Health Committee Inquiry – GP Out of Hours
Services
The College welcomes the opportunity to submit written
evidence to the Health Committee’s new Inquiry into GP Out of Hours
Services. We are also willing to give oral evidence to the
Inquiry.
The Royal College of General Practitioners is the largest
membership organisation in the United Kingdom solely for GPs. It
aims to encourage and maintain the highest standards of general
medical practice and to act as the “voice” of GPs on issues
concerned with education, training, research, and clinical
standards. Founded in 1952, the RCGP has over 21,000 members who
are committed to improving patient care, developing their own
skills and promoting general practice as a discipline.
Back
1. The general readiness of Primary Care Trusts to
undertake their responsibilities with regard to Out-of-Hours
services
From recent experience, most PCTs display a lack of understanding
of OOHs issues and, in general, are not in readiness for this
responsibility. In particular, PCTs lack understanding of GP OOHs
issues generally. This may be less of an issue in areas where good
GP co-operatives have been long established. Where PCTs have clear
arrangements in place, they will need to turn their attention to
modernising, rationalising and building a sustainable
service.
PCTs are also seen as reactive rather that proactive organisations
thus far, that underestimate risks, true costs and practicalities
of the OOH issue. They also generally fail to have an appreciation
of the good work done by GPs up to now.
There is a fear that PCTs hold false perceptions that there is no
real need for GPs to work OOHs and that GPs can be replaced by
nurses and other healthcare professionals. Although we would
welcome greater involvement of other professionals, the College
does not agree that GPs can safely be replaced. Our view is that
the skills of the generalist physician are an essential element
within the skill-mix for provision of safe OOH care. We also
question whether an adequate workforce to provide effective
skill-mix for OOH cover can be found.
We suspect that senior leadership within many PCTs could be
improved. Currently many junior managers and inexperienced
Directors within PCTs are left to lead on this critical
issue.
In our view, PCTs often often demonstrate a lack of strategic
capacity, possessing a poor view of the whole system and being
currently pre-occupied with targets, such as the A&E 4hr
target. PCTs can also display a lack of understanding of the
consequences of their actions and in general, suffer from a lack of
effective negotiation skills. They tend to act as single units,
working in a diverse way, rather than delivering a cohesive
approach for a whole city or area. They also tend to epitomise an
NHS as being an ‘organisation without a memory’.
Many PCT Chief Executive Officers do not give the impression of
being fully engaged with, or having a full understanding of, the
implications of the new GMS contract (nGMS). Nor are many PCTs
working positively with GP Co-operatives, often being adversarial
and generating conflict.
It is our view that many Strategic Health Authorities (SHAs) in
fact lack strategic capacity and are not being proactive in pushing
PCTs.
We regret that generally there is little patient or user
involvement in discussions and where it exists, it is often
reactive.
2. The role of GP co-operatives
Co-operatives are in transition and some feel under threat. The
larger ones are more in tune with what is needed for the transition
period and for new models of service delivery.
Urban & inner city co-operatives are more likely to advise GP
members to remain opted in to OOH responsibilities as most of these
co-operatives are in a state of readiness with experienced and
established workforces.
There are uncertainties around the new role in GP Registrar (GPR)
training and in the role and performance of Primecare, although
contingencies are being worked through.
3. The role of NHS Direct
There are doubts in the system about the ability of NHSD to cope
with volumes of calls in the integrated model and questions are
arising around the clinical sorting of NHSD (very risk averse) with
high levels of urgent dispositions to 999/A&E/GP 4hrs.
At present, transitional arrangements are in place with NHS Direct
taking on the full role of accepting all calls to OOHs
services by the end of 2006. This approach will put at risk many of
the existing GP OOHs providers and in any case, we question whether
NHS Direct will ever have the capacity to handle that volume of
calls.
4. The potential impact on other NHS
services, including community hospitals, minor injury units, GP
clinics, and A&E services
The potential impact has not been fully
thought through by PCTs or local health economies.
They are slow to respond and lack a strategic
view. There is merit in recommissioning OOHs General Practice and
nurse clinician support on the basis of providing a quality
response. It is inadvisable to allow OOHs providers to carry out
additional layers of triage, particularly as when they are busy
there is anecdotal evidence that work bounces back to the Emergency
Services.
PCTs and local health economies are not
working as cohesively as they could, with too much time and
resource placed on A&E targets in isolation.
Although the mutual model (community benefit
societies) proposed by DH/NAGPC appears, at this stage, not to be
popular, we suggest that consideration is given to the appointment
of a Care Co-Ordination Centre in each area (c.f. also the French
SAMU model) to ensure that General Practice, Ambulance Services,
Nursing and Social Care work more closely together.
The point of first patient contact with a
clinician is key. Previously, a patient was more likely to see a GP
in the home, who would then refer the patient directly to the
appropriate destination. This has changed and currently an
ambulance or a response unit is sent, the patient is taken to A
& E and the decision about treatment or admission is now made
by a front-line Senior House Officer with limited
skills.
5. Potential financial
implications
We perceive a general underestimation of costs
of providing OOHs services with little recall of the good will
displayed by GPs who have been performing the OOH services until
now. Attention is drawn to the resourcefulness of GP Co-operatives
in keeping costs down to members, thereby masking the true cost of
GP OOHs service.
Most PCTs do not display the strategic
perspective to make funding shifts for "whole system"
considerations; most PCTs do not appear to have considered the
potential of whole system redesign with funding shifts post
December 2004.
6. Potential implications for quality
of Out-of-Hours services, including rapidity of response, provision
of backup and quality of patient care
Individual organisation risk only is being
considered rather than the whole system presenting the risk of a
lack of an integrated approach.
It is our view that GP co-operatives have
been, and are working towards Carson standards with little support
from PCTs.
NHSD is working towards Carson standards - but
the system needs a new approach for faster and more appropriate
responses to maintain and improve quality of patient care. We also
have concerns regarding inconsistent approaches by PCTs and GP
co-operatives to appraisal of GPs working OOHs and the implications
of GPR training in the OOHs role.
7. Skill-mix within Out-of-Hours
services
There is a general acceptance that a mix of
skills is needed but alternatives to GPs are scarce. Thus the main
professional during OOHs is expected to be the GP in the
foreseeable future. Deaneries and Workforce Confederations are seen
as very slow to respond in providing a workforce fit for
purpose.
8. Arrangements for monitoring
Out-of-Hours services
Where SHAs have got PCTs around the table a
process is developing - but this is patchy. There is a perceived
lack of timely guidance from DH in the post accreditation era for
OOHs standards.
9. Implications for urban and rural
populations
In urban areas GPs are more likely to remain
and opt in but service re-design by PCTs may be challenged where
problems are encountered, especially over funding from PCTs. Unless
primary care OOHs services are as easy and convenient to access as
A & E services, patients will tend to go to the latter which
places an unfair burden on the A& E services.
Rural areas are likely to experience a much
greater opting out of OOHs services by GPs. While some
contingencies have been made, PCTs are not perceived as
sufficiently innovative.
Other Issues
Children
The College draws the attention of the
Committee to the specific needs of children, particularly around
issues of access, environment and clinical care.
Access Issues: current OOH arrangements tend
to discriminate against children and young people, particularly in
relation to access such as difficulties in travelling to out of
hours centres with an ill child, especially in the situation of a
single parent with more than one child and limited social support.
Although 'low users', teenagers are also unlikely to be able to
access OOH care easily, without parental involvement, because of
travel issues.
Environmental Issues: it is not clear how
'child friendly' out of hours centres are and whether there are any
national standards on this. Centres should have child centred
facilities and staff that would enable appropriate observation over
a short period of time (e.g. to monitor response to anti-pyretic),
or such monitoring should be available within the
home.
Clinical Care: concerns have been aired about
the adequacy of training of general practitioners to deal with
acute medical problems in children. This should be a core skill but
this is not necessarily the case.
The College also suggests that there is a need
to avoid the current trend for more children to be seen in A&E
out of hours, and assessed by paediatricians.
Access to
Defibrillators
We are supportive of the Resuscitation Council
(UK)’s view that all those covering OOHs should carry and have
access to defibrillators. Approximately 5% of all patients with
acute infarction arrest in the presence of their GP and if the GP
has access to a defibrillator more than 60% survive.
At present, the British Heart Foundation
statistics show that around 75% of patients who arrest in a GP
surgery also survive, provided the practice has a defibrillator on
the premises.
Community
Pharmacies
The Committee may wish to consider an issue
that seems not to have been covered in their considerations so far,
that is the potential role of community pharmacy outside normal
surgery hours.
The compilation of these comments has been
assisted by a number of contributions, including those from Dr Tina
Ambury, Professor Tony Avery, Dr Dick Churchill and Dr Agnelo
Fernandes.
4 June 2004
Dr Maureen Baker CBE DM FRCGP
Honorary Secretary of Council