Memorandum by Mike Farrar, NHS North West
(OHS 06)
The recent issues raised in respect of GP out
of hours services can be tracked back to the early 1990s when
GPs were first allowed to delegate their out of hours responsibilities
to a third party. This significant change was lamented by many,
who believed that "continuity of care by their much loved
local family doctor" had been compromised. However, the changes
at that time reflected wider concerns about the quality of care
which GPs were able to deliver when operating on a 24/7 basis,
and the impact which such time and clinical commitments were having
on GP recruitment.
Throughout the 90's, during which time I was
Head of Primary Care at the Department of Health (1997-2000),
out of hours care, even on a delegated basis, provided a major
area for patient complaints and a reported barrier to GP recruitment.
Furthermore, with the advent in the late 1990's of multiple access
points for urgent, non-planned care GP out of hours services became
increasingly part of a more complex and intricate range of service
options. It therefore made sense that as part of the new GMS contract
negotiations to address GP out of hours services with a view to
requiring PCTs to commission them directly as part of a coherent
service response that enabled patients to navigate access to urgent
care appropriately and effectively. It was intended that such
a move would also potentially herald an increase in the popularity
of general practice as a career and also, given the concerns over
quality of out of hours services, could lead to its improvement.
The new GMS contract created a platform for
improving the quality of out of hours services. The negotiators
believed that, whilst the unit costs of GP input would increase
(as GPs were no longer obliged to provide out of hours care),
a more coherent service based on call-triaging, better patient
navigation and reduction in duplication would more than compensate
with improved service quality.
The detailed competency of the individual doctors
was considered to be manageable through the NHS Performers List
arrangements and active contract monitoring by PCTs.
Experience since the introduction of the new
arrangements would suggest that robust arrangements are in place
to ensure delivery of improved out of hours care but that there
is some variation in how PCTs undertake their role. In particular,
I believe, some PCTs have yet to commission a coherent out of
hours urgent care system although the current QIPP programme and
recent rises in non elective activity are driving all PCTs to
focus on the effectiveness and efficiency of their current service
offer. SHAs have focussed most of their performance management
role on this larger urgent care commissioning agenda and the management
of demand for acute care. Also SHAs have and do scrutinise the
local actions by PCTs to ensure the quality of out of hours service
provision as part of their overall performance management role.
This has often been brought to the fore at times when out of hours
contracts have been tendered and/or where numbers of complaints
or untoward incidents have provoked concern.
Mike Farrar
CEO North West
(and ex lead negotiator for NHS Confederation re
new GMS Contract)
March 2010
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