Urgent care - Improving out-of-hours care

GP consortia must hold urgent care providers to account and push for improvements, says Rick Stern.

Rick Stern: 'Commissioners are responsible for developing a compelling vision for out-of-hours and urgent care' (Photograph: NHS Alliances)
Rick Stern: 'Commissioners are responsible for developing a compelling vision for out-of-hours and urgent care' (Photograph: NHS Alliances)

Out-of-hours services have been under intense scrutiny.

A DoH review followed by an exhaustive enquiry into the avoidable death of David Gray last year, described by the coroner as an 'unlawful killing', have led to a series of recommendations and intense performance management.

Although the shape and face of commissioning may be changing, commissioners will be expected to 'get to grips' with out-of-hours.

Commissioners' challenge
GP services are the biggest component of the out-of-hours urgent care service, which includes the ambulance service, A & E, GP '8 to 8' centres, walk-in centres and minor injuries units, as well as out-of-hours community and social care services.

The challenge for commissioners is to ensure each of these components is commissioned and delivered in a way that is sensible for patients and avoids duplication of services and facilities.

So what does this mean for GPs - both as the new commissioners and as the main providers of out-of-hours care?

First, commissioning does matter. The shift to GP commissioning offers a great opportunity for those who are best informed to shape and improve local services. As the NHS Alliance has always argued, it is vital to have more direct clinical knowledge in the commissioning process.

But this needs GPs to invest the time and energy to hold providers to account and drive service improvements. If they give out-of-hours care too little attention - or, as was the case with too many PCTs, it is relegated to a minor item in a crowded list of priorities - it will return to haunt them.

To do the job effectively, good information is essential. This is now easily available through the National Out-of-Hours Benchmark (see primarycarefoundation.co.uk) offering credible comparisons on cost, quality, outcomes, productivity and patient experience.

Putting all these things together offers a powerful tool for reviewing a service and driving improvements in patient care.

Working with partners
It will also be important to work with partners across urgent and emergency care to look at a co-ordinated approach for improving services.

Although some of the recent high-profile failures, such as those of GP out-of-hours provider Take Care Now, have been in one service, it is often the gaps between services that fail patients rather than the care within each organisation.

Most important of all, commissioners are responsible for developing a compelling vision for out-of-hours and urgent care, working with all local partners and the local community.

Commissioners have an important role but, in the end, it is providers who implement change. At the heart of any effective health service are well-supported clinicians who receive clear feedback about the care they provide.

Comparisons between organisations are helpful, but it is the clinical variation between individual doctors and nurses that mark out good performers. The best out-of-hours providers regularly show its clinicians how they are doing compared with their peers, leading to the outliers changing the way they work.

At the same time, the work of in-hours general practice has a major impact on the work carried out in the rest of the healthcare system, including out-of-hours. When GPs are effective at managing urgent care in their own practices, fewer cases will end up with out-of-hours services.

There is increasing evidence to show that a rapid response early in the working day leads to better management of care, and there are effective tools to help with this. Crucially, a practice that manages this well makes life easier for its own staff, has happier patients and reduces the workload on others, including colleagues in out-of-hours services.

Finally, there is one last area that needs urgent attention.

The spotlight on out-of-hours care has led to more rules and guidance for commissioners and providers. Clarifying what is expected is all very well, but all too often the real failing is the prevailing culture that discourages people from reporting things that go wrong.

The very low level of formal reporting in out-of-hours services to the National Patient Safety Agency suggests that too many clinicians choose to keep their heads down when something goes wrong, rather than seeing it as opportunity for others to learn and protect patient safety.

Failing to act
In other cases, leaders fail to act on what they are told - at Take Care Now there were two similar serious drug errors before David Gray was killed with a lethal overdose. Or serious incidents, including avoidable deaths, are discussed within a health community but not shared more widely.

To tackle this, the NHS Alliance is spearheading efforts to establish a new initiative for sharing learning rapidly when something has gone wrong. We hope that by making it easier and safer for clinicians to report problems, in a way that does not identify them, and for everyone to review incidents and learn from them, we can establish a longer lasting and a more effective legacy to recent high profile incidents than reports that pile up on the shelves.

Improving out-of-hours services
  • GP commissioners are well placed to use their clinical knowledge to drive improvements.
  • It will be important to work closely with other services to commission at the right level.
  • There is now good benchmark information to help identify areas for improvement.
  • Time and attention is needed. Unless GP consortia give out-of-hours care the priority it deserves, it may come back to haunt them.
  • A shift in culture to supporting clinicians who report problems is as important as meeting standards.

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