House of Commons - Out-of-hours GP services in England

Out-of-hours GP services in England - Public Accounts Committee Contents

1 Oversight and Assurance

1. On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department) and NHS England about out-of-hours GP services in England.[1] Out-of-hours GP services provide urgent primary care when GP surgeries are typically closed, from 6.30 pm to 8.00 am on weekdays and all day at weekends and on bank holidays. In 2013-14, out-of-hours GP services in England handled an estimated 5.8 million cases—3.3 million were face-to-face consultations, of which 800,000 were home visits.[2]

2. Since 2004, GPs have been able to opt out of providing out-of-hours care and most have done so. In these areas, NHS England has delegated responsibility for commissioning services to 211 clinical commissioning groups. Clinical commissioning groups contract with a range of service providers, including social enterprises and commercial organisations, such as Care UK.[3]

3. An estimated 10% of GPs have retained responsibility for out-of-hours care and NHS England's 27 local area teams commission services directly from the GP practices concerned. NHS England told us that, since the National Audit Office report was published, it had collected data across the country and established that most of these GP practices sub-contract the provision of out-of-hours care to a range of providers, in the same way as clinical commissioning groups do.[4]

4. NHS England is accountable to the Department for the outcomes the NHS achieves and for securing value for money for spending on NHS services, including out-of-hours GP services. The Department is ultimately accountable to Parliament for the overall value for money of health services and has set standards—national quality requirements—for all out-of-hours GP services to meet. The 13 requirements are designed to ensure that patients receive the same levels of high-quality and responsive care across the country.[5]

5. We asked NHS England how it oversees out-of-hours GP services and gains assurance about value for money. It said that, during 2013-14, its focus had been on getting the new clinical commissioning groups working effectively.[6] Monitoring out-of-hours GP services had not been a priority for the clinical commissioning groups or NHS England, as the performance of these services was thought to be reasonable.[7] The National Audit Office noted in its report that NHS England did not analyse the data generated by the GP Patient Survey, which is carried out every six months, to investigate trends in performance, such as the recent drop in patient satisfaction.[8]

6. NHS England told us that it was increasing its scrutiny of out-of-hours GP services during 2014. It has told all clinical commissioning groups that, by the end of the year, they must publish comprehensive data on their out-of-hours GP service, including details of who provides the service, levels of patient satisfaction, and how many people are accessing the service.[9] At present, only around two-fifths of clinical commissioning groups are publishing this kind of information. Clinical commissioning groups will also need to be part of a national benchmarking scheme which will cover the cost of the service, patient satisfaction, and performance against the national quality requirements.[10] This follows our recommendation in 2013 that NHS England should require clinical commissioning groups to publish comparable data, in a common format, showing local performance against the national quality requirements to support transparency and accountability.[11] At present, the most recent benchmarking data on out-of-hours GP services is that published by the Primary Care Foundation in April 2012.[12]

7. NHS England also highlighted that the Care Quality Commission will be inspecting all out-of-hours GP services, under its new inspection regime. The results of each inspection will be published.[13] During its first wave of inspections, covering 30 out-of-hours GP services, the Care Quality Commission found that most were providing 'safe, effective, caring, responsive and well-led care'.[14]

8. The National Audit Office estimated that out-of-hours GP services in England cost some £400 million in 2013-14, equivalent to £7.50 per person on average. The total cost was some £75 million less than in 2005-06, after adjusting for inflation.[15] However, there was wide variation across the country in the cost per person and the cost per case. For example, 95% of contracts fell within a range of £28.30 and £134.30 per case in 2013-14, with the average cost being £68.30.[16] NHS England told us that it was hard to draw conclusions on variation because the comparisons were not necessarily like-for-like. In general terms, it considered that some of the difference could be explained by the age, deprivation and mix of local populations. Variation could also be caused by geographic factors, which affect travel distances, and differences in what was included within the scope of different out-of-hours contracts.[17] However NHS England had not carried out the analysis to support its assertions.

9. NHS England told us that, on the basis of the available data, it could not say whether out-of-hours GP services were more efficient now than they had been. We asked about the cost of hiring GPs, which is one of the main drivers of cost. NHS England noted that this cost varied widely across the country. However, it could not tell us what the cost per hour was, or how the cost now compared with the cost in 2008 when it ranged between £50 and £70.[18]

10. There is also significant variation in patient satisfaction with out-of-hours GP services across the country. The GP Patient Survey in July 2014 found that 66% of people rated their overall experience as 'very good' or 'fairly good'. However, the proportion in each clinical commissioning group ranged from 86% to 49%.[19] NHS England noted that the variation in satisfaction related to a variety of factors such as patient characteristics and geography. Younger people and people from minority ethnic backgrounds tend to be less positive about their experience, and levels of satisfaction with out-of-hours GP services are lower in London. In these respects, the position on out-of-hours GP services is consistent with other NHS services.[20]

11. The reforms to the health system, which took effect in April 2013, put GP-led clinical commissioning groups in charge of commissioning healthcare locally, including out-of-hours GP services.[21] The design of the system brings an inherent risk of conflicts of interest as GPs can be part of both clinical commissioning groups and organisations that provide, or bid to provide, out-of-hours care.[22] We highlighted the case of Barnet, Enfield and Haringey clinical commissioning groups where Barnet takes the lead in managing the contract with the provider, Barndoc Limited. We understand that eight members of Barnet clinical commissioning group are also shareholders in Barndoc Limited, with one member acting as the chair of Barndoc. In addition, across Enfield and Haringey, five members of the clinical commissioning groups are shareholders in Barndoc.[23]

12. NHS England told us that, if the aim was for local GPs to provide out-of-hours care, then by definition they could also be involved in the local clinical commissioning group. Nevertheless, there had to be 'clear daylight' between the people making commissioning decisions and the people who would benefit from those decisions.[24] It confirmed that it had issued guidance to clinical commissioning groups on how to manage conflicts of interest, including in circumstances where a significant number of clinical commissioning group members have a conflict. The guidance sets out possible alternative arrangements such as the NHS England local area team awarding the contract, or another clinical commissioning group running the procurement process, where it is not feasible for the conflicts of interest to be managed by members of the clinical commissioning group excusing themselves from discussions.[25]

13. The National Audit Office found that clinical commissioning groups understood the risk of conflicts of interest and were acting to manage them. However, the safeguards relied on the people concerned disclosing their interests.[26] NHS England told us that it planned to assess compliance with the requirements that people involved in bidding exempt themselves from any involvement in the procurement process. As part of the quarterly assurance process in September 2014, it would be asking clinical commissioning groups to demonstrate how they were managing conflicts of interest.[27]

14. NHS England also noted that transparent processes to test value for money, including competitive procurement where that made sense, should help to address the risk of conflicts of interest. However, the National Audit Office found that not all services were being competitively tendered: in five of the eight cases examined, contracts had been re-awarded without a competitive procurement process. NHS England said that, in a number of these cases, the contract had been rolled forward for a period to allow a combined, integrated contract covering, for example, out-of-hours GP services and NHS 111, to be procured at a later date.[28]

1 C&AG's Report, Out-of-hours GP services in England, Session 2014-15, HC 439, 9 September 2014 Back

2 Q 43; C&AG's Report, paras 1, 1.2, 1.12 Back

3 Qq 11, 79; C&AG's Report, paras 2, 1.7-1.9 Back

4 Q 62-64; C&AG's Report, paras 3, 1.7 Back

5 C&AG's Report, paras 1.5, 2.3, 3.21 Back

6 Q 75 Back

7 Q 16 Back

8 C&AG's Report, para 3.24 Back

9 Qq 16, 64, 94 Back

10 Q 95 Back

11 HC Committee of Public Accounts, The provision of the out-of-hours GP service in Cornwall, Fifteenth Report of Session 2013-14, June 2013 Back



© Parliamentary copyright 2014	Prepared 12 November 2014