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Special Report

Commissioning Out of Hours Services Commissioning Out of Hours Services Health Needs are 24 Hour Choosing the Best Matching the Service to Place and Needs A Sensitive Practice

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SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

SPECIAL REPORT

Commissioning Out of Hours Services Commissioning Out of Hours Services Health Needs are 24 Hour

Contents

Choosing the Best Matching the Service to Place and Needs A Sensitive Practice

Foreword

2

John Hancock, Editor

Commissioning Out of Hours Services 3 Wendy Tankard, Director of Service Design, Harmoni

Sponsored by

Published by Global Business Media

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks Editor John Hancock Senior Project Manager Steve Banks Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles.

The Carson Recommendations The Need to Show both Financial and Qualitative Benefits The Impact of NHS 111 Integrating NHS 111 with Out of Hours Providers Home Visiting The Effect of NHS 111 on Current Contracts Looking to the Future

Health Needs are 24 Hour

6

John Hancock

GPs Have the Experience and Knowledge A Catastrophe Reform

Choosing the Best

8

Peter Dunwell, Medical Correspondent

Not Only Professionals A Broad Area of Work Evidence-Based Developments

Matching the Service to Place and Needs

10

John Hancock

Unfamiliar Territory Knowing the Language Access to Medicine

A Sensitive Practice

12

Camilla Slade, Staff Writer

A High Risk Area Vulnerable Patients End of Life Public Opinion

References 14

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SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

Foreword W

hile most people will be able to access their

Before 2004, the arrangements for this out of hours

GP practice during normal working hours,

service were the responsibility of the GP, although

there are some whose conditions render them

it was often a less elaborate arrangement along the

vulnerable to unplanned ill-health episodes which

lines of ‘night call cover’. After 2004, out of hours

often require clinical intervention at times when the

service was the responsibility of the Primary Care

surgery will be closed. These ‘out of hours’ periods

Trust (PCT) and it all became a little remote from

are clearly defined in the UK as being from 6:30 pm

patients and driven, like so much else, by the need

to 8:00 am on weekdays, and all day at weekends

to tick boxes. At this time the service was rated very

and on bank holidays. At these times, callers to the

poorly by patients.

surgery who need to see a doctor will be directed to an out of hours service.

In the most recent health reforms, GPs have had the responsibility for commissioning out of

The first article in this Special Report traces the

our services shifted back to their area. Given that

recommendations for performance commissioning

between 7 and 8.6 million people contact GP out

and managing out of hours providers made by

of hours services every year and that they tend

David Carson in the early 2000s, which were

to be the more vulnerable patients, this is a very

followed by the National Quality Requirements,

important function of the practice, whether the

first introduced and published in 2004. It goes

GP undertakes it himself or herself or whether,

on to describe the impact of NHS 111 on out of

with other GPs, they pass the job to their own

hours providers, and why new data needs to be

commissioning group.

analysed to structure future modelling of out of

The articles in this paper set out some of the

hours provision to ensure the best level of care for

matters that commissioners will need to consider,

patients. The integration of NHS 111 with out of

and/or take into account, when commissioning for

hours providers and the subject of home visits are

out of hours services.

other factors that need to be considered carefully to meet patients’ expectations in a cost-effective and safe manner.

John Hancock Editor

John Hancock has been Editor of Primary Care Reports since its launch. A journalist for nearly 25 years, John has written and edited articles, papers and books on a range of medical and management topics. Subjects have included management of long-term conditions, elective and non-elective surgery, Schizophrenia, health risks of travel, local health management and NHS management and reforms – including current changes.

2 | www.primarycarereports.co.uk


SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

Commissioning Out of Hours Services Wendy Tankard, Director of Service Design, Harmoni Excellence History

Out of Hours

Safety

Telehealth

NHS 111 Commissioned

Diversity

Clinical

Patients

Clinicians Training

Care

Services

Leadership

Healthcare Face-to-face

Design

Delivery

Technology

Values

Primary Care Ethical Co-operative

Salaried

Committed

Telephony

Efficiency

Triage Partnerships

Prospects

Family

Local

Opportunities Encourage

Team

Community

Robust

Nurses

Professional

The Carson review in 2000 changed the commissioning landscape for out of hours, and made a number of recommendations to PCTs in order to effectively commission and performance manage out of hours providers and ensure that a high quality standard of care was delivered to the public. Interestingly, the ‘Carson Report 2004’ ‘Raising Standards for Patients: New Partnerships in Out of Hours Care’ recommended that patients should be dealt with in one call, no double triage and a face-to-face appointment arranged where

Performance

The Carson Recommendations

necessary. This further aligns with the philosophy and introduction of NHS 111. The introduction of the National Quality Requirements, first introduced and published in 2004 with a recommendation that all out of hours services would have to be compliant by 2005, further ensured out of hours services were performance managed and therefore provided a qualitative service to patients that was consistent across all out of hours provision. This provided commissioners with a framework to effectively manage out of hours provision that was consistent and enabled poor or underperforming providers of out of hours care to be exposed, managed and de-commissioned where appropriate. These qualitative requirements need to be reassessed and reviewed with the introduction of NHS 111 to reflect quality of care along the entirety of the pathway between the assessment and face-toface care of the patient. Benchmarking also needs to be mandatory. The Primary Care Foundation has undertaken a huge amount of work that has enabled commissioners nationally to benchmark out of hours. It is, however, not mandatory, which is a shame because perhaps this would benefit all commissioners in understanding their own out of hours arrangement, and how they compare to other out of hours providers.

Engage

here are many factors that influence the commissioning of out of hours services, not least ensuring that a high quality, safe and effective service is delivered and the fact that out of hours services play a major role within the urgent care transformation agenda. Both elements are complex and require sophisticated commissioning and performance management, not only due to the diverse range of patients with complex conditions accessing the service but also with the introduction of NHS 111. The delivery of out of hours provision requires careful consideration and modelling in order to realise the full system- wide benefits.

Success

NHS 111 Health Advisor

T

Support

GPs

Innovation

Evidence-based

Dignity Development

Quality

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SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

The integration of services across urgent care pathways that result in shifting activity to more appropriate lower cost settings can be realised with true benefits to patients, and commissioners alike.

out of hours gp

The Need to Show Benefits both Financial and Qualitative Out of hours is, and remains, a high profile service that requires a high standard of clinical provision, assessment and ongoing referral in order to meet the presenting needs of patients, whilst remaining cost effective for commissioners. Commissioning remains complex not least due to the ability for GPs to ‘opt out’ of out of hours care following the introduction of the GMS contract in 2004 as well as the introduction of NHS 111. Commissioners are now faced with a further dimension in redefining out of hours care. Commissioning future out of hours provision needs to clearly show benefits of transformation, not just financial but qualitative, while aligning with NHS 111 in order to provide ongoing benefits to patients and commissioners.

The Impact of NHS 111 NHS 111 is seen as pivotal to urgent care transformation. It includes 24/7 call handling, assessment and ongoing referral, incorporating that previously undertaken by existing out of hours providers. There are undoubtedly benefits to the patient with this new model, but there are also associated risks that need to be factored into commissioning out of hours care. These include ensuring out of hours providers integrate and align with NHS 111 providers as the introduction of NHS 111 does link directly to the provision of out of hours care. The impact and subsequent landscape of provision for out of hours needs to be redefined. This is difficult when the actual impact of NHS 111 on outcomes or dispositions may not be entirely understood for some time. Early analysis within our own provision shows 4 | www.primarycarereports.co.uk

that, whilst the general referrals into out of hours maybe lower, the urgency of cases has increased. We recognise it is far too early to use these indicators to inform a future model, but this does make commissioning out of hours difficult. There is pressure on commissioners to reduce costs and undoubtedly the changing out of hours model will be seen as a means of delivering a proportion of these savings. In order to effectively commission face-to-face out of hours services, more disposition and outcome data needs to be analysed and assessed in order to inform future modelling of out of hours care. The current risk is that commissioners will be looking to re-procure existing out of hours contracts simply because the contract has come to the end of its natural life, or with the advent of NHS 111, in order to make further financial savings. Whilst recognising a new model for out of hours needs to be forthcoming, the full impact of NHS 111 must be understood in order to provide the best level and quality of out of hours care for patients. A concern for providers in this new world will be the top slicing of current out of hours finances to correlate with the loss of call handling. This may seem a logical solution to prevent double cost for commissioners and is completely acceptable in some circumstances, but certain factors must be taken into consideration: • “ Face-to-face” dispositions may increase, including the urgency in timeframes for patients to be seen and assessed • “ Speak to” dispositions will decrease since NQR9 is met by NHS 111. This does not necessarily negate the need for further clinical assessment.


SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

Commissioned

Diversity

Clinical

Clinicians Training

Services

Leadership

Success

Care

Innovation

Support

GPs

Technology

Healthcare Face-to-face

Design

Values

Primary Care Ethical Co-operative

Salaried

Committed

Telephony

Efficiency

Triage Partnerships

Prospects

Family

Local

Opportunities Encourage

Team

Community

Robust

Nurses

Professional

These factors need to be considered in order to model effectively new out of hours service provision. Difficult commissioning decisions will be required in order to enable the full impact of NHS 111 to be assessed. Decisions will need to be made as to whether current contracts need to be re-procured or extended. Re-procurement at a time of immense change may have advantages, but it can also have disadvantages until the actual impact of introducing NHS 111 is assessed from an out of hours provision perspective. Across the UK currently, there is a myriad of differing models of out of hours care. These range from traditional GP provision to urgent care

NHS 111

Dignity Development

Performance

The Effect of NHS 111 on Current Contracts

Telehealth

Patients

Engage

Another complexity is that of home visiting. This requires close collaboration and partnership working between the out of hours provider and the NHS 111 service so that specific criteria are adopted that; meets patients’ expectations, does not increase costs for providers and commissioners but ultimately is safe and effective. This area needs careful handling and consideration by all parties throughout implementation, delivery and ongoing contractual management.

In the longer term, revisions to existing primary care strategies should see an amalgamation and expansion of primary and urgent care services, with GPs and other staff providing the required breadth of scheduled and unscheduled care through appointment and walk-in for both chronic and one-off conditions. In some areas, this is being provided, but in other areas the urgent care models are not so sophisticated. This needs to further align with a new model for out of hours provision which will also be fundamental to the success of NHS 111 in the urgent care transformation agenda. Throughout these challenging but exciting times of change, positive patient experience and engagement is a key prerequisite, both in terms of design and throughout the ongoing delivery of new services. For all future service designs, patient engagement and experience must be seen as integral to successful implementation.

Safety

Evidence-based

Home Visiting

Looking to the Future

Out of Hours

Excellence History

One of the most complicated aspects of commissioning NHS 111 and the impact on out of hours will be integration and management of end-to-end pathways for patients between NHS 111 and out of hours providers. An example of this integration is when both services are delivered by the same provider. Appointment booking and the front end of the service should be seamless, thereby reducing costs for commissioners. When working with different providers, this becomes complicated for a variety of reasons. For instance, there may be an existing contract with the out of hours provider for call handling and the PCT is therefore reliant on successful renegotiation of that contract in order to gain the anticipated financial benefits. Likewise, if the out of hours provider will not accept direct patient appointment booking, this can cause complexities between the NHS 111 and the out of hours provider which the commissioner will need to resolve. The NHS 111 service could potentially need to warm transfer the patient to the out of hours provider within a defined period, in line with the NQR. The provider may not have the capacity to accept warm transfers due to the reduction in call handling, either in actual people or financially, as a result of top slicing their existing contract due to the introduction of the NHS 111 call handling element.

centres, A&E front end services to communitybased models. NHS 111 provides an exciting opportunity for both commissioners and providers to further align urgent care with Quality, Innovation, Productivity and Prevention (QIPP) and transformation agendas. The opportunity to develop models regionally to gain all round benefits is immense. The integration of services across urgent care pathways that result in shifting activity to more appropriate lower cost settings can be realised with true benefits to patients, and commissioners alike.

Delivery

Integrating NHS 111 with Out of Hours Providers

Quality

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SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

Health Needs are 24 Hour John Hancock

Patients will need care out of hours as well as in Surgery hours

GP commissioners who might be experienced out of hours doctors themselves should have the advantage of being physically familiar with the service.

U

sually, when patients need to see their doctor, they will book an appointment with the surgery, attend the appointment, get their diagnosis and treatment and, within a reasonable time, be cured. However, for almost everyone, at some time in their life and for some people more frequently, they will need to be seen by a doctor at a time when the surgery is not open; Out of Hours (OOH). The Department of Health defines urgent care as: ‘… the range of responses that health and care services provide to people who require – or who perceive the need for – urgent advice, care, treatment or diagnosis.’ In the UK, Out of Hours is defined as the period from 6:30 pm to 8:00 am on weekdays and all day at weekends and bank holidays. At these times patients need to contact an out of hours service which will either direct them to an appropriate location or, if a GP consultation is required, arrange a home visit.

GPs Have the Experience and Knowledge Around 7 million people contact GP out of hours services every year and with the recent shift of commissioning responsibility to GPs, these out of hours services will need to be very much part of the practice. “Out of Hours services cannot be considered in isolation and need to be an integral part of the local strategy for urgent care with an appropriately competent skill mix of staff including available GPs.” This from the 2010 NHS East of England ‘Out of Hours Visits Programme1.’ All out of hours services should comply with the Department of Health National Quality Requirements which aim to ensure that patients have access to high-quality and responsive care, regardless of where they live. Although it is currently the responsibility of a PCT is to ensure that providers comply with these requirements, it will soon fall to GPs to manage this service. In their 2010 report ‘General Practice Out of Hours Services’2, Dr David Colin-Thomé and Professor Steve Field summed up this obligation; “The out of hours service is commissioned to meet the needs of the local population, and reflects the views of local public engagement and/ or consultation. It is also complimentary to other services available… so that patients are clear 6 | www.primarycarereports.co.uk

on their service options.” Out of hours services have always existed but because, prior to April 2004, they were delivered by the same GPs who saw patients in their surgeries during the day and who could often be called out at any time during the night or weekend, they didn’t really feature high on the Health Service’s priorities. In reality, by 2004, nearly 95% of GPs already operated in co-operatives or with private sector providers to better manage their out of hours cover. But the 2004 contract freed GPs from the obligation to provide out of hours services, placing responsibility on the then Primary Care Trusts (PCTs).

A Catastrophe The manner of commissioning and managing the services was not always good and when, in February 2008, Mr David Gray, an out of hours patient in Cambridgeshire, was killed by an overdose of diamorphine administered by Dr Ubani, a German doctor with limited knowledge of the English language and no knowledge of Mr Gray, but who had literally flown into the UK to work his out of hours shift before returning to Germany, out of hours services hit the national headlines and not in a good way. The Care Quality Commission (CQC) conducted an investigation3 into out of hours services in the East of England and especially of ‘Take Care Now’, the provider who supplied Dr Ubani. This investigation was applicable to the whole NHS and made a number of recommendations as to how out of hours service could be improved, including an improved commissioning and management process.

Reform Following the CQC Report, the House of Commons Health Committee also reported on ‘The use of overseas doctors in providing out of hours services’. In 2010, the incoming coalition government accepted most of the committee’s recommendations4, stating; “There is no doubt that out of hours care needs urgent reform.” Their response went on to confirm, “The government is committed to providing universal access to high-quality urgent care services 24 hours a day, seven days a week, including out of hours services.” That ambition was crystallised in the recent health service reforms. It was also cited


SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

Excellence History

Out of Hours

Safety

Telehealth

NHS 111 Commissioned

Diversity

Clinical

Patients

Training

Services

Leadership

Technology

Healthcare Face-to-face

Design

Delivery

Success

Care

Innovation

Clinicians

Triage Partnerships Values

Prospects

Primary Care Ethical Co-operative

Salaried

Committed

Telephony

Efficiency

Performance

it “they are best placed to ensure patients are treated properly.” In another RCGP 2007 paper6, it was stated that it is ‘vital that GPs do not become disengaged from the process of redesigning out of hours services… and their expertise and local knowledge [be] lost.’ Putting GPs in charge of the commissioning of out of hours services is clearly a move that is refreshingly acceptable across the landscape of healthcare provision. I’ll close with two other quotes from papers already referred to above. From the RCGP: “The GP is the proven expert in the field of delivering urgent care…” And from the House of Commons select committee: “We believe that GPs are best placed to ensure that patients get the care they need when they need it. Empowering GPs in this way will achieve better services for patients and more control of local services for GPs.”

Support

GPs

Engage

Family

Local

Opportunities Encourage

Team

Community

Robust

Nurses

Professional

as a specific purpose when in January 2012, Health Secretary, Andrew Lansley allocated an additional £100 million to the NHS to improve services in, among other things, ‘out of hours services for patients’. We have already mentioned that, prior to 2004, GPs were often involved in arrangements to share or outsource the delivery of out of hours care, especially home visits. So they do have some residual group experience in this area and it was the opinion of the authors of the East of England report (see above) that: “GP consortia will be well placed in this regard to offer increased clinical leadership to this [out of hours services] agenda. Clear lines of clinical responsibility and accountability for the service being delivered are necessary to demonstrate the effectiveness of clinical leadership in both commissioners and out of hours providers.” The report also made the point that GP commissioners who might be experienced out of hours doctors themselves should have the advantage of being physically familiar with the service. However they went on to emphasise that, as commissioners, GPs will need to view out of hours services from the perspective of a commissioner [on behalf of their patients] rather than a provider. Dr Johnson, chairman of the Northern Ireland Council of the Royal College of General Practitioners (RCGP) went further in a recent speech5 to speculate that the exclusion of GPs from out of hours care, particularly in England, has had predictable [and catastrophic] results. He went on to agree heartily with the recent conversion of politicians to the idea that GPs should be collectively responsible for commissioning out of hours services. As he put

Evidence-based

oral examination

Dignity Development

Quality

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SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

Choosing the Best Camilla Slade, Staff Writer

Out of hours care should be to the same standard as the rest of the practice’s care

Commissioners will need to assure themselves that providers recruit appropriately qualified and trained staff and that there is an appropriate skill mix, including the fact that doctors should be on an English Medical Performers List, have UK in-hours GP experience and speak English.

G

Ps have often in the past made corporative or outsourcing arrangements to cover out of hours visits to patients. Many of those arrangements were not too formal ranging from something as simple as a group of GPs agreeing among themselves to have ‘duty nights’ to more formal contracts with providers of services from the private sector. Commissioning of out of hours care services within the new NHS architecture will be a considerably more complex matter. GPs will now be responsible not only for the training and management of their own practices, but also for the selection and appointment, and continuing management of providers of out of hours care services. They will need to be well prepared for these tasks. The Royal College of General Practitioners (RCGP) Centre for Commissioning has built one of its Master Class Series, ‘Commissioning Integrated Urgent and Emergency Care’7 aimed at those who are actively involved with their local Clinical Commissioning Group (CCG) and are interested in learning more about commissioning effective urgent and emergency care services. It also makes the point that, whereas the old national performance targets mainly related to timeliness, GPs should be more able to focus on improving quality and the patient experience. The RCGP has been taking this subject seriously for some time. It’s March 2007 position statement on ‘Urgent Care’8 made recommendations for all of those then involved in the process including PCTs, but the statement would hold good for GPs about to embark on commissioning urgent and out of hours care now. The process essentially falls into two stages: selecting and appointing a provider, and managing them.

Selecting and Appointing a Provider Commissioners will need to assure themselves that providers recruit appropriately qualified and trained staff and that there is an appropriate skill mix, including the fact that doctors should be on an English Medical Performers List, have UK in8 | www.primarycarereports.co.uk

hours GP experience and speak English. They should also assess for themselves the clinical skills or competence of any provider: although one can check qualifications and Medical Performers List status (where applicable), because it is the GP’s own patients that are involved, nothing can better applying his or her own knowledge to test an applicant provider. Commissioning GPs should also make themselves aware of the processes used by providers in the selection and induction of their own staff. And don’t imagine that a high price means a high quality service. In their paper for the Department of Health ‘General Practice Out-of-Hours Services’9, Dr David Colin-Thomé and Professor Steve Field stated, “Generally there appeared to be little relationship between the cost of the service and the quality. Interestingly, a provider which used only doctors and call handlers in its service was much cheaper (and more productive) than a service which used a majority of specialist nurses along with some doctors.” It is also important that the expertise profile in any urgent or out of hours care service should reflect likely clinical needs and not simply the skills that happened to be available locally. This is not an area where ‘one size fits all’. Contracts with out of hours service providers should detail the standards for quality of care, clinical governance and risk management in those out of hours GP services.

Managing OOH Service Providers If one lesson stood out from the death of Mr David Gray following an incorrect administration of diamorphine by an out of hours locum who had, literally, flown from his home in Germany to the UK just to fulfil his shift, it was that out of hours service providers need to be managed as members of the whole care delivery team. In the Care Quality Commissions Report10 on this case, Dame Jo Williams, CQC chairman said: “Take Care Now [the service provider] failed on many fronts. Not only did it ignore explicit warnings about the use of diamorphine, it failed to address deep-rooted problems across its entire out of


SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

Excellence History

Out of Hours

Safety

It is not only the doctors

NHS 111 Commissioned

Diversity

who need proper training

Clinical

Patients

be subject to clinical

Clinicians Training

Services

Technology

Healthcare Face-to-face

Design

Triage Partnerships Values

Prospects

Primary Care Ethical Co-operative

Salaried

Committed

Telephony

Performance

Efficiency

high-quality manner.

Care

Leadership

Engage

handling patients in a

Success

audits from time to time to ensure that they are

Support

GPs

Innovation

handlers also should

Dignity Development

Delivery

and management – call

Evidence-based

Family

Local

Opportunities Encourage

Team

Community

Robust

Nurses

Professional

hours service. This had tragic consequences for Mr Gray.” She went on to say: “… The lessons are clear – the competency of overseas doctors must be properly tested; serious incidents must be properly investigated and quality of care must be monitored closely.” It is not only the doctors who need proper training and management – call handlers also should be subject to clinical audits from time to time to ensure that they are handling patients in a high-quality manner. For instance, the RCGP believes that the direction of symptomatic patients by call handlers to emergency departments, or making appointments at a primary care centre or other locations without the caller having undergone a clinical assessment by a clinician (or the call handler having used an approved assessment system such as NHS Pathways) poses a potential clinical risk to patients. The commissioning GP should also ensure that any provider has a robust clinical (or serious) incident reporting process and that there is a structure for regular sharing of information between Commissioner and provider. The provider’s medicines management process should be robust and should have reference to the practice for whom the service is being provided. After the David Gray case, the RCGP said that the specific requirements relating to controlled drugs cannot be underestimated and need to be embedded in commissioners’ and providers’ medicines management policies. Also, in those policies should be provision for regular meetings between commissioners and providers in which the provider’s performance will be judged against the contractual requirements as agreed at the outset. Quality is everything; the National Quality Requirement requires all staff involved in patient care out of hours to have a sample of their calls of consultations audited at least quarterly. Additionaly, feedback from patients should be encouraged. If out of hours services are accorded the same priority as other areas of primary care, they will continue to be an invaluable asset to GP practices and, more importantly, their patients.

Telehealth

Quality

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SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

Matching the Service to Place and Needs John Hancock

Out-of-hours services must be a good fit with the area and community in which they operate

Staff working for out of hours providers treat patients who are not known to them often without access to their medical records. They may also be working in an area that is unfamiliar to them and with colleagues who are equally unknown.

10 | www.primarycarereports.co.uk

T

here are lots of things that have to be considered when commissioning out of hours services, not least of which is where the service has to be delivered. This matters because access to out of hours services must be predictable, reliable and available in a timely manner. Almost by definition, people who need out of hours services will be people with significant needs; perhaps terminally ill or with multiple and complex conditions or even with mental conditions; or simply elderly or ill and worried. Wherever possible, urgent care and out of hours services should be designed around the needs of patients. They should also be structured in a way which is appropriate for the area. As the RCGP (Royal College of General Practitioners) position statement on Urgent Care11 puts it; “While centralised schemes may work well in urban areas, they may diminish access in rural areas. This should be addressed through careful planning and engagement of communities. Arrangements must be tailored to local needs. Better and wider use of technologies such as telemedicine can be helpful.”

Unfamiliar Territory Out of hours staff have to find their patients in often unfamiliar territory. In most cases they will have a driver and satellite navigation but on, say, a large estate with pedestrianized areas or blocks of flats, that won’t get them to the front door they need to reach at two o’clock in the morning. If possible they should be supplied with a local street map. Also, it must be remembered that staff working for out of hours providers treat patients who are not known to them often without access to their medical records. They may also be working in an area that is unfamiliar to them and with colleagues who are equally unknown. Yet, in working out of hours they will inevitably deal with a higher proportion of patients in need of urgent care which will make them particularly vulnerable. Whether it’s

children (and their parents), the elderly, patients with chronic, complex or terminal conditions, they will all need the reassurance of a reliable service that delivers what it promises. And, if the doctor doesn’t know the patient, the patient won’t know the doctor so his or her ‘bedside manner’ will be more important than ever.

Knowing the Language One thing to consider in particular is the matter of language. In recent decades, both through legislation and practice, we have learned not to be overly critical of somebody simply on the grounds that they don’t speak good English. In a social setting that is fine but in the case of a doctor who has to sometimes talk to a call centre agent (while many cases will be sent by e-mail, often there are nuances in a case that only a discussion can clarify), interview a patient who will almost certainly be unknown to them and who may speak with a regional accent, make a diagnosis from that interview and then call either a dispensing pharmacy or another service, a poor grasp of English may be positively dangerous. Language was certainly one of the factors in the 2008 case where Mr David Gray, died as a result of an out of hours consultation with a doctor who spoke poor English. As a result of that case and the subsequent enquiry by the Department of Health, Sir David Nicholson, then NHS Chief Executive, wrote to all Primary Care Trusts (PCTs) with a number of recommendations12 including; “I would also like to remind you that the Performers List Regulations 2004 place a legal duty on a PCT to refuse to admit practitioners to its Performers List if it is not satisfied they have the knowledge of English necessary to perform primary care services in its area. It is of the utmost importance that doctors are able to communicate effectively with their patients.” That stricture would now apply to commissioning groups and GPs and it is government policy in line with the recommendations of the House of Commons


SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

Excellence History

Out of Hours

Safety

Telehealth

NHS 111 Commissioned

Diversity

Clinical

Patients

Care

Services

Innovation

Training

Leadership

Face-to-face

Design

Delivery

Technology

Healthcare

Triage Partnerships Values

Prospects

Primary Care Ethical Co-operative

Salaried

Committed

Telephony

Efficiency

Performance

Family

Local

Opportunities Encourage

Team

Community

Robust

Nurses

Professional

Almost as important as the provision of highquality clinical care out of hours is to ensure that a structure is in place through which patients who need them can get proper access to medicines in out of hours periods. The Department of Health guidance14 in 2004 address this issue albeit that the information was then directed at PCTs (at that time responsible for commissioning out of hours provision). But today the same factors will apply. Where patients’ clinical needs are such that treatment should start without delay, they will need to be able to access the medicines they need at the same time and the same place as their out of hours consultation. [Commissioners] will therefore need to develop systems that will allow this to happen, ensuring that the responsibility for locating a pharmacy or source of medicine supply will no longer be with the patient or their representative but with the out of hours provider. Similarly, commissioners will need to ensure that all health professionals are able to access appropriate levels of pharmaceutical advice out of hours. Commissioning out of hours services is not simply ‘getting somebody to cover’ but involves the establishment of a team and an architecture to ensure that patients with urgent and out of hours needs receive the same quality of service as the practice seeks to deliver at all times.

Clinicians

Engage

Access to Medicine

Support

GPs

Success

Health Committee report on ‘The use of overseas doctors in providing out-of-hours services’13. The report goes on to express similar sentiments with regard to clinical competence where the UK NHS services have to accept qualifications issued by another EU competent authority.

Evidence-based

home visit to elderly patient

Dignity Development

Quality

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SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

A Sensitive Practice Camilla Slade, Staff Writer

Out of hours services are more than simple clinical delivery systems, they also support a relationship

Far from being a second line service, out of hours provision is regarded as a high risk area in health care; high risk because a higher proportion of the people who use the service will

gp conducting temperature check

have serious underlying health problems.

W

hen, in 2004, GPs were relieved of the responsibility to arrange out of hours provision, the move received a not altogether positive response in the media. People felt that GPs were abandoning them to faceless private services whose objective was profit rather than care. This complaint ignored the fact that, by 2004, 95% of GPs had entered arrangements to relieve themselves of the burden of being always ‘on-call’ by either forming area cooperatives or by contracting a private out of hours service provider.

A High Risk Area Sadly, under this system, some out of hours provision was not to a high standard and when a Mr David Gray in Cambridgeshire died as a result of poor out of hours service delivered by a doctor on a 24 hour shift from Germany and with little English language, there was a justifiably loud outcry against out of hours service being commissioned from a remote office with little or no knowledge of the patients. In reality, far from being a second line service, out of hours provision is regarded as a high risk area in health care; high risk because a higher 12 | www.primarycarereports.co.uk

proportion of the people who use the service will have serious underlying health problems. Also, because the service itself is not the service that they usually use, they may find it difficult to access. One issue that accompanies the commissioning of out of hours services is the need to ensure that, as much as is possible, patients likely to use the service are familiar with how it works. Being ill in the middle of the night can be a frightening experience. When the Royal College of General Practitioners (RCGP) with others devised and published an ‘Urgent and Emergency Care Clinical Audit Toolkit’15, the introduction included the statement, “Out of hours care is usually accessed at a time when patients can be at their most frightened and vulnerable. There are of course many excellent examples of services but patients can find it difficult and complicated to navigate the system… patients have a basic right to a high quality of urgent care at whatever time they use the health service…”

Vulnerable Patients When people need out of hours care, it is more than likely that they will be experiencing a health crisis, defined by the National Institute for Health and Clinical Excellence (NICE)16 as; “… a significant unplanned event where there is an element of distress or disruption requiring urgent response and appropriate intervention.” The reasons for such a crisis can vary but there are a number of groups for whom this is more likely to be an issue. People with long-term illnesses may well suffer increasing frequency of poor health events as their illness progresses or, as with the conditions such as diabetes, events such as comas. For somebody who already knows their health is poor, to feel that there is some sudden or unexpected deterioration is very worrying and when these things happen during out of hours times, the patient will feel even more uneasy that they do not have access to the usual support system on which they rely. In a similar category to people with long-term conditions, and often the same people, are patients with multiple needs. Once again these


SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

Excellence History

Out of Hours

Safety

Telehealth

NHS 111 Commissioned

Diversity

Clinical

Patients

Services

Innovation

Care

Leadership

Face-to-face

Design

Delivery

Technology

Healthcare

Triage Partnerships Values

Prospects

Primary Care Ethical Co-operative

Salaried

Committed

Telephony

Efficiency

Family

Local

Opportunities Encourage

Team

Community

Robust

Nurses

Given the problems that there have been with public opinion, this remains an area where

Success

Public Opinion

Training

Professional

Reference was made above to patients who are terminally ill but there is an even more challenging situation for out of hours care providers dealing with end of life care. Palliative care and the weeks or months preceding death can see many changes in condition and treatment, and the commissioning GP needs to ensure that the out of hours service is kept up-to-date with these changes for any given patient. In the NICE paper referred to above (‘Urgent care’) it is stated that among the outcomes that Commissioner of out of hours services would want is that “people approaching the end of life [and their carers] feel that any crisis or need for urgent care [is] addressed in a prompt, safe and effective way appropriate to their needs and preferences.”

Clinicians

Performance

End of Life

perceptions of the service in the public and in the media are very important. For instance, it is generally accepted that the public should be able to assume that the doctors who they see or speak to out of hours are as well qualified and experienced as the doctors they would see during daytime consultation. As well as the quality of healthcare, patients also value responsiveness and, if an out of hours service is perceived as responding quickly, it is more likely that its users will also think that it provides good care. Commissioning out of hours provision is not just outsourcing of service but also entails making sure that that service meets the emotional as well as the healthcare needs of those who are most likely to use it.

Support

GPs

Engage

are people who often feel that they are not really in control of their own condition and who rely very heavily on the resources of their normal healthcare providers. To suffer an episode out of hours when they are unable to contact their normal service will only add to their stress. Continuity in the health service that they receive is very important for some groups of patients such as the terminally ill, older patients who may be frail and suffering with multiple and complex medical conditions, and those who have mental illness. Out of hours care must be delivered in a way that is sensitive to these feelings as well as in a way that can deal with the health issues for which the call is made.

Evidence-based

NHS 111 Clinical Advisor

Dignity Development

Quality

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SPECIAL REPORT:COMMISSIONING OUT OF HOURS SERVICES

References: 1

 NHS East of England ‘Out of Hours Visits Programme’ http://www.rcgp.org.uk/pdf/CIRC_EoE%20OOH%20VP%20Report%20Jan%202011%20%282%29.pdf

2

2010 report ‘General Practice Out of Hours Services’, Dr David Colin-Thomé and Professor Steve Field http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_111893.pdf

3

Care Quality Commission http://www.cqc.org.uk/media/care-quality-commissions-investigation-gp-out-hours-provider-take-care-now-reveals-serious-fai

4

Response to the House of Commons Health Committee report The use of overseas doctors in providing out–of–hours services http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118015.pdf

5

Launch of 10 Year Strategy: Dr Johnstons Speech http://www.rcgp.org.uk/pdf/Dr%20Johnstons%20Speech%20%282%29%20%28Read-Only%29.pdf

6

RCGP Urgent Care http://www.rcgp.org.uk/pdf/RCGP%20position%20statement%20urgent%20care%20March%202007%201%20.pdf

7

RCGP Centre for Commissioning, ‘Commissioning Integrated Urgent and Emergency Care’ http://www.rcgp.org.uk/pdf/events/flyer/Outline%20-%20Commissioning%20Integrated%20Urgent%20and%20Emergency%20Care.pdf

8

9

RCGP, Position Statement, ‘Urgent Care’ http://www.rcgp.org.uk/pdf/RCGP%20position%20statement%20urgent%20care%20March%202007%201%20.pdf Department of Health ‘General Practice Out-of-Hours Services http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_111893.pdf

Care Quality Commissions report http://www.cqc.org.uk/media/care-quality-commissions-investigation-gp-out-hours-provider-take-care-now-reveals-serious-fai

10

11

RCGP, position statement on Urgent Care http://www.rcgp.org.uk/pdf/RCGP%20position%20statement%20urgent%20care%20March%202007%201%20.pdf

12

Letter from Sir David Nicholson http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_112072.pdf

13

Response to the House of Commons Health Committee report The use of overseas doctors in providing out–of–hours services http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118015.pdf

14 Department of Health guidance, Securing Proper Access to Medicines in the Out-of-Hours Period http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4134238.pdf

15

RCGP, ‘Urgent and Emergency Care Clinical Audit Toolkit’http://www.rcgp.org.uk/pdf/Urgent_Emergency_Care_Toolkit_30_March_2011.pdf

16

NICE, ‘Urgent care’ http://www.nice.org.uk/guidance/qualitystandards/endoflifecare/UrgentCare.jsp

14 | www.primarycarereports.co.uk


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Special Report – Commissioning Out of Hours Services  

Primary Care – Special Report on Commissioning Out of Hours Services