House of Commons - Public Accounts

Select Committee on Public Accounts Sixteenth Report

1 The Department of Health's preparation for the new service

1. Each year, approximately 9 million patients receive urgent primary out-of-hours care in England. The term 'out-of-hours' refers to care delivered between 6:30 pm and 8:00 am on weekdays and at all times during weekends and public and bank holidays.[3]

2. Out-of-hours services are provided by a range of organisations, including in-house Primary Care Trust teams, GP co-operatives, mutual organisations[4], commercial deputising services, ambulance services and NHS Direct. Treatment options include advice over the telephone, face-to-face clinical assessments at out-of-hours clinics, and home visits. These services are provided by a range of professionals, including doctors, nurses, paramedics and emergency care practitioners, depending on clinical need and the nature of the service. All services must meet a series of standards, known as Quality Requirements, mandated by the Department of Health. The Quality Requirements cover response times, clinical audit, organisational elements, information flows and patient feedback.[5] More frequent users of the service include women, those with one or more children under 16 in their household and those aged between 35 and 54.[6] A survey of Primary Care Trusts by the National Audit Office during 2005-06 showed likely spending in 2005-06 of £392 million compared with a budget of £322 million.

3. Prior to April 2004 GPs were responsible for the provision of out-of-hours services, but most provided the service either by pooling their responsibility through a GP co-operative or by employing a commercial deputising service. During the last decade, responsibility for this service became increasingly unpopular with GPs and the number of complaints from patients rose. In the new General Medical Services contract that came into effect in 2004 the Department therefore gave GPs the chance to opt out of personal responsibility for providing the service. Where GPs opted out, responsibility passed to the local Primary Care Trust, although many GPs remained involved in the delivery of out-of-hours care, working for Primary Care Trusts or for service providers appointed by Primary Care Trusts. The new contract allowed GPs to opt out of their out-of-hours responsibilities from 1 April 2004. If Primary Care Trusts were not ready to take on responsibility at that point, they could defer the transfer until a final deadline of 1 January 2005.[7]

SUPPORT TO PRIMARY CARE TRUSTS

4. The Department provided a range of guidance for Primary Care Trusts before the handover of the service. For example, new guidance was published in 2003, an Exemplar Programme was created to pilot new ways of working, 11 regional centres were established to spread good practice, and a template to aid performance monitoring and reporting was distributed around providers. Despite the range of guidance provided, however, many Primary Care Trusts encountered difficulties in establishing new services because of time constraints and a lack of information to inform the planning of services. Many providers had difficulties in using the template designed to aid performance monitoring and reporting, and only 25 Primary Care Trusts actually used it. In light of this experience, the Department decided to re-examine common reporting processes. Although variable outcomes are likely in a system with 300 Primary Care Trusts, the Department accepted that it should have provided more practical support to all Primary Care Trusts.[8]

5. A key difficulty for Primary Care Trusts in their preparation for the handover was ongoing confusion over whether the new service should provide 'unscheduled' care to treat all patients that required attention, or restrict access to 'urgent' cases and ask all others to see a GP in-hours the next day. The Department wanted the public to be able to choose which service they want to use, and its aim during the handover was not to restrict access for patients but to advise them on how they could receive the most appropriate care or advice. It had not defined whether out-of-hours should be urgent or unscheduled, either at the time of the handover or in the contract negotiations, but has since recognised that it needed to do so.[9]

THE SHAPE OF THE NEW SERVICE

6. The handover resulted in the service being delivered by a range of providers from both private and public sectors. The Department was keen to encourage plurality of provision; it saw an important ongoing role for the voluntary, private and independent sectors as well as the NHS, and wanted everyone so far as possible to be able to participate. The Department was also keen to encourage greater movement towards the integration of all unscheduled and urgent care services, including Accident & Emergency, out-of-hours services, district nursing and ambulance services.[10]

7. Primary Care Trusts were not required to run competitive tenders, and only 39% did so. The price of the service being paid by Primary Care Trusts that tendered was only 29 pence per head of population lower than that paid by those who did not tender, and quality standards did not vary at all. In many instances the specifications had been written by providers, however, and there was a favouring of local co-operatives. The Department's view was that more competition was needed.[11]

8. Out-of-hours providers have increasingly used nurses and other health professionals to work with GPs in out-of-hours services. The increased use of nurses has been seen as a way of making services more cost-effective. Whilst GPs remain essential, nurses can handle many aspects of out-of-hours care.[12]

3 C&AG's Report, para 1.1 Back

4 Mutual organisations are GP co-operatives organised on a community ownership model-C&AG's Report, para 5.1 and Figure 12 Back



© Parliamentary copyright 2007	Prepared 14 March 2007