out the OOH service will be provided
by one PCT for the whole of the county in the same configuration
as currently (at least at first). The issues are:
— GP manpower—in a rural setting
the demand is greater because of the travelling of both patients
and doctors which leads to less efficient use of manpower.
— Nurse practitioner manpower—the
current training courses do not provide us with nurses with the
hands on skills that are needed if they are to provide a large
amount of care. Work is ongoing to design training that does provide
for our needs.
— Finance—this remains a major
issue but is only one of the drivers to have a service provided
substantially by nurses.
— Integration with A&E—cross
cover may make good use of resources in some places but can lead
to inappropriate use of centres by patients without A&E facilities
to the detriment of patient care.
— Lack of national definition of what
OOH care is for—is it for patient convenience or for emergency
care that cannot wait until working hours. The mixed messages
given to the public nationally are unhelpful in local service
development.
Our GPs opted out of OOH on 1 April 2004.
Our plan is to have paramedic cover 24/7 and
these are in training, employed by local ambulance Trust.
In the interim there is a local enhanced service
to cover OOH shifts, on paid basis £65/hr weekday evening
to £90/hour BH shift. This arrangement is in place to end
of June but likely to extend to end August.
At that point the paramedics will do overnight
cover (11-8) with doctor call triage from local PCT. Over subsequent
months the paramedics will do more routine visits in evening and
weekends, with a doctor being available at the
base. Ultimately the visiting service is likely to be paramedic
only.
We think that 12-15 of our 56 GPs will continue
to work OOH from 1/9. We have some experienced nurses who had
been doing nurse triage for several years, and this will continue
and be developed.
1. Migrated existing GP Co-op to PCT management
1 April 2004.
2. Good continuing engagement of principals
as well as non-principals.
3. Next stage is the integration of ex-Primecare
(etc) practices, whose patients will double the numbers for whom
we are on call. This is happening gradually over the next three
months as existing contracts expire. Some principals may join
the extended rota that will be needed but many will not.
4. Plans are to develop greater nursing
involvement (inc improving our evening/night district nursing
service) plus other skill mix such as use of paramedics, but no
progress yet that I am aware of.
5. Goal is integrated unscheduled care service,
so that all primary care cases are dealt with by primary care
trained personnel.
6. Major issue is that some ex-Co-op principals
are not keen on the "all-comers" approach that would
be involved in integrating the Walk-In Centre's philosophy into
the strengths of the Co-op.
7. OOH service is offering cover for half-days
if all practices migrate to Thursday half-day; costings being
reviewed.
8. Recently two GP principals have been
appointed as joint Clinical Directors for OOH, so that management
of the integration process, and quality issues like audit and
complaints, can be supported.
We have got a vision—triaged by NHS Direct,
front lined by ECPs (emergency care practitioners of which we
have nine) but supported by GPs at all times, supported by a 24
hour district nursing service. We are developing a working relationship
with our acute trust so that inappropriate attendees at A+E are
sent over to the OOHs centre (starting with an agreed case mix)
and our ECPs are working in A+E for the equivalent of one 8 hour
shift per day "in hours" to see these inappropriate
cases when the OOHs centre is shut.
We will have a patient transport service so
we don't exclude those rurally secluded or those from low socio-economic
groups, and will of course continue to do home visits for those
cases that require one.
Main problems—no project manager, not
enough managerial time to progress it, and a Board decision to
put the whole service out to tender, which has slipped start dates,
and means we are still not sure if we will be commissioners or
providers! You try to recruit gps if you cant give absolute guarantees!
Of course it is going to cost more than now, and that is a problem
too.
We are aiming at official start date of 1 October
04, and have over 40 gps expressing initial interest in working
in the service.
If we can make it work, and don't lose our own
tender, then it should be a very good service for patients, and
satisfying and enjoyable for the staff to work in.
In partnership with three of our neighbouring
PCTs, we have a provisional arrangement with Harmoni to provide
OOH cover starting on 1 October 2004.
Costs are high but service level is high. We.
want to arrange a primary care centre adjacent to our local general
hospital A&E providing ooh service initially but becoming
more integrated with A&E in the longer term.
We are experiencing problems in that we are
wishing to contract with NHS direct for call handling under the
fast track arrangement (assuming our application is approved)
but harmoni have requested funding from us to set up their own
call centre in Hertfordshire at an additional cost above that
agreed in our negotiations. Timing is very tight. We are confident
of having the service ready by 1/10.
We have a GP lead for unscheduled care, working
with primary, secondary care, the local A&E and harmoni—and
much co-operation between the three PCTs (although this PCT leads
the process).
Our long term aim is much greater collaboration
including A&E, Primary care and nurse cover, to provide a
more user friendly speedy unscheduled care provision. We have
to keep the process under constant review .
PCTs very slow on the uptake of what was required.
We could have commenced in April 2004 if 5-6 months had not been
spent in (PCTs) hoping a cheap solution would materialize out
of the air.
Fundamental problem is/was that PCT money (budget)
for OOH in this rural area is-4 million and actual cost likely
to be double. PCTs & SHA did not understand OOH & felt
unable to take advice from people who did (GPs). The reason for
this was a) it was believed GPs had not accepted the financial
discipline that PCTs live with all the time (although PCTs down
here manage to overspend regularly on Acute Hosp Care) and b)
also that the GP advice on costs was coming from GPs who might
benefit financially from the new arrangements.
We are on line for new OOH 1 October.
PCTs and others do not understand that skill
mix (apparently the key to massive cost savings) does not work
in low volume settings eg if you have six patients all evening
in a center 25 miles from the next center and three patients need
GP input and three can be managed by nurse what does the staffing
structure look like bearing in mind that the arrival/appointment
times of patients may be scattered through a six hour session
and some of them unknown until midway through the clinic.
Costs: Day time locums now charging £50-60
per hour—what is the OOH rate (especially after midnight)
going to settle at? How will PCTs cope—will they attempt
to run dodgy services to save cash?
Here we have a strong Co-op. The general idea
was to continue with this and then gradually evolve. However at
the last minute one of our PCTs have decided for audit and legal
reasons to move to a contracting process. The other PCT has fallen
in line with them and they have adopted a closed contracting process
inviting four providers to tender. They have given the four organisations
three weeks to tender. the three outside organisations have just
done a similar process in Leeds and this seems to put the local
co-op at a major disadvantage.
The local co-op has managed to maintain good
involvement of its membership with 50% (80 GPs) still working
regularly. There is danger if they lose the contract that many
GPs will disengage from OOH permanently.
The local acute trust has severe financial pressures
that have impacted on the PCTs and I feel that they are looking
to save money on OOHs. I do not think they realise what a big
risk area OOHs is if it goes wrong.
There is no worry about innovative working practices
but very little training has been undertaken and so they will
have no choice but to adopt a fairly traditional model of OOH
provision initially and evolve in time.
I believe out of order there is the potential
to produce chaos. Also I am unsure how acceptable some of the
proposed models of care will be with the public eg the tender
document states that home visits should be done in exceptional
circumstances.
We are in the process of going out to tender
for three main components of OOH, which are;
1. telephone call handling/triage.
2. peak OOH clinical service which is 6;30
to 10pm Monday to Friday, and Saturday and Sunday 8am till 7pm.
3. off peak OOH which is 10pm till 8am Monday-Friday
and 7pm till 8am Saturday and Sunday.
A committee from the PCT is to look at all tenders
at the end of next week, and decide. The PCT is also in the process
of tendering for the peak OOH service depending on local enthusiasm
of gps.
We hope to start a scheme on 1 November 2004.
We have decided, larger co-op taking over existing,
run f WIC site co-located w A&E, major shortfall on money,
unclear how many local GPs will be prepared to do it so whether
viable or not!- as will now be paid rather than goodwill etc,
and MPIG areas PCTs suffer as % GS not MPIG.
Our area is stuck, but hopefully will end up
commissioning the, service from a local co-operative. The problem
is finance. The PCT has as available OOH funds approx 1.3 million.
The service will cost about 2.2 million. Which if you are here
is a huge problem because we are millions overspent anyway.
What stage are we at?
Have agreed preferred provider for local area.
Have served notice on contracts with other existing
provider (Primecare)
Have set date for PCT taking over full responsibility—4
October 2004—with gradual introduction of Saturday morning
cover before this date.
Working on links to OOH dental services.
Issues still to be sorted:
Costs to GP practices of single call access
for patients—should be no charge incurred until call received
by OOH provider.
Looking at involvement of Community Pharmacists,
especially on Saturday mornings. Recognition that emergency medical
cover is only one part of Saturday morning issue and that many
patients and carers order or collect prescriptions on Saturday
mornings—need to put in place ways to make the ordering
of repeat prescriptions easier (postal, electronic, fax, collection
by pharmacists, delivery by pharmacists, use of pharmacist supplementary
prescribing etc.)
Public relations campaign to handle changes
to Saturday mornings especially not yet started. This will be
more of a change for patients than changes to the rest of OOH
which for Nottingham will continue much as before.
Still scope for further integration with other
unscheduled care providers—Ambulance, A&E, WiC.
NHS Direct capability to handle calls in doubt
and need to look at alternative providers of this service if NHS
Direct can't deliver.
We have a plan which is far too expensive but
probably reflects market forces. We will need to modernise with
skill mix issues in future but are concerned about knock on effects
in emergency admissions.
We have reached point of short listing to preferred
provider. This is in partnership with two other local PCTs, we
plan to offer to take over out of hours care from 1 October 2004
for those practices wishing to relinquish 24 hour care, approximately
50% practice indicating will opt out at present, the other 50%
are waiting to know the cost if they opt in with their current
Co-op. We have concerns re NHS Direct being able to meet demand,
and if the welcome additional funding for PCTs will cover the
costs.
We are taking over OOH from 1 June but commissioning
back Sat AMs until 1 October when our walk-in-centre opens. This
will replace existing co-op which is winding up. Most of these
staff. will transfer to PCT employment. Developing an integrated
service using Nurse Practitioners etc but initially service will
look similar to existing service. I anticipate a gradual change
over the next year. We have advertised for OOH salaried Drs and
recruited an experienced Primary care—A&E Doctor who
will do shifts and act as lead clinician for the service. He will
be very useful in establishing good working with the local acute
trust. He will work with the lead nurse also appointed and help
to develop in-house training. Many local GPs wish to carry on,
naturally at much higher (50%) rates of pay. We've had good input
from local GPs and one in particular is acting as clinical lead
whilst the service is being set up. Lots of niggles but I think
they are gradually being ironed out and I am confident that on
June 1st the PCT will be providing an OOH service that is comparable
to our well respected local co-op. Incidentally our decision to
take over OOH earlier than needed has been well received by local
GPs and has bought some goodwill for the inevitable teething problems
that await us. It's also hopefully going to be a quieter time
of the year!
We've had very fruitful conversations with the
local co-op and are very confident we will have a safe service
and a robust service in place by 1 September 2004. Indeed, on
1 July the local co-op will start to cover Saturday mornings for
practices and that has also gone very well.
The main issues have not been about money, interestingly,
as we know there isn't enough! We also know patients need the
care which is the main issue. Anyway the issues have been the
housing of the service ie where is it situated, the long term
vision is to have an integrated service with nurse triage, telephone
consultations, 24 hour community nursing when required and this
is best co-located with A&E for better care and sharing of
learning. That has been a difficulty though because there is no
space!
The other issues of no doctors wanting to do
shifts or patients accessing the service have been dealt with.
So, the main task now is to ensure the vision is do-able and right.
Out of Hours GP Co-op is now part of a larger
alliance, a local Co-op is a cell running our service until 11.00
pm then run on wider basis. All GP's have opted to continue with
responsibility for Out of Hours and all practices work in the
GP Co-op.
Our local GP Out of Hours service is being hosted
by one PCT on behalf of all three local PCTs and covers over 0.5
million patients.
Patients call one 0845 number where calls are
triaged by nursing staff. Depending on the clinical need, the
patient is:
— Asked to attend a centre,
— Home visit is arranged, using a dedicated
car and driver.
The scheme operates from six primary care centres
across the county, with two of the rural centres closing overnight.
All six primary care centres are linked to the same system.
In terms of GP cover the approach taken involves
two phases:
Phase 1—Red eye shift cover is organised
by the PCT, in return the GPs pay a monthly subscription, which
they can earn back. This phase has been operational since February
2004.
Phase 2—Total GP opt out under the new
contract. It is hoped to go live with the phase from November
2004.
KEY ISSUES
FOR TOTAL
OPT OUT
1. Finance
Maintaining the current level of GP cover is
extremely expensive. Every £10 per hour extra spent on GPs
will cost the scheme over £400,000. The fear is that market
forces will substantially increase the acceptable hourly rate
for GPs. Modelling GP costs on what we are informed is the mid
range of acceptable hourly rates gives a potential shortfall of
nearly £1 million for 2004-05, which PCTs will have to find
from very limited funds. This is after the Out of Hours Development
fund has been nearly doubled, and GPs have given up the part year
share of 6% of the global sum under the new contract. The PCT
is looking at alternative skill mixes to ensure that this position
does not deteriorate further in a full year of opt out. However,
these will take time to secure.
2. Managing Down Demand and Patient Expectations—especially
around Saturday mornings. Call volume within the scheme to date
indicates that patients are using the scheme as an alternative
to visiting surgeries when they are open.
3. The impact on GP surgeries in hours.
Out of hours now covers 70% of available time with Access Targets
having to be met within the 30%.
Two local PCTs have agreed to commission from
the existing OHH provider, a so called "transitional model"
from Oct 2004 to March 2005. Thereafter we will work together
on a "transformational model" of care evolving the service
to meet changing demand with a changing workforce. This allows
stability in the short term and an evolution to new models of
care.
We recognise and share the risk of being unable
to find sufficient GPs to fill OOH shifts.
We recognise that the current provider has achieved
high performance in its assessments and we are keen not to lose
this service.
PCT committed to commission the OOH services
rather than provide.
Going through a protracted process of developing
service specification, tendering process and appointment of preferred
provider.
Delay will be inevitable in implementation.
Major issue on costs and affordability for the
PCT.
Vast majority of GP's opting out but do not
want to provide services in the new era.
Sessional fees for GP's will not be raised sufficiently
in the service specification to attract/retain a GP workforce
in the interim before a multi-professional workforce can be developed.
Significant capacity issues in GP workforce
to maintain/deliver OOH in the new system.
PCT's will not be able to afford the true costs
of OOH if we are to retain/attract a viable workforce.
Worst case scenario of minimal GP input into
OOH with no other professionals to deliver is a reality, hence
major impact on secondary care activity and also patients satisfaction
(which is by and large currently very good).
One PCT has lead the process of commissioning
OOH's from four neighbouring Coop's, in conjunction with other
other PCT's. Three quarters of a million patients are now covered
by the service. Local GP's have been given virtual opt out from
1 April and total opt out from 1 July subject to sign up to conditions.
There seems little difficulty in rota sign up and OCC are advanced
in own nurse power triage. Moving towards face to face. We are
working with the Ambulance Trust. The project is tied to a £1.7
million Emergency Care Centre development on the local A&E
dept site where all aspects of emergency care, including OOH will
be integrated, a great place for primary and secondary care to
merge, Opening at the end of this year.
Responses to Out of Hours Questionnaire—Compiled
by NHS Alliance from Responses Received from Survey of the NHS
Alliance (GP 26A)
Four local PCTs will contract ***, currently
a GP cooperative, to start in early October. Planning going well
and to time. Primecare staying around to continue the service
to the 25% of practices that still use them up until the handover.
Negotiations continue re: costs. Service will contain a Dr presence
at all times but will have increasing Nurse input.
MAIN ISSUES
AROUND REPROVISION
OF OOH SERVICES
1. Finance—struggling in the short-term
despite the various non-recurring pump-priming resources announced,
and will definitely struggle long-term, especially if the going
rate for doctor time is higher than anticipated.
2. Integrating the service, both between
the four different PCTs in our locality and also across different
relevant professions (gps, community nurses, Macmillan services,
paramedics, social services etc). This is not due to a lack of
co-operation—indeed the level of joint working in this area
is refreshingly high, but is due to the complexity of the problem
in making sure the future model is an improvement on the existing
one and will deliver a better service to patients as a result
(ie the right professional dealing with the right person at the
right time).
3. Ensuring that the current gp—based
OOH service and NHS Direct use the same protocols/triage software
etc. NHS Direct are pretty restrictive about only being able to
use their software and there are concerns about how good it is
from other professionals.
4. Buying a new site and getting built the
building we will need to house the new service—again, good
progress but the timetable is tight and reliant on an overly bureaucratic
consultation process before we even get to being at the mercy
of the architects and builders!
Three PCTs are combining to provide a PCT led
service from 1 October. This is based on the old cooperative,
which has now been taken over by the PCTs.
The service will be hosted by ** PCT.
Primecare got the hump and pulled out of the
area in April!.
PCT heading full speed for cliff edge with eyes
shut !
Reason for yes vote in GMS mainly for OOH opt
out at bargain 6K price.
PCT hopes loads of GPs will carry on working
at previous coop rate.
Promises of paramedics and nurse practitioners
in team with GP but very few exist as yet.
Here all five PCTs have been ordered by Sir
Ian to scrap their plans and join pan-** scheme, contract awarded
to floundering no star Ambulance Trust three days ago.
We await details of proposed pay and conditions
for GPs with interest. Worried that timescales have been left
deliberately tight so pressure can be applied to GPs to work at
low rates or risk Sir Ian refusing opt out notices.
And it is all going to be working by 1 October
Info on our plans and preparedness:
planning to reprovide the current GP coop service
across two PCTs with mix of salaried GPs (have 6.5 wte recruited
to date but this is not adequate to run service and they are very
expensive, pay up to £110 per hour) and sessions provided
by GPs currently working in the system; main problem is being
sure we will have enough GPs to cover total hours.
Have set aside £4-5k funds in each LDP
in addition to expected claw back from GMS contract and also have
qualified for £50k each PCT of "preparedness" funding.
One practice from my PCT coming into coop not
currently covered (currently their own practice still doing traditional
on-call)—patients in this area anxious as they perceive
deterioration in service, with them having to travel to centre
(even though transport provided) and also no Saturday am surgery—public
consultation here is a challenge.
The coop was originally set up and run by GPs
but recently has been handed over to PCT for management. PCT is
still contracting with GP company for provision of medical services
but directly employs receptionists, nurses etc. GPs don't pay
themselves, just do shifts according to number of patients per
practice—so when PCT takes over providing medical services
too will have to set up clinical governance systems etc which
are currently just responsibility of individual GPs; this is proving
a little bureaucratic.
Overall—complexities of PCT providing
the system are greater than when GPs ran it themselves; for PCTs
it's more difficult taking the risk of providing GP cover because
of the accountabilities—GPs individual responsibilities
were always met but the organisation's employees don't have the
same sense of accountability, interesting culture change. Plus
costs are higher to PCT to run a safe system compared with individual
GPs working together.
Starting 1 September across two PCTs. Rurality
is an issue but working with rapid response paramedics and 24
hour district nurses to provide a triage visiting service—they
will assess and call the OOHs centre to discuss with GP for best
course of action. Advertising for salaried doctors. 50% of GPs
say they will work on the rota. Looking good at the moment.
nightmare!! transferring on 1.7.04.
went through tender process with three tenderers
with neighbouring pct resulted in own present co-op losing out
to major nearby player also a co-op this caused a stink!! although
the tender process was correct and backed by pct boards [there
was] loss of good . . .
major headache for our chief exec—ongoing
meetings to try and keep every one on board by organising subcontracting
for the two co-ops during the next 9 months—we will then
make arrangements for next april and beyond.
Ongoing problems:
termination of existing contracts with commercial
organisations and possible fees for early termination,
different hours of cover—telephone answering/triage/calls,
cross boundary/cross cover arrangements,
confusion over accreditation for one or three
years?
still confusion over how one town will offer
Saturday and Sunday surgeries,
if the local co-op falls—unemployment
for 30 staff—drivers, sec, telephonists etc Imc then got
involved (inappropriately) with an unnecessary and wasteful vote,
it is all an unnecessary disruption which has lost good will and
almost destroyed a service—it should have been a better
process if any change really needed to happen at all—what
is wrong with the systems that works—if it works why break
it when all it needs is a little development so much of this new
GMS contract which promises so much is delivering so little and
destroying general practice along the way we can develop services
by keeping everyone on board as we have done for years we don't
need this unnecessary rigid interference generally a disaster
but thanks to our chief exec hopefully all will be ok—many
management hours have been spent to achieve very little.
In the short term delivering doctor cover will
prove challenging. As the fruits of the new contract are delivered
I have doubts about the number of GPs willing to work ooh . .
. and this is in an area well served by GPs in the past. The other
key issue is cost. The available funds are inadequate and the
resulting deficit reduces our ability to deliver other plans .
. . ie practice based commissioning and care closer to home.
We are working across two PCTs to build on our
OOH Co-Op that already exists.
We have recruited 5.5 salaried Drs and will
be ready to take over OOH GPs from 1.11.04
We are also working to integrate our service
with A+E and currently do the following
1. Share reception with A+E
2. Run an integrated transport service with
our Acute Trust, GP OOH and the Ambulance Trust.
3. Run a rapid response team and a hospice
at home scheme form the centre
4. Provide 24 hour district nursing from
the centre.
5. Have started to skill mix with Nurse
Practitioners
We have avoided using Emergency Care Practitioners
until we see how the pilots work out in our neighbouring PCTs.
We are part of the development of an Emergency
Care Directorate across General Medicine A+E and Primary Care
to run 24 hours a day.
We have sorted out our plans for our technical
links to NHS Direct and we already run a completely paperless
electronic medical record in the centre. We are about to pilot
the electronic transfer of records from our GPs to our OOHs centre
so that records are available 24 hours per day.
We have submitted our plans for OOH to the SHA
and have been told that we have been put forward to receive the
£50K funds for having successfully produced our implementation
plan.
We have access to pathology but not radiology
out of hours and have good relations with A+E. We have good access
to mental health services.
Funding is our main issue but as we have employed
salaried Drs on a salary of £110,000 each—the bulk
of the cost will be covered by the money recouped from Practices.
We have already invested heavily in services such as transport
and have looked after the Co-Op since being a PCG.
Two of our practices have decided to retain
their own On Call but we will call handle for them and already
provide district nursing cover.
We have 35 practices two are run by the PCT.
Two single handers have opted out—all other practices will
do their own on call as part of a cooperative that currently includes
all practices in the PCT and which covers the PCT practices and
two from a neighbouring PCT.
Our current position is as follows
On 1 April the PCT took responsibility for providing
OOH for one area of our PCT and from 1 June we took responsibility
for the whole PCT area (220,000 population).
We had many months ago canvassed GPs as to whether
they were going to opt out (99%), whether the existing three co-ops
wished to continue or expand to cover the whole PCT (no and no!)
and whether GPs would be willing to work in a new PCT led integrated
OOH service (60% yes).
Our new service has a single point of access
through the ambulance trust call handling, nurse triage of calls
(100% overnight, less in evenings/weekends but to be 100% in next
few months), transport with drivers for the doctors/nurses, multi-professional
provision with GPs and first contact nurses/nurse practitioners.
There is extended district nursing to 22.00 hours 365 days/year,
a new mental health crisis resolution team available 365 days/year
24hrs.
After midnight the service will be entirely
nurse delivered once the nurses have completed all the modules
in the first contact course with A+E doctor back-up for any queries
(The service runs adjacent to our local A+E dept.)
Currently however we have volunteer GPs rota'd
to staff pink-eye shifts from mid-night to 03.00 and an extra
A+E staff grade doctor to work with our OOH nurse from 03.00 to
08.00. There is also a back-up for palliative care/nursing home
etc. visits of the on call GP police surgeon available if necessary
between 03.00—08.00.
The system currently requires 160 GP shifts/month
to populate the rota but we anticipate as the nurses complete
their training they will populate more of the shifts and ultimately
we will require around 100 GP shifts/month. This will reduce costs.
Filling 160 shifts/month with volunteers has been difficult. We
do not anticipate difficulties filling 100-120 shifts/month with
our volunteer GPs.
The monies recovered from our GP opt-out were—£1
million and the service, as presently configured, is costing £1.2
million annualised. When the balance of shifts changes to more
first contact nurse involvement the cost will be less than £1
million.
There were undoubtedly some organisational difficulties
in pulling together all the strands that make the service work.
To date we still are behind in various things eg:
1. Signing off the Patient Group Directions
for our trainee first contact nurses to be able to dispense emergency
medicines to patients without them having to see a doctor.
2. Increasing our previous single triage
computer point to six (so far we have 3 up and running).
3. Our planned 24 hour nursing response
team to prevent unnecessary hospital admissions won't be up and
running until December.
4. Admission rights for our nurses are still
under negotiation.
Nevertheless we are up and running and to date
everything has gone well !
Our PCT took over responsibility for OOH 19
April, on behalf of all GPs in the city. From the start of the
year the existing GP coop began working for all GPs (the rival
Primecare stopped) and the PCT has based the service initially
on the expanded coop, using the local ambulance service to take
calls. The site is next to the existing Walk In Centre which operates
evenings and weekends. The plan is to introduce triage by nurse
and additionally trained ambulance paramedics by the end of this
year, for appropriate cases, and to develop an integrated service
for all OOH health needs.
CURRENT MODEL
Our PCT has had an Out of hours service up and
running since 1st April with the exception of Saturday mornings.
Saturday mornings done by practices as a LES
for 0.5% of the Global Sum
Evenings and Weekends contracted to a consortium
of local GPs who guarantee to provide 2 GPs for each shift (one
at primary care centre base adjacent to A&E at local Horton
Hospital, and the other mobile in car with driver).
Red-eye shift (11pm-8am) contracted to Primecare
who provide mobile GP.
HOW IS
IT GOING
?
Working very well with patients appreciative
of the input of local GPs. However it is costly for the PCT—an
additional cost pressure over funding of approx £400K. This
has been funded out of the Enhanced Services floor with only very
reluctant agreement of the LMC—this will need to be revisited
next year.
THE FUTURE
Currently negotiating with consortium of GPs
to alter shift times—increasing to 3 GPs on Sunday mornings
and reducing the hours of one of the GPs in the evenings.
Paramedics currently being trained and we hope
to integrate them into the model later in the year.
Also working on involving District Nurses.
A wider model is being worked on which may allow
some economies of scale.
Closer working with next-door A&E is happening
ad hoc but we are beginning to formalise these links which may
also allow some reduction in GP time in the future however we
do not envisage that we will ever be able to do entirely without
any GPs—not if we are going to be able to keep a lid on
our emergency admissions.
The key to our current model is that it is safe
with the local GPs and flexible enough to allow grafting on of
these other professionals and services as time goes on thus reducing
the input of GPs.
Our PCT went live on the 5 April, initially
taking over the red-eye shifts entirely, and with a phased programme
to take over the other shifts during this Autumn. The regulations
did not allow us to operate a partial opt-out. Therefore, our
GPs have all officially opted-out from the 5 April, although they
have agreed to maintain GP cover for shifts until the phased programme
kicks in.
Our red-eye shifts (11pm-8am) are now manned
entirely by nurses. We have two First Contact Practitioners (FCPs)
on duty, with a team of twilight and night-shift community nurses
and a health-care assistant who acts as driver and general helper.
They operate from an "emergency centre" which is located
next to A&E. They give telephone advice, see patients at the
centre, or do home visits as deemed necessary. They can assess,
diagnose, give advice, treat, refer onwards or admit. They currently
use Patient Group Directions to supply medication but are undergoing
training to become prescribers.
During this red-eye shift we have "no"
GP on-call or available. However, for the first few months we
are paying a distant GP co-op to provide telephone GP advice to
our First Contact Practitioners if needed (this is rarely used
and has not been helpful). Our local A&E departments have
agreed to assess patients in the department if our FCPs think
further medical examination and advice would be helpful (again,
seems rarely used). We have secured agreement from our two local
hospitals that our FCPs can have direct admission rights, following
advice from staff on MAU, SAU etc, to all the major acute admitting
areas.
We are currently analysing the data from the
first 6 weeks. Initial results look promising with no evidence
of a surge in admissions and high patient satisfaction. Final
results due shortly and I have asked the team if we could produce
any interim results to inform the House of Commons Select Committee.
Background:
Our teaching PCT covers 185,000 patients spread
over a wide geographical area in 5 market towns and surrounding
villages. We started work on OOH back in 2002 when we realised
we had a major problem looming. We had three small co-ops, none
of which were interested in providing a full integrated OOH service
across the PCT. Initial surveys of GPs attitudes flagged up that
any OOH provider(s) would have a problem covering shifts with
our existing GPs and there was virtually no interest by GPs in
covering overnight shifts. We collected extensive data from the
existing OOH services and used this data to inform our planning.
Being a teaching PCT we had the opportunity to train FCPs, and
we grasped this when we realised this could help solve our OOH
problem. We planned a "nurse-led, doctor-supervised"
model, operating from two "emergency care centres" during
the day and evening, and from one centre for the red-eye shift.
Consultation:
We didn't go out to formal consultation, having
been advised we did not need to do this. However, we involved
everyone, GPs, Hospital Trusts, patients, ambulance, etc. in the
planning of our service. This doesn't mean, of course, that everyone
agrees with the model! But all views were heard and the final
model was kept fluid to accommodate emerging views and experience.
Publicity was extensive with all the local papers printing articles
and thousands of leaflets produced.
Finances:
The PCT took over the infrastructure of the
existing GP co-ops on the 5 April. The GPs are still currently
receiving their full average 6K for OOH services. The red-eye
shift has been provided FOC by the PCT for the first two months.
This month (June) we will begin deducting amounts from that 6K
for the red-eye cover, based on pro rata per unit of time covered.
As we phase in other shifts, the amounts deducted will grow. From
October, GPs will be able to work paid shifts for the service.
Planned GP involvement in OOH service:
We are planning to offer 3 hour shifts to GPs,
1 shift per evening, 3 shifts per weekend (am, pm, eve). By shortening
the hours and concentrating the GPs work we can (a) make the shifts
less onerous time-wise to GPs and (b)pay more per shift. The GPs
will work alongside FCPs and nurses. GPs will probably see booked
patients in booked "surgeries" during their shifts,
but could, if they wish, choose to triage or do visits. We are
deliberately keeping this fluid until we see how things work out.
Issues:
Some problems caused by having no GPs over the
red-eye period: controlled drugs for palliative care, mental health
"sections", residual concerns by a few secondary care
clinicians. Retaining our First Contact Practitioners, who have
already had offers from other PCTs and co-ops! Recruiting enough
GP to fill the shifts, despite the shortened hours and generous
pay and realisation that our "nurse-led, doctor-supervised"
model could turn into a "nurse-led, doctor-less" model.
(Based on our experience with the red-eye shifts, this model could
work—but is not what we originally planned.) Uncertainty
and fear that political interference could jeopardise our hard
work and planning.
Our PCT has worked with the other PCTs in the
Strategic Health Authority area to draw up a Service Specification
for a preferred OOH provider (attached). The next step is to hold
a selection process between the local contenders who are the existing
coop and a commercial provider.
In our PCT 39 out of 40 practices have opted
to continue to provide OOH care; the PCT has arranged cover for
the single opting out practice through the existing coop.
The big issue is not arranging OOH cover from
December using the existing model but developing a new model.
Like most areas we wish to re-shape and integrate emergency and
OOH. Work on this has only just begun through the establishment
of an Urgent Care Network.
We are looking at a mutual organisation arising
out of the present co-op. Bit small population of 400,000 so exploring
risk sharing with another area to give over 1,000,000.
Task group making progress. Hoping to be sorted
and responsibility transferred by October. Issues around governance
of the organisation and availability / willingness for GP's to
work, training around other professionals and service redesign
needing public buy in (ie decreased doctor visiting etc) we are
generally on track and should be ready to go live in December.
Our co ops are linking up and we have a building
part of walk in centre planned.
Our PCT has tendered and selected. The successful
provider is a combination of the PCT and the local hospital trust
with a subcontract to ** to provide medical staff, call handling
and triage. They are providing a similar role for other local
areas. This will provide economies of scale and allow us to integrate
the service with existing services including community nursing,
A&E and walk in centre. This was never possible with the previous
provider—Primecare who have lost out in a big way in our
region.
Main issues are getting everything set up for
1 September particularly IT.
Doctor recruitment is underway and may be a
concern although a lot of interest in salaried posts.
Finance is obviously a concern and how much
of a problem this is will depend on doctor recruitment.
3PCTs locally have arranged with 3 OOHs Coops
a service to officially start 1/7/2004. Don't know population
size or total area-but must be large-nearly 500,000 people. They
have started to employ lots of nurses. Costing more than original
quote-due to redundancy costs and superannuation.
A few words re OOH. The OOH service covers 3PCT
areas. We have appointed the former Coops to run the new service
and they have formed a new mutual vehicle. The process has been
a lengthy one and working across three PCTs and former coops has
been complicated but eventually worthwhile, GPs essentially were
able to opt out from 1st April though we expect to sign formal
3 year contract in the next week or two.
The service is based on the existing but we
are moving to
1. greater nurse triage
2. whole systems working
3. integration with our new Emergency Care
Centre
Two big issues—finance and GP expectations.
Overall a very time consuming process-has enabled
us to engage with secondary care and other providers to look to
re-engineer the service.
As you are probably already aware, our 4 local
PCTs have developed a county wide plan for the OOH service. The
organisation of the new service is being lead by one PCT on behalf
of all four.
In brief this service is front ended by NHS
Direct who will filter calls to a "central" triaging
GP. This GP will then have the option of referring on calls to
local PCT based services—MIUs with enhanced nursing/paramedic
cover, mobile paramedic, GP in base surgeries or mobile GP. The
plan is to phase in the new service with the "red eye"
shift of the new service starting on 1st July. The remainder of
the service to start on 1st October all being well.
However there are still some outstanding issues—mainly
around funding. Despite `trimming' the service (including reducing
the "red eye" shift to three mobile GPs for the whole
county) there is still a funding gap of around £880k.
Quite rightly we have resisted pressure form
the SHA to trim the service further to reduce the cost of the
new service—any further changes could put patient care at
increase risk.
A major challenge for us revolves around the
rural nature of our patch and the long distances to travel to
see patients + poor transport infrastructure.
As with all PCTs we will be embarking on a PR
plan to inform the public of the changes—which it is hoped
will be viewed as an enhanced service rather than a reduced one.
Quick thoughts:
We have developed a new model to fit with the
new GMS provisions.
Main issue is likely to be availability of practitioners
We are actively seeking views of GPs as to whether
and how much they are prepared to work. We are interviewing for
salaried GPs to cover some shifts
We are piloting nurse/paramedic teams as part
of OOH provision
We are appointing some extended scope nurse
practitioners to supplement and perhaps replace some of the GP
sessions.
We are considering taking in the Sat am sessions
to the OOH service in the summer and intend to have the new system
running by October.
We have been extremely lucky in that we had
a functioning GP co-op in situ. This had been doing 7-11pm week
days and weekends after 12.00 Saturdays for about seven years.
It took over the over night sessions in January 2002 and all OOH
inc Sat mornings in April 2004. We now cover the entire PCT population
with calls triaged through NHSd and operate out of refurbished
accommodation which we share with the Minor Injuries Unit -a nurse
practitioner led service, at our local hospital. (The PCT used
part of its 3 star bonus on this work). We have been designated
an Exemplar site. Plans are well advanced to further integrate
the service with the District Nursing team and to enhance the
service with the use of Nurse Practitioners and ECPs. All the
practices are enthusiastic about the levels of service which the
co-op provides—as are the patients, and there is a large
pool of GPs willing to work the required number of shifts. Registrar
OOH training is incorporated into the process and supervised by
the GP trainers on the rota. There is a real feeling of teamwork
across the district.
We seem to be on schedule to go live with OOH
opt out on 1 Sept. This has been an unhappy transition, mainly
because of the adherence of our PCTs to the edict to aim for OOH
organisations to cover approx 250,000 head of population.
This in turn has led to the need to merge two
adjacent (current) OOH organisations—who are very different
in many respects!
It seems that the new arrangement will be more
expensive than the one it replaces; a further irony. No doubt
it will all settle down with time.
We are in discussion with the local Co-Op. Hoping
to take over on 1/10/04.
We have had an exemplar status GP Cooperative
which we hope to continue within the cost constraints and GP availability,
making working for it attractive. The hourly rate will vary according
to time of week and day/night. the telephone/ pcc base consultations
shifts are about to be lengthened from 3-4 hours.
We will be commissioning the model as from October
1st. the GPs have elected to manage the service after quite a
bit of internal discussion around taking on the risks above. the
pcts have worked closely with the co-operative directorate through
a series of workshops to demonstrate a system wide [and regional]
view of possibilities and constraints. we will be working on a
transitional model up to March 05 engaging GPs in working with
A&E streams.
Our BIGGEST PROBLEM is uncontrolled variety
of access points for patients. about 25% emergency admissions
are 999, untriaged patients are using both the co-operative's
clinics and A&E as Walk in Centres.
Personally I am concerned about GPs retaining
and gaining OoH work experience and skills with the 24hr opt out.
Plans seem to be progressing well (touch wood)
for the launch of a region-wide scheme (ie, across 3PCTs) in October
2004. We are at the moment advertising for salaried GPs and other
healthcare workers. The "risk" which we are contemplating
is that, as indicated elsewhere in the country, hourly/sessional/weekly
fees may come in at higher-than-budget cost. This is why we are
trying to attract a range of people; not just GPs.
The PCT has signed up with a former deputising
service that has transformed itself into a mutual to provide a
service on the PCT's behalf from 1 July 2004. This agreement runs
until 31.03.05 when it will be reviewed. The PCT has developed
a model of the way it eventually wishes to provide a full unscheduled
care service in the longer term and the co-operative have agreed
to facilitate the development of the new service. The new service
is expected to be fully implemented by 1 September 2005.
This arrangement is only affordable because
it is a part year cost and the PCT has carried forward some unspent
funding from 2003-04 that can be applied also. The new service
model is expected to be more cost-efficient in its use of skilled
manpower and reduce levels of secondary care activity.
Progressing steadily. Hope to outsource rather
than be run by the PCT. Local GP Co-op bidding and probably the
favorite. Aim will be to have more triage than currently. Hope
to better integrate with district nurses and other teams in order
to provide a more joined up service and have less attending A+E
( a big problem in this area). There has been some piloting of
nurse triage at the co-op already In middle distance will need
to work better with ambulance trust.
Hope to go live by 1 October or at latest 31
October.
We are working collaboratively to produce an
out of hours & emergency unscheduled care service by the end
of the year with some service up and running by 1 October. There
is much work to do & clearly there are major financial issues
to resolve well before then. We plan to advertise for "expressions
of interest" in working the service shortly and for a provider
to be appointed in due course.
We worked with the local co-operative and PCT
to arrange a revised OOH service wef 1 October 2003 and our GP's
have benefited from a virtual opt-out arrangement since that date.
This meant that the PCT invested in the revised service configuration
and ahead of formal opt-out in order to gain practical experience
of likely future market conditions re GP supply all cover slots
have been "sold". Up until 1 October 2004 GP's are obliged
to back-fill a slot if it cannot be covered but in practice this
has been a rare occurrence. This has been useful learning ahead
of the formal transfer of responsibilities to the PCT.
The PCT has also been working with partners
to look at the opportunities of moving away from traditional models
of service to broader unscheduled care and in particular looking
at how other professions can be skill mixed into the service.
We have looked in particular at how we can expand the role of
Minor Injury Unit nurses to train them in managing Minor Illness.
In this way we will have a range of skills available in or visiting
treatment centres—trying to balance rural access with cost
effectiveness.
An agreed plan for the development of the service
is in place and the PCT anticipate being in a position to formally
sign a contract for the new service shortly.
One of the early issues arising is Doctor availability
for particular shifts at weekends—we have addressed this
by working with ** to increase supply by jointly recruiting a
small number of GP's wanting portfolio careers and willing to
do 50%-60% OOH and the balance working for the PCT (either in
practices or as GPs with Special Interests). We have been pleased
to see that this type of arrangement is able to bring extra potential
recruits into the area.
Costs are significant—the additional rural
funding will help but the new service configuration is requiring
a greater level of investment that originally envisaged. Our priority
is to ensure a smooth hand-over and a safe and secure service
Over time we believe that costs will be able to be reduced a little
through skill mix and modernisation of the unscheduled care work-stream
This is however not a quick fix!
As a PCT we have had a joint OOH service in
place with our colleagues in the neighbouring PCT since April
2003. Originally, this was commissioned by individual practices
who each held contracts with the provider but this has been taken
over by the PCTs from April 2004 in line with the nGMS requirements
and covered under a SLA agreement.
In terms of issues there are no major concerns
except that of affordability, the 6% top slice from nGMS has been
way short of the figure required to commission a robust and efficient
service to patients out-of-hours. Naturally we expect to further
develop the service over the coming months and years but as it
stands we are confident that the service in place is in line with
nGMS.
We are working with the three local PCTs (our
nearest neighbours) to provide a service. In the short term this
will be not dissimilar to existing deputising services but will
eventually follow other models involving Paramedics, Emergency
Care Practitioners, Walk in Centres etc etc.
We have put it out to tender and will be assessing
and interviewing in three weeks time, with the aim of having a
shadow service up and running by October to take over fully before
the deadline.
Of course finance is a problem.
Another problem may be with Practitioners who
are unwilling to let go but would struggle to meet required criteria.
All the GPs in our PCT area have opted into
out of hours dare. They will be providing out of hours care via
a well established co-op.
A few points:
— all GPs "opting out"—December
04.
— new arrangements based on further
cooperative plus local developing service, with county-wide visiting
service.
— establishment of PCCs a challenge,
both financially and staff, but proposals look workable.
We are taking over OOH from end July. Using
two providers—one an expanded and invested in local co-op—the
other via private OOH provider. One practice out of 44 has decided
to carry on itself. We are to date feeling confident re earlier
take over that is essential in the contract.
We have agreed to take over financial and legal
responsibility for OOH cover from 1st October 2004 by contracting
with our present GP co-operatives. We had originally intended
to take over from April 1st 2004 but the shortfall in funding
caused by the difference between global sums and MPIGs gave us
a financial gap we could not hope to cover—we still have
a far wider gap than we feel comfortable with. Unfortunately one
of our co-operatives covers across other three counties at present.
In order to be financially viable it requires input from the other
PCTs. This is at present hoped for and expected but not certain.
We know we will lose some GP workforce in October but hope that
using Nurse Practitioners (as we already do) will enable us to
sustain a service. However, a continuing service depends on the
existing GP workforce (we know of no other large source of Primary
Care trained doctors) and their continuance depends on working
conditions (they aren't going to work OOH if the conditions are
onerous, most of them don't need the money) reasonable rates of
pay (they already have fairly well paid day jobs) and continued
goodwill and a sense of belonging and responsibility to the organisation
and the population. The risks are that there will be a gradual
and continued reduction in the number off GPs prepared to work
for an OOH service (that I feel is certain, it is the rate of
loss that is uncertain) and that in order to maintain a workforce
we will have to provide rates of pay that we cannot afford. In
addition the EWTD will impact as although at the moment medical
staff can opt to work longer hours we understand that there will
be a duty on organisations not to knowingly employ staff who will
be exceeding the working time directive by working for you.
The local PCTs have been working together for
the last two years to implement the recommendations of the Carson
Report and move towards PCT commissioning of out-of-hours services.
One co-op is now the only organised provider
in the county and over the last two years their coverage has been
increased from c. 80% of the population of the county to 100%.
They are accredited until December 2004.
The eight PCTs have agreed to jointly commission
the co-op with effect from 1 October 2004 with one PCT as lead.
A contract is currently being drawn up and will be finalised within
the next two months. Meanwhile all PCT chief executives have written
letters of intent to commission the co-op. The co-op will become
a public interest "mutual" organisation in line with
Department of Health guidelines.
We have been piloting "virtual opt-outs"
in many parts of the county over the last year. These allow GPs
to choose when and whether to work before the actual opt-out date
and have given valuable information on the numbers of GPs who
are expected to work post October and on the expected market rates
for different sessions.
The new model of out-of-hours care makes much
more extensive use of other healthcare professionals, particularly
MIU nurses, WIC nurses and district nurses. We are also piloting
paramedic involvement but without a definite commitment to use
them as part of the service at this stage. These measures will
reduce the numbers of GPs required to work out-of-hours thereby
reducing the cost for the PCTs and the demands on GPs. Not all
PCTs will have the full complement of nurses in place and trained
by October.
In the four "urban" PCTs links are
being established with crisis resolution teams to streamline the
management of mental health issues.
The co-op is now linked to NHS Direct so that
patients who elect to telephone NHS Direct can have their details
passed seamlessly to the organised provider. Further integration
with NHS Direct may be implemented within the next two to three
years depending on funding flows under the PCT commissioning of
NHS Direct.
We are still waiting for the final version of
the DoH document "medicine supply out of hours" so that
we can implement its recommendations. However we have been implementing
or piloting the anticipated improvements wherever possible and
are well positioned to implement fully via the co-op once the
final document is published.
All primary care treatment centres are now set
up in their correct locations, co-located with either community
hospital MIUs or DGH A&E departments. One combined WIC and
out-of-hours treatment centre is operating on Saturdays only pending
the completion of an extension in October from which date the
integration will be complete.
The PCTs are concerned about the heavy cost
burden represented by this process. Even with some financial assistance
for rurality the costs of providing the new service are well in
excess of the revenue available to pay for it. In particular the
entitlement of all clinicians and staff to join the NHS pension
scheme creates a heavy burden on the PCTs.
In our area we have attempted to utilise the
4 providers that have historically been in place to continue to
provide the service. There are three Cooperatives (covering 600,000
population mainly around the suburbs and rural hinterland of the
city) and Primecare (covering approximately 350,000 mainly in
the city centre). The PCTs have worked with the Coops to encourage
them attain ubiquitous coverage and are working hard to keep Primecare
in place (not because we are happy with their quality—we
are not—but because the Coops cannot assimilate the "Primecare
practices" within the timescale required). Quite a number
of local practices are trying to leave Primecare, as the service
has been so poor, but the PCTs are not encouraging destabilisation
of Primecare in our local area for the reason above.
The Coops, which have been offering a very high
quality service, are changing. There is now a mixture of full
members and associate member practices. There is the ability of
groups of doctors to form syndicates and to offer to cover regular
sessions after the 1 October, our provisional OOH opt out date,
for the benefit of not only an hourly rate of pay but a retainer
for recognising the commitment undertaken. Doctors can also agree
to do occasional sessions where required, though regularly committed
doctors get priority in session allocation. The Coops have been
working on skill-mix, employing nurses to give advice and recently
to start to see some patients at the primary care bases (all located
on the acute hospital sites). For many of the week's sessions,
however, there is currently no nursing availability and the doctors
deal with all calls. Coops are also interested in diversifying
into in-hours services and have a number of ideas about this.
Most of their current energy though is being spent in trying to
get the service safe and sustainable beyond 1 October.
However, the hourly and retainer rates of pay
that will apply have still not been agreed. Sessions that are
not able to be covered by specific doctors now are currently starting
to attract higher and higher monetary values. Doctors are also
worried that as pay rates go up, the Coops will try to compensate
for this by increasing workloads to the extent that doing sessions
becomes increasingly unpalatable. No contracts have as yet been
signed between the PCTs and the Coops, though the PCTs have indicated
to the Coops that they wish this distribution of coverage to work.
Most doctors locally will exercise their right of opt-out. The
PCTs still seem to feel that they can run the OOH services on
the amount that was spent on OOH previously—I think this
is very unlikely. Also, until rates of pay are known, it is impossible
to know whether or not GPs will sign up to do sessions—and
unless rates of pay rise significantly, my informal soundings
from colleagues suggests that many of them will not.
So there's the makings of some sensible changes,
but there is still great risk and the PCTs do not seem to be aware
quite how fragile the situation still is.
We moved to a countywide structure for OOH care
earlier this year in line with a plan that predated the GMS contract.
Its structure is based on the previous cooperatives and their
coming together was facilitated by the PCTs. The organisation
of the new system is managed by one PCT on behalf of the 3 in
our county but the GPs remain responsible, in essence, for the
care of their patients and for the hands on provision of care
except during the red eye shift from 11 to 8.
The current situation is light on when responsibilities
lie as the system retains some of the ethos of a cooperative but
with PCT involvement and some management. However it is a transitional
phase which should facilitate a smooth change into the new world.
Under the opt out the OOH service will be provided
by one PCT for the whole of the county in the same configuration
as currently (at least at first). The issues are:
— GP manpower—in a rural setting
the demand is greater because of the travelling of both patients
and doctors which leads to less efficient use of manpower.
— Nurse practitioner manpower—the
current training courses do not provide us with nurses with the
hands on skills that are needed if they are to provide a large
amount of care. Work is ongoing to design training that does provide
for our needs.
— Finance—this remains a major
issue but is only one of the drivers to have a service provided
substantially by nurses.
— Integration with A&E—cross
cover may make good use of resources in some places but can lead
to inappropriate use of centres by patients without A&E facilities
to the detriment of patient care.
— Lack of national definition of what
OOH care is for—is it for patient convenience or for emergency
care that cannot wait until working hours. The mixed messages
given to the public nationally are unhelpful in local service
development.
Our GPs opted out of OOH on 1/4/04.
Our plan is to have paramedic cover 24/7 and
these are in training, employed by local ambulance Trust.
In the interim there is a local enhanced service
to cover OOH shifts, on paid basis £65/hr weekday evening
to £90/hour BH shift. This arrangement is in place to end
of June but likely to extend to end August.
At that point the paramedics will do overnight
cover (11-8) with doctor call triage from local PCT. Over subsequent
months the paramedics will do more routine visits in evening and
weekends, with a doctor being available at the base. Ultimately
the visiting service is likely to be paramedic only.
We think that 12-15 of our 56 GPs will continue
to work OOH from 1/9. We have some experienced nurses who had
been doing nurse triage for several years, and this will continue
and be developed.
1. Migrated existing GP Co-op to PCT management
1.4.04.
2. Good continuing engagement of principals
as well as non-principals.
3. Next stage is the integration of ex-Primecare
(etc) practices, whose patients will double the numbers for whom
we are on call. This is happening gradually over the next three
months as existing contracts expire. Some principals may join
the extended rota that will be needed but many will not.
4. Plans are to develop greater nursing
involvement (inc improving our evening/night district nursing
service) plus other skill mix such as use of paramedics, but no
progress yet that I am aware of.
5. Goal is integrated unscheduled care service,
so that all primary care cases are dealt with by primary care
trained personnel.
6. Major issue is that some ex-Co-op principals
are not keen on the "all-comers" approach that would
be involved in integrating the Walk-In Centre's philosophy into
the strengths of the Co-op.
7. OOH service is offering cover for half-days
if all practices migrate to Thursday half-day; costings being
reviewed.
8. Recently two GP principals have been
appointed as joint Clinical Directors for OOH, so that management
of the integration process, and quality issues like audit and
complaints, can be supported.
We have got a vision—triaged by NHS Direct,
front lined by ECPs (emergency care practitioners of which we
have 9) but supported by GPs at all times, supported by a 24 hour
district nursing service. We are developing a working relationship
with our acute trust so that inappropriate attendees at A+E are
sent over to the OOHs centre (starting with an agreed case mix)
and our ECPs are working in A+E for the equivalent of one 8 hour
shift per day "in hours" to see these inappropriate
cases when the OOHs centre is shut.
We will have a patient transport service so
we don't exclude those rurally secluded or those from low socio-economic
groups, and will of course continue to do home visits for those
cases that require one.
main problems—no project manager, not
enough managerial time to progress it, and a Board decision to
put the whole service out to tender, which has slipped start dates,
and means we are still not sure if we will be commissioners or
providers! You try to recruit gps if you cant give absolute guarantees!
Of course it is going to cost more than now, and that is a problem
too.
We are aiming at official start date of 1 October
04, and have over 40 gps expressing initial interest in working
in the service.
If we can make it work, and don't lose our own
tender, then it should be a very good service for patients, and
satisfying and enjoyable for the staff to work in.
In partnership with three of our neighbouring
PCTs, we have a provisional arrangement with Harmoni to provide
OOH cover starting on 1 October 2004.
Costs are high but service level is high. We
want to arrange a primary care centre adjacent to our local general
hospital A&E providing ooh service initially but becoming
more integrated with A&E in the longer term.
We are experiencing problems in that we are
wishing to contract with NHS direct for call handling under the
fast track arrangement (assuming our application is approved)
but harmoni have requested funding from us to set up their own
call centre in Hertfordshire at an additional cost above that
agreed in our negotiations . Timing is very tight. We are confident
of having the service ready by 1/10.
We have a GP lead for unscheduled care, working
with primary secondary care, the local A&E and harmoni—and
much co-operation between the 3 PCTs (although this PCT leads
the process).
Our long term aim is much greater collaboration
including A&E, Primary care and nurse cover, to provide a
more user friendly speedy unscheduled care provision . We have
to keep the process under constant review.
PCTs very slow on the uptake of what was required.
We could have commenced in April 2004 if 5-6 months had not been
spent in (PCTs) hoping a cheap solution would materialize out
of the air.
Fundamental problem is/was that PCT money (budget)
for OOH in this rural area is-4 million & actual cost likely
to be double. PCTs & SHA did not understand OOH and felt unable
to take advice from people who did (GPs). The reason for this
was a) it was believed GPs had not accepted the financial discipline
that PCTs live with all the time (although PCTs down here manage
to overspend regularly on Acute Hosp Care ! ) & b) also that
the GP advice on costs was coming from GPs who might benefit financially
from the new arrangements.
We are on line for new OOH 1 October.
PCTs & others do not understand that skill
mix (apparently the key to massive cost savings) does not work
in low volume settings eg if you have six patients all evening
in a center 25 miles from the next center & 3 patients need
GP input & three can be managed by nurse what does the staffing
structure look like bearing in mind that the arrival/appointment
times of patients may be scattered through a 6 hr session &
some of them unknown until midway through the clinic.
Costs : Day time locums now charging £50-60
per hour—what is the OOH rate (especially after midnight)
going to settle at? How will PCTs cope—will they attempt
to run dodgy services to save cash?
Here we have a strong Co-op. The general idea
was to continue with this and then gradually evolve. However at
the last minute one of our PCTs have decided for audit & legal
reasons to move to a contracting process. The other PCT has fallen
in line with them and they have adopted a closed contracting process
inviting four providers to tender. They have given the four organisations
three weeks to tender. the three outside organisations have just
done a similar process in Leeds and this seems to put the local
co-op at a major disadvantage.
The local co-op has managed to maintain good
involvement of it's membership with 50% (80 GPs) still working
regularly. There is danger if they lose the contract that many
GPs will disengage from OOH permanently.
The local acute trust has severe financial pressures
that have impacted on the PCTs and I feel that they are looking
to save money on OOHs. I do not think they realise what a big
risk area OOHs is if it goes wrong.
There is no worry about innovative working practices
but very little training has been undertaken and so they will
have no choice but to adopt a fairly traditional model of OOH
provision initially and evolve in time.
I believe out of order there is the potential
to produce chaos. Also I am unsure how acceptable some of the
proposed models of care will be with the public eg the tender
document states that home visits should be done in exceptional
circumstances.
We are in the process of going out to tender
for three main components of OOH, which are:
1. telephone call handling/triage.
2. peak OOH clinical service which is 6;30
to 10 pm Monday to Friday, and Saturday and Sunday 8am till 7pm.
3. off peak OOH which is 10pm till 8am Monday
to Friday and 7pm till 8am Saturday and Sunday.
A committee from the pct is to look at all tenders
at the end of next week, and decide. The pct is also in the process
of tendering for the peak OOH service depending on local enthusiasm
of gps.
We hope to start a scheme on 1/11/4.
We have decided, larger co-op taking over existing,
run f WIC site co-located w A&E, major shortfall on money,
unclear how many local GPs will be prepared to do it so whether
viable or not!- as will now be paid rather than goodwill etc,
and MPIG areas PCTs suffer as % GS not MPIG.
Our area is stuck, but hopefully will end up
commissioning the service from a local co-operative. The problem
is finance. The PCT has as available OOH funds approx 1.3 million.
The service will cost about 2.2 million. Which if you are here
is a huge problem because we are millions overspent anyway.
What stage are we at?
Have agreed preferred provider for local area.
Have served notice on contracts with other existing
provider (Primecare)
Have set date for PCT taking over full responsibility—4
October 2004—with gradual introduction of Saturday morning
cover before this date.
Working on links to OOH dental services.
Issues still to be sorted:
Costs to GP practices of single call access
for patients—should be no charge incurred until call received
by OOH provider.
Looking at involvement of Community Pharmacists,
especially on Saturday mornings. Recognition that emergency medical
cover is only one part of Saturday morning issue and that many
patients & carers order or collect prescriptions on Saturday
mornings—need to put in place ways to make the ordering
of repeat prescriptions easier (postal, electronic, fax, collection
by pharmacists, delivery by pharmacists, use of pharmacist supplementary
prescribing etc.)
Public relations campaign to handle changes
to Saturday mornings especially not yet started. This will be
more of a change for patients than changes to the rest of OOH
which for Nottingham will continue much as before.
Still scope for further integration with other
unscheduled care providers—Ambulance, A&E, WiC.
NHS Direct capability to handle calls in doubt
and need to look at alternative providers of this service if NHS
Direct can't deliver.
We have a plan which is far too expensive but
probably reflects market forces. We will need to modernise with
skill mix issues in future but are concerned about knock on effects
in emergency admissions.
We have reached point of short listing to preferred
provider. This is in partnership with 2 other local PCTs, we plan
to offer to take over out of hours care from 1 October 2004 for
those practices wishing to relinquish 24 hour care, approximately
50% practice indicating will opt out at present, the other 50%
are waiting to know the cost if they opt in with their current
Co-op. We have concerns re NHS Direct being able to meet demand,
and if the welcome additional funding for PCTs will cover the
costs.
We are taking over OOH from June 1st but commissioning
back Sat AMs until 1 October when our walk-in-centre opens. This
will replace existing co-op which is winding up. Most of these
staff will transfer to PCT employment. Developing an integrated
service using Nurse Practitioners etc but initially service will
look similar to existing service. I anticipate a gradual change
over the next year. We have advertised for OOH salaried Drs and
recruited an experienced Primary care/ A&E Doctor who will
do shifts and act as lead clinician for the service. He will be
very useful in establishing good working with the local acute
trust. He will work with the lead nurse also appointed and help
to develop in-house training. Many local GPs wish to carry on,
naturally at much higher (50%) rates of pay. We've had good input
from local GPs and one in particular is acting as clinical lead
whilst the service is being setup. Lots of niggles but I think
they are gradually being ironed out and I am confident that on
June 1st the PCT will be providing an OOH service that is comparable
to our well respected local co-op. Incidentally our decision to
take over OOH earlier than needed has been well received by local
GPs and has bought some goodwill for the inevitable teething problems
that await us. It's also hopefully going to be a quieter time
of the year!
We've had very fruitful conversations with the
local co-op and are very confident we will have a safe service
and a robust service in place by 1 September 2004. Indeed, on
July 1st the local co-op will start to cover Saturday mornings
for practices and that has also gone very well.
The main issues have not been about money, interestingly,
as we know there isn't enough! We also know patients need the
care which is the main issue. Anyway the issues have been the
housing of the service ie where is it situated, the long term
vision is to have an integrated service with nurse triage, telephone
consultations, 24 hour community nursing when required and this
is best co-located with A&E for better care and sharing of
learning. That has been a difficulty though because there is no
space!
The other issues of no doctors wanting to do
shifts or patients accessing the service have been dealt with.
So, the main task now is to ensure the vision is do-able and right.
Out of Hours GP Co-op is now part of a larger
alliance, a local Co-op is a cell running our service until 11.00
pm then run on wider basis. All GP's have opted to continue with
responsibility for Out of Hours and all practices work in the
GP Co-op.
Our local GP Out of Hours service is being hosted
by one PCT on behalf of all 3 local PCTs and covers over 0.5 million
patients.
Patients call one 0845 number where calls are
triaged by nursing staff. Depending on the clinical need, the
patient is:
— Asked to attend a centre,
— Home visit is arranged, using a dedicated
car and driver.
The scheme operates from six primary care centres
across the county, with two of the rural centres closing overnight.
All six primary care centres are linked to the same system.
In terms of GP cover the approach taken involves
two phases:
Phase 1—Red eye shift cover is organised
by the PCT, in return the GPs pay a monthly subscription, which
they can earn back. This phase has been operational since February
2004.
Phase 2—Total GP opt out under the new
contract. It is hoped to go live with the phase from November
2004.
KEY ISSUES
FOR TOTAL
OPT OUT
1. Finance
Maintaining the current level of GP cover is
extremely expensive. Every £10 per hour extra spent on GPs
will cost the scheme over £400,000. The fear is that market
forces will substantially increase the acceptable hourly rate
for GPs. Modelling GP costs on what we are informed is the mid
range of acceptable hourly rates gives a potential shortfall of
nearly £1 million for 2004-05, which PCTs will have to find
from very limited funds. This is after the Out of Hours Development
fund has been nearly doubled, and GPs have given up the part year
share of 6% of the global sum under the new contract. The PCT
is looking at alternative skill mixes to ensure that this position
does not deteriorate further in a full year of opt out. However,
these will take time to secure.
2. Managing Down Demand and Patient Expectations—especially
around Saturday mornings. Call volume within the scheme to date
indicates that patients are using the scheme as an alternative
to visiting surgeries when they are open.
3. The impact on GP surgeries in hours.
Out of hours now covers 70% of available time with Access Targets
having to be met within the 30%.
Two local PCTs have agreed to commission from
the existing OHH provider, a so called transitional model' from
Oct 2004 to March 2005. Thereafter we will work together on a
"transformational model" of care evolving the service
to meet changing demand with a changing workforce. This allows
stability in the short term and an evolution to new models of
care.
We recognise and share the risk of being unable
to find sufficient GPs to fill OOH shifts.
We recognise that the current provider has achieved
high performance in its assessments and we are keen not to lose
this service.
PCT committed to commission the OOH services
rather than provide.
Going through a protracted process of developing
service specification, tendering process and appointment of preferred
provider.
Delay will be inevitable in implementation.
Major issue on costs and affordability for the
PCT.
Vast majority of GP's opting out but do not
want to provide services in the new era.
Sessional fees—for GP's, will not be raised
sufficiently in the service specification to attract/retain a
GP workforce in the interim before a multi-professional workforce
can be developed.
Significant capacity issues in GP workforce
to maintain/deliver OOH in the new system.
PCT's will not be able to afford the true costs
of OOH if we are to retain/attract a viable workforce.
Worst case scenario of minimal GP input into
OOH with no other professionals to deliver is a reality, hence
major impact on secondary care activity and also patients satisfaction
(which is by and large currently very good).
One PCT has lead the process of commissioning
OOH's from four neighbouring Coop's, in conjunction with other
other PCT's. three quarters of a million patients are now covered
by the service. Local GP's have been given virtual opt out from
1 April and total opt out from 1 July subject to sign up to conditions.
There seems little difficulty in rota sign up and OCC are advanced
in own nurse power triage. Moving towards face to face. We are
working with the Ambulance Trust. The project is tied to a £1.7
million Emergency Care Centre development on the local A&E
dept site where all aspects of emergency care, including OOH will
be integrated, a great place for primary and secondary care to
merge, Opening at the end of this year.
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