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Has the quality of out-of-hours care really declined?

Tony Lithgow examines the evidence for fears that the out-of-hours opt-out has hit the quality of services

Tony Lithgow examines the evidence for fears that the out-of-hours opt-out has hit the quality of services

Out-of-hours care is suffering a crisis of confidence. Ever since GPs handed responsibility for provision to PCTs, headlines have told of organisational chaos, plummeting standards and high-profile failures.

A new Pulse survey of almost 600 GPs reveals 47% believe out-of-hours services have declined in quality since 2004, while only 19% think they have got better.

But are these fears well-founded, or misconceptions built on negative news coverage and coloured by the glitches that inevitably occurred during the handover?

It is a difficult question to answer, partly because there is very little data allowing a direct comparison of quality before and after the opt-out.

PCTs only started collecting data on expenditure on out-of-hours services, and number of patient complaints, on taking over services in 2004.

What the figures do show, however, is astonishing variations between trusts in how much they spend on out-of-hours services.

Statistics revealed under the Freedom of Information Act show that at the top end, Coventry PCT is spending £35 and Wirral £50.80 per patient each year.

But at the other end of the spectrum, Lambeth in London is spending just £2.99 per patient, while Hammersmith and Fulham and Kensington and Chelsea devote £4.95.

With differences that marked, variation in quality would seem inevitable.

Lottery in care

Dr Nick Morton, a GP and assistant medical director of East of England Ambulance Service, is one of those who believe there is an acute postcode lottery in the quality of out-of-hours provision: ‘Certainly it varies tremendously, depending on investment by the commissioning PCT.'

He says it is essential for politicians to ‘dig deep' and find the cash to improve the services. ‘It would make a huge impact,' he insists.

Statistics on the number of complaints per PCT do vary dramatically, from an average of just 2.3 a year between 2004/5 and 2007/8 at Buckingham PCT, to a high of 64 a year at Bournemouth and Poole.

But our figures suggest there is not a clear relationship between expenditure and level of patient dissatisfaction.

High-spenders Coventry saw an average of 14.3 complaints a year and Wirral 22.5, and low-spenders Lambeth had 33.5 complaints a year, Kensington and Chelsea 23.8 and Hammersmith and Fulham 21.0.

Overall, complaints appeared to leap between the first and second years of PCT responsibility, from an average of 16.9 in 2004/5 to 23.4 in 2005/6, before settling at around the 22 mark for the last two years.

There are fears that complaints could be driven by some of the financial cutbacks PCTs have chosen to implement. Pulse's survey suggested as many as two-thirds of trusts may be cutting back on their number of GP shifts, with nurses and emergency care practitioners increasingly used instead.

Dr Stephen Bamber, a GP in Fritton, Norfolk, is among a growing number of GPs who believe the 2004 contract changes are coming come home to roost.

‘GPs were excluded from any role in the planning,' he says. ‘The new arrangements were flawed in concept and execution, and it was soon apparent that the Government and the Department of Health had seriously miscalculated the costs.'

And there are fears that the number of recorded complaints might not fully reflect the full scale of public dissatisfaction.

Critics fear some callers to out-of-hours services simply give up in disgust as they are unable to get connected quickly enough, and grumble about it afterwards instead of making an official protest.

East Staffordshire PCT, in a report on out-of-hours care, acknowledges that issue. ‘Published quality indicators would seem to show a problem with "abandoned calls".

Abandoned calls include those that are not answered because the caller rang off,' it says.

Dr Krishna Korlipara, founder of the now-defunct National Association of GP Co-operatives, says he takes PCT figures on complaints with ‘a big pinch of salt', arguing that some trusts log complaints from patients as merely ‘comments' unless they are written in a very formal manner.

Dr Korlipara claims that since PCTs took control of out-of-hours services from GPs, the outcome has been ‘disastrous', with a ‘dramatic increase' in patients seeking A&E treatment instead. He believes GPs should be handed responsibility for commissioning out-of-hours services.

But that's not a view shared by Dr Ray Montague, chief executive of out-of-hours company BrisDoc. He says: ‘GP out-of-hours services are something everybody likes to beat up. The GP profession who aren't involved in it seems to enjoy jumping on that bandwagon.'

Opt-out effect

But last May, the only academic study to look at out-of-hours care before and after the 2004 opt-out appeared at least partly to back up criticism of the effect of the opt-out.

The study of care in Devon found evidence of ‘significant increases' in triage time for cancer patients since 2004, and added: ‘Potentially adverse changes to communication between out-of-hours and in-hours clinicians were observed.'

The report noted ‘widespread concern' that patients with complex needs might have been put at risk by changes in the contract, although it also found that potential quality indicators, such as hospital admissions and home visiting rates, remained constant.

But Dr Chris Wright, chief executive of out-of-hours provider Devon Doctors, insists there is no convincing evidence of a fall in standards: ‘Out-of-hours services are often an easy target.

There is rarely, if ever, convincing arguments to prove the correlation [between number of complaints and service standard].'

Although it is difficult to provide hard data to demonstrate a drop in standards, there is certainly a feeling among GPs that things are not as they should be.

Only 58% of GPs in Pulse's survey felt their own local out-of-hours service was of high quality.

As one senior BMA figure puts it: ‘I doubt if anyone will be able to quantify the true scale of the problem because PCTs and the Government have deliberately devised a reporting and accounting structure that even the most skilful use of the Freedom of Information Act will be unable to penetrate.

They simply do not want the public to know.'

Has the quality of out of hours care really declined?

How PCTs compare
Average annual spend(2004/5-2007/8), annual complaints
Wirral £50.80, 22.5
Coventry £35.00, 14.25
Oxfordshire £25.53, 33
North Somerset £10.94, 7
Brighton and Hove £9.99, 9
West Cheshire £9.80, 13
Eastern & Coastal Kent £9.67, 11.5
Torbay £9.35, 11.5
Worcestershire £9.10, 52.5
East Berkshire £9.10, 2.8
Plymouth £9.10, 19.8
Bournemouth and Poole £8.99, 64
Swindon £8.76, 3.3
Berkshire West £8.34, 23.3
Portsmouth City £7.65, 37
Barnsley £7.41, 33.8
Wolverhampton City £7.00, 20.8
Knowsley £6.89, 6
Dudley £6.51, 31
Sheffield £6.24, 20
Buckingham £6.31, 2.3
Huddersfield £6.22, N/A
Havering £5.77, 22.7
Kensington and Chelsea £4.95, 23.8
Hammersmith and Fulham £4.95, 21
Lambeth £2.99, 33.5
Camden Commercially sensitive, 9
Islington Commercially sensitive, 10.8
Nottingham N/A, 47.8

Source: Data supplied by PCTs under the Freedom of Information Act

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