- Most primary medical care takes place during the working day,
but patients sometimes need care at other times as well. Such care
is known as out-of-hours care, the term currently being used to
describe the period from 6:30pm until 8:00am on weekdays, and all
weekends, bank holidays and public holidays.
- Out-of-hours services have undergone significant change since
2000, when the Department of Health (the Department) commissioned a
review of these services in order to consider issues such as
quality of care and links with wider NHS services. This review,
known as the Carson Review [Footnote 1],
made recommendations which combined with the NHS Plan, set the
foundations for current out-of-hours services.
- Many General Practitioners (GPs) had already used powers
granted in the mid-1990s to delegate out-of-hours provision to a
third party. However, a new General Medical Services (GMS) contract
came into force in 2004, which allowed GPs to opt out of the
responsibility of organising out-of-hours care entirely from 1
April 2004. Where GPs opted out, they gave up an average of £6,000
per annum and passed on responsibility to their Primary Care Trust
(PCT).
- This report examines whether the Department is on the right
track towards providing high-quality out-of-hours services.
Appendix 1 sets out our methodology. Our work has found that:
- There were some shortcomings in the initial commissioning
process because PCTs lacked experience, time and reliable
management data. There is also confusion over whether out-of-hours
services should be restricted to urgent care.
- Out-of-hours providers are beginning to deliver a satisfactory
standard of service but most are not yet meeting all the national
Quality Requirements, particularly on speed of response.
- In a survey of PCTs we found that the actual costs of providing
out-of-hours are £392 million, considerably more than the £322
million allocated by the Department.
- Commissioners are entering into contracts with multiple
providers and the market is maturing
- Our more detailed findings are as follows.
There were some shortcomings in the commissioning
process
- In 2005, many PCTs had not previously managed or delivered
out-of-hours services and so lacked both knowledge and experience
in this area. There was little, if any, reliable management
information, for example on demand, activity and cost. This
shortfall in information made it very difficult for PCTs to write
service specifications and commission effectively. Some PCTs were,
and remain, confused as to whether the out-of-hours service should
be restricted to urgent care, or should respond to any request for
medical care from members of the public. In addition, many PCTs
allowed insufficient time for commissioning out-of-hours services,
reducing the quality of the process.
- Many contracts were signed late or not at all, with significant
legal implications. This was due to poor service specifications,
disagreements between commissioners and providers over
risk-sharing, and the inability to reconcile PCTs’ limited budgets
with providers’ estimated costs of meeting all the Quality
Requirements. Our survey of PCTs, carried out jointly with the
Audit Commission, found that, where external providers deliver
services, signed contracts were in place in only nine per cent of
cases by the time the service began. This increased to 34 per cent
by 30 September 2005. Whilst services continued to be provided
despite the lack of signed contracts, several providers told us
that the lack of a formal contractual agreement forced them to
carry extremely high operational and legal risks.
- Our survey found that 39 per cent of PCTs ran a competitive
tendering process to award a contract. Those that did not often
cited departmental guidance, which stated that there was no
requirement to undertake a formal tender exercise. Our survey found
that the more rural a PCT was, the less likely it was to have
undertaken formal tenders. The lack of competition from commercial
providers in rural areas stems from the difficulty of achieving
economies of scale. However, overall we found that services which
had been subject to a tendering process were no cheaper or better
than those which had not.
Out-of-hours providers are beginning to deliver a
satisfactory standard of service
- Anecdotal evidence suggests that patients suffered longer waits
in at least 50 per cent of England during the first few days of the
new service, but there is no indication that safety was
compromised. Providers are not yet meeting all the Quality
Requirements, particularly on Saturday mornings when demand peaks.
Patient surveys run by PCTs show extremely high levels of
satisfaction with the service provided. However, our survey of
patients’ views of out-of-hours and other urgent care services
found that they had had broadly good experiences, but one in five
were dissatisfied. This suggests that there may be shortcomings in
patient experiences that are currently not being captured by
PCTs.
- Despite upgrades and improvements to IT systems, management
information is still poor, as demonstrated by the difficulties PCTs
experienced in obtaining management data to complete our survey.
This is not helped by inadequate call management technology in some
areas or difficulties in using the Department’s reporting template.
There is also some confusion over the definition of compliance with
the Quality Requirements, despite clear explanations in the
accompanying commentary.
- Limited progress has been made towards integration with other
parts of the NHS, such as local Accident & Emergency
Departments and ambulance services, but there are some individual
examples of strong efforts to join up services. Further planning
and commissioning of integrated services should reduce duplication
and improve value for money.
Costs of providing out-of-hours services are higher than
anticipated
- Prior to the conclusion of the new GMS contract negotiations,
the Department conducted an economic analysis of GP co-operatives
to estimate the cost to GPs of providing the service and arrived at
an approximate average figure of £9,500 per GP. The outcome of the
negotiations for the new GMS contract was an agreed average opt-out
figure of £6,000, although the precise amount for individual GPs
varied depending on list size. The Department increased its
out-of-hours development funding to around £3,500 per GP to help
establish the new service, giving an average total of £9,500 for
every GP opting out. Some 90 per cent of GPs decided to opt out, in
line with what the Department told us were their
expectations.
- The Department established a programme for PCTs to support the
implementation of the new out-of-hours arrangements. The programme
set out the expected average cost - of £9,500 per GP – to provide
out-of-hours services using the analysis that was completed in
advance of the new GMS contract negotiations. The Department also
explained their resource support package, which totalled an average
of £9,500 per GP. Despite this, some PCTs failed to understand that
the £6,000 ‘opt-out’ sum was not intended to represent the true
cost of the service, which led to many underestimating their costs.
Our survey found that the actual costs of providing out-of-hours
for 2005-06, the first full year of the new arrangements, were £392
million, 22 per cent more than the £322 million allocated by the
Department, and an average of £13,000 per whole-time equivalent
GP.
- The above funding gap may impact on investment in out-of-hours
infrastructure and staff training in the short term, but there is
significant scope to reduce costs in future. Our analysis
identified the best performing PCTs for each rural/urban
classification in terms of quality levels and cost per head.
Benchmarking PCTs in each category against the best suggested that
if all PCTs matched the best, a saving of £134 million could be
achieved without compromising quality. PCTs could make savings
through a number of actions, including benchmarking themselves
against similar PCTs and analysing local demand patterns to help
patients access the service more appropriately.
Commissioners are entering into contracts with multiple
providers and the market is maturing
- There is now a wide array of new out-of-hours providers,
including GP co-operatives, NHS Direct, PCTs themselves and private
sector companies, and it is common for commissioners to enter into
contracts with multiple providers to provide different elements of
the service.
- Whilst the GP-led model still predominates in both PCT-provided
and commissioned services, we have seen evidence of various
different models of skill mix, i.e. the employment of health
professionals other than doctors in out-of-hours primary care.
Providers tell us that changing skill mix increases the cost of the
service in the short term, for example due to training costs, but
savings are expected to materialise in the longer term. Many of the
emerging staffing models are still quite small-scale and it is not
yet clear how successful they will be in providing cost-effective
performance. Our survey analysis found that the most cost-effective
models varied depending on the rural classification of the
PCT.
- Providers are becoming more responsive to commissioners, who
now have better management information and are taking decisions to
penalise poor providers. England compares well both within the UK
and internationally in terms of service structure and quality
monitoring.
RECOMMENDATIONS
- The Department should:
- Although PCTs have the primary responsibility for out-of-hours
services, the Department should nonetheless use all the levers at
its disposal to encourage PCTs to improve the cost-effectiveness of
the service through benchmarking of costs, improvements to local
commissioning processes, and making available training and best
practice.
- Ensure that commissioners and providers understand the Quality
Requirements and that they are aware that full compliance is an
average performance of 95 per cent rather than 100 per cent, as set
out in the Department’s guidance. The Department should also
clarify the term ‘definitive clinical assessment’ and consider how
to focus the Quality Requirements further on quality and patient
experience.
- Provide adequate training to ensure that providers can use its
reporting template effectively, and work in partnership with
Adastra [Footnote 2] to improve the management
information which its various systems are producing to support
performance management.
- PCTs should:
- Benchmark their costs against those of other geographically
comparable PCTs to identify areas for improvement.
- Improve commissioners’ capacity in terms of writing service
specifications and market management in preparation for subsequent
rounds of commissioning.
- Ensure that they understand local drivers of demand to see if
they can help patients to access the service more appropriately.
They should conduct a thorough analysis of patient flows into all
unscheduled care services in order to see the detail of case-mix
and socio-economic groups using the different services.
- Ensure that they, or their providers, improve the quality of
their patient questionnaires and make the most of best practice
from pilot and academic work to ensure realistic patient
feedback.
- Use all the contractual and performance management levers at
their disposal to ensure that they or their providers meet the
access requirements within the national Quality
Requirements.