Rapid fall in GP out-of-hours cases behind huge rise in daytime GP work

A huge drop in GP out-of-hours cases may be contributing to soaring pressure on daytime GP services, GP leaders have warned.

Out-of-hours care: workload moving to daytime services (Photo: Christopher Jones)
Out-of-hours care: workload moving to daytime services (Photo: Christopher Jones)

The number of patients visiting out-of-hours GP services has dropped by a third over the last seven years, according to a report by financial watchdog the National Audit Office (NAO).

Out-of-hours funding has also dropped sharply in real terms in the past decade according to the NAO, but out-of-hours experts say workload has remained high because despite a fall in cases, patients the service now deals with are on average far more complex cases.

The NAO estimated that 5.8m cases were handled by out-of-hours services in 2013/14, a fall of nearly 3m from the 8.6m cases in 2007/8.

The NAO report found that a quarter of people (26%) were not even aware of out-of-hours GP services, a view particularly prevalent among younger people and black and minority ethnic communities.

Patients in these groups were more likely to go to A&E departments or call 999 to get treatment on a weekend or after hours.

The NAO suggested NHS 111 telephone triage services could be diverting patients away from out-of-hours services and piling extra workload pressures onto daytime general practice and A&E.

Patients switching to daytime services

Londonwide LMCs medical director Dr Tony Grewal said: ‘It’s very possible that patients who 10 years ago would have used out-of-hours services are now getting telephone advice and self-helping then seeking their GP the next day.

‘The problem is that general practice is about to explode, there is no further capacity and no investment to allow to us to increase capacity.’

After adjusting for inflation, the NAO also estimated that funding for out-of-hours services had fallen by £75m in the last decade. Out-of-hours services cost an estimated £400m during the 2013/14 financial year.

But out-of-hours experts say workload remains high. Dr Simon Abrams, chairman of Urgent Health UK said: ‘We do recognise NHS 111 is taking a number of cases off the top, but it is the easier and more straightforward cases that are being taken care of by NHS 111 pathways. Although numbers have gone down for out-of-hours services, the complexity has gone up because the simpler cases are being dealt with by non-clinicians through pathways.

'So it would be wrong to say there's been a huge decrease in the amount of work, it’s been disproportionately the simpler cases taken out of the equation for out-of-hours services. Contract values have gone down, and out-of-hours organisations are being squeezed.

'I think they're being squeezed more than the relative reduction that NHS 111 has introduced, and it’s getting harder and harder to meet national requirement targets. There is a risk that this financial squeeze is having an effect on patients. I would say the funding cuts are disproportionate to that decrease in work.’

The majority (87%) of ‘opted-out’ out-of-hours services, commissioned by CCGs, were found to be well-managed, appraised and good value for money.

But NHS England was found to have ‘very limited oversight’ and was doing ‘little to monitor performance’ of the out-of-hours services commissioned directly from GPs who have not opted out of out-of-hours responsibility, which account for 10% of practices.

This meant there was ‘little assurance’ that the out-of-hours GP services commissioned by NHS England were providing a service of acceptable quality or value for money, the NAO report said.

NAO auditor general Amyas Morse said: ‘Although some clinical commissioning groups are achieving value for money, this is not the case for the commissioning of all out-of-hours GP services.

NHS England must monitor out-of-hours services

‘NHS England has much to do to help secure improvements throughout the system and to increase its oversight of the out-of-hours GP services it commissions directly.

‘It should also work to raise public awareness of how and when patients should contact out-of-hours GP services, and needs to be prepared to take the lead in integrating these services effectively with other parts of the urgent care system.’

A spokesman for NHS England said it welcomed the report and would ‘consider it carefully’. He said: ‘We are confident that the new out-of-hours assurance process brought in March this year is robust and has addressed many of the issues outlined by the NAO.

‘We will however carry on developing processes to ensure patients continue to receive high quality care and access to a GP outside of surgery hours.’

In the GP Patient Survey, two thirds of patients rated their overall experience with out-of-hours care as a positive one, and 79% said they had confidence in and trusted their out-of-hours clinician.

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