Conclusions and Recommendations
1. NHS England's oversight of the value for
money of out-of-hours GP services has been inadequate. Out-of-hours
GP services are commissioned locally by clinical commissioning
groups or NHS England's local area teams. During 2013-14, NHS
England viewed out-of-hours GP services as low priority and did
not collect enough information to provide it with adequate assurance
on value for money. In addition, it did not analyse data that
was available from the GP Patient Survey to investigate services
which were performing poorly or why overall patient satisfaction
was falling. No up-to-date information is available to allow clinical
commissioning groups to benchmark the cost of their services and
how they perform against the national quality requirements. Available
data is over 2 years old. NHS England said that scrutiny of out-of-hours
GP services will increase in the future and that the Care Quality
Commission would be inspecting the quality and safety of all services.
However, assurances about future plans does not excuse the failure
to provide proper oversight so far.
Recommendation: NHS England should adopt
a proportionate oversight regime which provides it with assurance
on the value for money of out-of-hours GP services and allows
it to identify poorly performing services and make targeted interventions.
2. NHS England should do more to understand
the reasons for the significant variations in cost and patient
satisfaction. There is significant variation across the country
in both the cost of out-of-hours GP services and patient satisfaction
with these services. For example, the cost per case ranged from
less than £29 to more than £134 in 2013-14. The proportion
of people in each local area who rated their experience as 'very
good' or 'fairly good' ranged from 49% to 86% in July 2014. NHS
England demonstrated a general understanding of what may drive
the variation in cost and patient satisfaction, but it appeared
to have little specific information. In evidence to us, it relied
almost entirely on the cost data collected by the National Audit
Office and could not provide information on the specific reasons
for variation or on the costs of a key component of the service,
the hourly rates paid to GPs. A clear understanding of the reasons
for variation and whether it can be justified is essential. This
will help patients, NHS England, commissioners and providers to
understand what good performance and an efficient service look
like, and to drive improvements in value for money.
Recommendation: NHS England should take
responsibility for developing an understanding of the significant
variations across England in the cost of out-of-hours GP services
and in the level of patient satisfaction with these services.
3. Clinical commissioning groups are not presently
managing conflicts of interest when commissioning out-of-hours
GP services. They should be able to demonstrate that they are.
The design of the current system, where GPs can have interests
in both the clinical commissioning groups that commission out-of-hours
services and in the organisations that provide these services,
brings an inherent risk of conflicts of interest. This issue should
have been properly addressed before clinical commissioning groups
were introduced. For example, in Barnet, Enfield and Haringey,
a large number of GPs who work for the clinical commissioning
groups also have shareholdings in the organisation that provides
out-of-hours care. The National Audit Office found that clinical
commissioning groups understood these risks and were acting to
manage them, the potential for problems arising from conflicts
of interest are considerable. However, where the number of GPs
with conflicts is significant, this is not a practical solution.
Some clinical commissioning groups have awarded out-of-hours contracts
without a competitive procurement process which, when coupled
with the potential for conflicts of interest, increases the risk
to propriety and value for money. NHS England confirmed that it
had issued guidance to clinical commissioning groups on how to
handle conflicts of interest and that its local area teams would
be seeking more assurance on this issue this year.
Recommendation: NHS England should test
whether its guidance on conflicts of interest is being followed
and assess whether it offers enough safeguards. Where contracts
for out-of-hours GP services have been awarded since 1 April 2013,
it should seek documentary evidence that no one with an interest
in the successful provider organisation was involved in the procurement
process.
4. The urgent and emergency care system is
complex and fragmented and the present financial incentives run
the risk of undermining effective integration of the different
elements. The urgent and emergency care system includes out-of-hours
GP services, walk-in centres, urgent care centres and A&E
departments. The Government also has an ongoing £50 million
initiative to encourage GPs to extend their opening hours. These
elements have largely operated independently of each other and
the system is fragmented as a result. NHS England accepts that
a great deal needs to be done to redesign out-of-hours and emergency
services. NHS England's review of urgent and emergency care has
identified that the financial incentives are an important barrier
to encouraging integration and ensuring patients are treated in
the best place. Existing contracts provide incentives for A&E
to hang onto patients and do not provide incentives to encourage
out-of-hours services to take on more patients. This is because
A&E departments tend to be paid on the basis of activity,
while out-of-hours services tend to have block contracts where
payments are not based on the number of cases handled. NHS England
and Monitor are consulting on reforms to the payment frameworks
for urgent and emergency care.
Recommendation: Given the pressures on the
NHS budget it is important that NHS England should expedite the
redesign of urgent and emergency care services. NHS England, working
with Monitor, should urgently identify solutions for paying for
urgent and emergency care that address the current mis-aligned
incentives and promote the treatment of patients in the most appropriate
setting and the most effective use of NHS resources.
5. Too many people are unaware of the different
urgent care options and of how to contact them, meaning they may
not receive care in the most appropriate setting. There are
many ways to access urgent care which can leave people confused
about what is the most appropriate service for them. As a result,
too many go to A&E when they do not need to. NHS 111 is intended
to provide a single entry point to urgent care, but about a third
of adults in England have either not heard of NHS 111 or have
heard of it but do not know what it is for. In addition, a quarter
of adults have not heard of out-of-hours GP services. Awareness
was lower still among certain groups including younger people
and people from black and minority ethnic communities. While increasing
awareness does not necessarily lead people to change their behaviour,
NHS England acknowledged that it had a responsibility to improve
public awareness of urgent care services so that NHS resources
are used more efficiently.
Recommendation: NHS England should set targets
to increase public awareness of out-of-hours GP services and NHS
111, and collect data to monitor progress. As well as general
public awareness, it should focus particularly on those groups
with the lowest levels of awareness.
6. NHS England cannot at present assess how
many GPs will be needed over the coming years. Having enough
GPs is crucial to providing a safe and responsive out-of-hours
service and minimising expenditure on more expensive hospital
services. The National Audit Office found that, although only
6% of GP shifts were filled by agency GPs, out-of-hours providers
are finding it harder to attract enough GPs. The Department has
commissioned Health Education England to increase the number of
GP training places by 10,000. However, it is uncertain what the
overall impact on GP numbers will be, as existing GPs will be
retiring at the same time. NHS England does not currently have
a model to predict how many GPs will be needed in 2020 and does
not intend to develop one until it has more certainty about the
NHS budget to the end of the decade. In our view, NHS England
cannot afford to wait for budgets to be set given the time it
takes to train new GPs.
Recommendation: The Department and NHS England
should develop a model for the GP workforce now, and use the results
to inform discussions about the budget the NHS needs and decisions
about the number of GP training places required.
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