Conclusions and recommendations
1. The Department of Health (the Department)
failed to make clear whether it regarded out-of-hours care as
an urgent or unscheduled service.
It was therefore difficult for Primary Care Trusts to plan or
commission services according to the type and volume of demand
for out-of-hours care. The Department needs to decide which kind
of service it wants to provide, and give Primary Care Trusts a
definitive statement so that they can plan or commission services
for the future.
2. The new contract allowed GPs to opt out
of responsibility for the out-of-hours service at an average cost
of £6,000, less than half of the cost to the Primary Care
Trust of providing the service. This sum
was the outcome of a negotiation which was not rigorously conducted
by the Department, and which was based on a serious under-estimate
of Primary Care Trusts' likely costs. In future negotiations the
Department needs to improve value for money for the taxpayer by
being a lot better informed on the likely impact of decisions
under consideration.
3. By acting as an 'observer' in the new General
Medical Services contract negotiations, the Department was poorly
placed to achieve the best outcome for taxpayers.
Although the Department ultimately approved the outcome of negotiations,
their importance meant that it was not enough for the Department
simply to observe the negotiations that were being conducted by
the NHS Confederation. To reflect its accountability for the cost,
the Department should be a principal in future contract negotiations.
4. Inadequate performance measurement means
that some Primary Care Trusts do not know how good a service they
are providing for their patients. Two
thirds of Primary Care Trusts taking on out-of-hours services
in 2004 found that management information on the service either
did not exist or was of poor quality. Primary Care Trusts should
report their performance against all of the Quality Requirements.
5. Quality Requirements relating to access
are of most interest to patients, but performance against them
is poor. Fewer than half of all Primary
Care Trusts are meeting the required standard on measures of speed
of access to advice and treatment because of the combination of
inadequate performance measurement and poor performance. Primary
Care Trusts should improve their performance against all these
measures, with priority given to Quality Requirements (9a, 10a,
12a and 12b) relating to emergency and urgent cases. They should,
for example, plan out-of-hours staffing levels to match the peaks
and troughs of demand.
6. Primary Care Trusts remain unclear whether
they and their providers should aim for 95% or 100% compliance
with the Quality Requirements. In order
for Primary Care Trusts to know on what basis to commission and
performance manage services, the Department needs to make clear
what level of compliance is acceptable.
7. It did not occur to the Department that
ending GPs' Saturday morning surgeries would reduce the service
at a key time of the week for patients.
The Department should encourage Primary Care Trusts to use the
contractual arrangements for primary care at their disposal to
re-instate Saturday morning surgeries where there is the demand
for them.
8. The £70 million gap between departmental
allocations for out-of-hours services and actual expenditure has
forced many Primary Care Trusts to incur further deficits or raid
other parts of their budgets in order to maintain a safe out-of-hours
service for their patients. The Department
should rigorously evaluate the financial impacts of proposed initiatives
in advance, for example by forecasting the likely impact on pay
rates that might be caused by changes in a service, so that they
do not unintentionally lead to deficits or adversely affect other
services provided by Primary Care Trusts.
9. Comparisons between Primary Care Trusts
suggest that many could reduce their out-of-hours costs without
diminishing quality. If every Primary
Care Trust provided its service at the same cost as the most cost-effective
in their classification £134 million could be saved, while
£53 million could be saved if the most expensive 50% of Primary
Care Trusts reached the average performance level in each category.[2]
The Department should set a timetable for Primary Care Trusts
to benchmark their services against their peers, require Strategic
Health Authorities to report on their performance, and hold to
account Primary Care Trusts whose costs remain seriously out of
line.
2 C&AG's Report, paras 4.19, 4.20 Back
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