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The Provision of Out-of-Hours Care in England

There were shortcomings in the process of setting up new arrangements to provide out-of-hours primary medical care in 2004, although there is no evidence that patient safety was compromised, the National Audit Office reported today. The Primary Care Trusts (PCTs) who took over responsibility for organising out-of-hours services from GPs lacked knowledge and experience in this area. However, most patients say that they are receiving a good service, with six out of ten rating it as excellent or good.

The report finds that, after some initial problems, the service is beginning to reach a satisfactory standard, but that no providers are meeting all the required levels of performance and few are achieving the required levels for speed of response. The report also finds that the actual costs of providing out-of-hours care under the new system are considerably more than the specific Department of Health allocation made to support these services and that there is scope to reduce costs without compromising quality.

Before 2004, GPs were responsible for organising out-of-hours services, although seven out of ten GPs did not directly provide their out-of-hours service. In response to concerns that this system was not sustainable, the Department decided to offer GPs the chance to pass on their responsibility to Primary Care Trusts. Most GPs did so during a period from April to December 2004. By April 2005, 75 per cent of out-of-hours provision was being carried out by the Trusts themselves or through co-operatives, with the remaining 25 per cent provided by commercial providers, ambulance trusts and others, and with NHS Direct supplying initial call handling for many providers.

PCTs had not previously managed or delivered out-of-hours services and so lacked experience and reliable management data. When they took over, there was little information about fundamental factors such as demand or cost.

The service is now beginning to reach a satisfactory standard but no providers are meeting all the requirements and few are reaching the requirements for speed of response. Fewer than 10 per cent of PCTs who responded to the NAO’s survey are meeting the speed of response targets – that a clinical assessment should be started within 20 minutes of a call for urgent cases and within 60 minutes of a call for non-urgent cases.

Some PCTs are still confused over whether the out-of-hours services should be restricted to urgent cases or should respond to any request for medical care outside normal working hours – although there is no evidence patient safety is being compromised.

According to a survey conducted for the report, patient experience is generally good. Eight out of ten patients are satisfied with the service, while six out of ten rate the service as excellent or good. During the out-of-hours period, the majority of patients (six out of ten) are seen within two hours and many (four out of ten) are seen in less than one hour.

The actual costs of providing out-of-hours care under the new system are considerably more than specific Department of Health allocations to support out of hours services. The total cost for the first full financial year of arrangements was £392 million, 22 per cent more than the £322 million allocated by the Department.

There may be scope to reduce costs. The NAO’s analysis shows that if all Primary Care Trusts were as good as the best performers, a saving of £134 million a year could be achieved without compromising quality.

“The Department of Health is now on track towards providing high-quality out-of-hours services. I am glad to see signs that Primary Care Trusts are getting better at managing their providers. “However, it is disappointing that there were so many problems in starting the new arrangements and I am concerned that so few providers are meeting their targets for the time it takes respond to patients. And the continuing confusion over whether out-of-hours is supposed to be an urgent or unscheduled care service should be dispelled without delay.”

Sir John Bourn, 5 May 2006

Notes for Editors

  1. Press notices and reports are available from the date of publication on the NAO website, which is at www.nao.org.uk. Hard copies can be obtained from The Stationery Office on 0845 702 3474.
  2. The Comptroller and Auditor General, Sir John Bourn, is the head of the National Audit Office which employs some 800 staff. He and the NAO are totally independent of Government. He certifies the accounts of all Government departments and a wide range of other public sector bodies; and he has statutory authority to report to Parliament on the economy, efficiency and effectiveness with which departments and other bodies have used their resources.

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