What next for out-of-hours care?

Abi Rimmer examines some of the issues that are likely to shape the future of out-of-hours care

Dr Peter Holden: Practices should not be pressured into providing out-of-hours care themselves

GPs’ role in out-of-hours care
In 2004 the new GMS contract gave GPs the option to opt-out of providing out-of-hours care, in exchange for a 6% cut in the practice’s global sum. Some 90% of GPs in England decided to give up 24-hour responsibility and PCTs were handed the task of organising out-of-hours services.

Many GPs continue to do some out-of-hours work, by working shifts for the local provider, which in many cases is a GP co-op or a GP-led service.

The cost of out-of-hours services varies wildly across the country, and earlier this year a GP investigation found that a quarter of PCTs had cut spending on out-of-hours since 2010 through renegotiating or retendering contracts.

GP leaders warned that cost cutting and competitive tendering could force GP-led out-of-hours providers out of business because they will be unable to compete with private providers, something which already appears to be happening.

Despite the fact that most practices do not directly provide out-of-hours care, this hasn’t necessarily meant a huge reduction in workload for GPs. Many out-of-hours services continue to refer patients back to their GP for treatment, as do other urgent care services such as NHS Direct and walk-in centres.

Recent DoH statistics found that NHS 111, a new urgent care phone service that is currently being piloted, advised around 30% of patients to see a primary care provider, often their own GP.

GPC chairman Laurence Buckman raised concerns earlier this year that NHS 111 had in fact created extra work for out-of-hours services.

GP commissioners’ role in out-of-hours
When clinical commissioning groups (CCGs) take on commissioning in 2013, they will also inherit responsibility for out-of-hours and urgent care.

There are fears among the profession that increasingly high costs will force GPs to take back some out-of-hours responsibility.

Dr James Kingsland, national clinical commissioning network lead at the DoH, says many GP commissioners had been ‘shocked’ to discover the high level of NHS spending on urgent care. ‘There is a sense that urgent care is broken and something needs to be done to fix it,’ he explains.

One option to save money could be to shift some services delivered by walk-in centres to practices, by building on the extended hours access DES. This could allow some walk-in centres to be shut down or to cut staff, Dr Kingsland says.

However Dr Kingsland stresses this does not mean that GPs would have to take back full 24-hour responsibility.

‘I don’t think it's a case of wanting to opt in, take a few grand back and supply all that is needed in out-of-hours care,’ he explains. ‘It is a bigger process of looking at all of urgent care.’

GPC negotiator Dr Peter Holden says CCG leads are ‘out of touch’ if they think GPs will be willing to take on out-of-hours work.

‘If any consortia leads think they can lean on GPs in any way, shape or form to do out-of-hours they will find themselves not elected,’ Dr Holden says.

‘This is a line in the sand that they cannot cross. It has to be absolutely voluntary. There can be no pressure on practices.’

Dr Fay Wilson, chairwoman of the BADGER out-of-hours co-op in Birmingham also warns that tough quality standards for out-of-hours care means it is not a simple task to transfer urgent care work to practices.

‘There is quite a distance from thinking about it to executing it,’ she says.

Minimum price for out-of-hours services
It is not only GP commissioning that may have an effect on the future of out-of-hours. A motion passed by delegates at the LMCs conference in June instructed the GPC to ‘pressurise the government to declare a realistic minimum contract price to which commissioners must adhere’. 

GP Dr Mark Sanford-Wood, who wrote the motion on behalf of Devon LMC, said the purpose of a minimum contract price was to ensure patient safety.

‘We have found some PCTs have chosen to assign really unrealistic budgets for out-of-hours,’ Dr Sanford-Wood said. ‘It would not be difficult to put together a realistic minimum contract price. We envisage £10 as being the price per patient per head of population.'

However Dr Holden warns it would be dangerous to negotiate a minimum contract price. ‘The danger in the current economic climate is that if you set ‘x’ as a minimum ‘x’ would not only become the minimum it would become the maximum as well,’ he says.

GP Dr Mark Reynolds, chairman of Urgent Health UK, agrees. He also believes that a single minimum contract price would be difficult to establish due to regional variations in contract prices and rates.

Dr Reynolds suggests a price banding system for different areas might work. ‘There could be bands for densely urban, semi-rural and rural areas,’ he says.

Jon Ford is head of the BMA’s health policy and economic research unit, which would take on the task of calculating the minimum price for out-of-hours. He says that although regional and geographical variations might make a minimum price ‘less practical’ it is still a possibility. ‘You could have regional bandings,’ he explains.

However, before a minimum price could be established, Mr Ford says that his department would first need to establish the average cost of out-of-hours.

Although it is difficult to calculate an exact figure, Mr Ford believes the minimum price would be higher than what GPs currently pay to op-out. The 6% of global sum paid by GPs to opt out ‘isn’t sufficient to provide out-of-hours,’ he says.

The cost of out-of-hours has risen in recent years, particularly in light of new regulations introduced following the case of case of German locum Dr Daniel Ubani, who killed a patient on his first out-of-hours shift in the UK. However because GP income has plateaued there has effectively been no increase in the amount of funding available for out-of-hours.

There are concerns that GP commissioners will face a difficult challenge in providing a high quality service within the available resources, and some GPs fear that CCGs could inherit cut-price out-of-hours systems from PCTs.

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