Out-of-hours - Maintaining service standards

How big a burden will it be for consortia to ensure out-of-hours services comply with standards? By Dr Donald Law

All calls must be answered within 60 seconds of an introductory message (Photograph: Istock)
All calls must be answered within 60 seconds of an introductory message (Photograph: Istock)

In 2004 when the new GMS contract came into operation, most GPs sighed with relief and forgot about the out-of-hours period.

Gone was the responsibility for all patients 24/7, and the only time GPs got involved was to pass on any complaints to the right person at their primary care organisation (PCO).

A few hardy souls retained the responsibility for their own patients, and a larger number continued their role in the local out-of-hours service as a way to supplement their income.

PCOs seemed most interested in value for money when commissioning out-of-hours providers. As long as there were no major complaints, the service was pretty much left to its own devices.

But during the past couple of years, out-of-hours has appeared on the radar of more GPs for two very good reasons.

First, this is because of the death of a patient from an opiate overdose administered by a locum doctor who had flown in from Germany to cover an out-of-hours session.

The second reason is that under the government's shake-up of the NHS in England, responsibility for commissioning out-of-hours services is to pass from PCTs to GP commissioning consortia.

Quality requirements
What until now has only been appreciated by those involved in providing out-of-hours services is that there is a raft of national quality requirements (NQRs), formulated by the DoH, each consortium will need to hold the service it contracts with to account for delivering.

To ensure providers comply with these NQRs requires monthly clinical governance and contractual meetings with providers and, in addition, announced and unannounced visits to triage and primary care centres. All this must be commissioned within limits narrowly defined by the DoH on cost per call and cost per head of population.

Soon all GPs will be aware of out-of-hours care, as no doubt their local consortium will not look favourably on their practice if it generates high out-of-hours usage.

National quality standards for out-of-hours services

Compliance: Providers must report regularly to PCTs (in future, GP consortia) on their compliance with the NQRs.

Consultations: Providers must send details of all out-of-hours consultations to the practice where the patient is registered by 8am the next working day.

Exchange of information: Providers must encourage the regular exchange of comprehensive information between all those providing care to patients with predefined needs.

Regular audits: Providers must regularly audit and report on a random sample of patient contacts to the PCT so that the clinical performance of individuals working in the service can be reviewed, and any appropriate action on those audits can be taken. Audits must be led by a clinician with experience in providing out-of-hours care.

Patient experience: Providers must report audits of a random sample of patients' experiences (for example, 1 per cent per quarter) and action taken as a result of those audits.

Complaints: Providers must deal with complaints in compliance with the NHS complaints procedure and report anonymised details of each complaint, and its resolution. All complaints must be audited in relation to individual staff to allow action to be taken.

Capacity: Providers must demonstrate their ability to match their capacity to periods of peak demand, such as weekend mornings and bank holiday Mondays, and have contingency plans for how they will meet unexpected demand.

Initial telephone call

  • No more than 0.1 per cent of patients calling should be unable to get through because phones are engaged; no more than 5 per cent of calls by patients should be abandoned.
  • All calls must be answered within 60 seconds of the end of a maximum 30 seconds introductory message.
  • Where there is no introductory message, all calls must be answered within 30 seconds

Telephone clinical assessment: There should be a robust system for identifying all life-threatening conditions and such calls must be passed to the ambulance service within three minutes.

A clinically safe and effective system for prioritising calls must:

  • Start definitive clinical assessment for urgent calls within 20 minutes of the call being answered and for all other calls within 60 minutes.
  • Without such a system, definitive clinical assessment for all calls must start within 20 minutes of the call being answered.
  • At the end of the assessment, the patient must be clear about the outcome, including the timescale of further action and the location where any face-to-face consultation is to take place.

Face-to-face clinical assessment: There should be a robust system for identifying all patients with immediately life-threatening conditions and such patients should passed on to the most appropriate service within three minutes.

The service should:

  • Start definitive clinical assessment of patients with urgent needs within 20 minutes of the patient arriving in the centre and for all other patients within 60 minutes.
  • Without a robust system, definitive clinical assessment for all patients must start within 20 minutes of the patient arriving at the centre.
  • At the end of the assessment, the patient must be clear about the outcome, including (where appropriate) the timescale of further action.

Appropriate clinician and location: Providers must ensure that patients are treated by the clinician best equipped to meet their needs in the most appropriate location including, where clinically appropriate, at the patient's home.

Face-to-face consultations: Following telephone clinical assessment, these must start within:

  • One hour in an emergency.
  • Two hours if urgent.
  • Six hours if less urgent.

Communication difficulties: Patients unable to communicate in English must be provided with an interpretation service within 15 minutes of initial contact. Providers must also make appropriate provision for patients with impaired hearing or sight.

  • Dr Law is medical adviser on out-of-hours services for the East of England Ambulance NHS Trust in Essex

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