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Should GPs take on out-of-hours commissioning?

Amid criticism of the cost and quality of out-of-hours care, we examine proposals for GPs to take on commissioning.

By Gareth Iacobucci

Amid criticism of the cost and quality of out-of-hours care, we examine proposals for GPs to take on commissioning.

When GPs opted out of responsibility for out-of-hours care, the over-riding feeling was one of relief, but for a few it was tempered by trepidation.

No one knew quite how PCTs would cope in taking on out-of-hours services, but there were real concerns that the Department of Health might have under-estimated the size of the task.

‘The Government thought GPs were just moaning and groaning, and really, this wasn't such a big deal,' recalls Dr Gurmit Mahay, medical secretary of Wolverhampton LMC. ‘But the NHS has got far more complex and the demands have grown immeasurably.'

Sure enough, PCTs have faced an uphill battle to run services effectively. A Pulse investigation last year revealed growing discontent among GPs over out-of-hours care, with almost two-thirds believing the standard had declined since the 2004 opt-out.

Those concerns were heightened last week as Pulse revealed that cash-strapped out-of-hours providers were benchmarking GPs against performance criteria, in an attempt to control rates of home visits and hospital referrals – leading to warnings that financial pressures might be compromising quality of care.

Against this backdrop, the NHS alliance and the Conservatives have called for GPs to take back responsibility for 24 hour care, which they say will solve some of the most serious of the current problems.

The NHS Alliance is keen to stress that it is only talking about responsibility in a commissioning sense, but its call has still provoked fears that the Government might be considering returning full responsibility to general practice – a move that would be hugely unpopular with GPs.

Dr Michael Dixon, chair of the NHS Alliance, stresses that the plans, outlined in the Alliance's new document In Sickness and In Health, do not spell a return to GPs being on call at 4am, but instead involve them taking on a much more proactive role in the management of services through practice-based commissioning.

But, with PBC uptake at practice level still patchy in the face of inadequate data and a lack of meaningful budgets, would PBC clusters be able to manage the high cost of providing out of hours care any better than current providers?

‘On the one hand, there would be the same amount of money for OOH as before, so it would be cost neutral,' he admits.

‘The difference will be that PBC collectives will have a better idea of what local people want. If it is better co-ordinated, there will be some savings on patients not needing to go to the local district general hospital, and then costs rocketing as we know has happened.'

Welcomed

The Department of Health has welcomed the proposals, with a spokesman telling Pulse: ‘We are actively considering the recommendations. Officials will meet with the NHS Alliance to discuss its specific recommendations on urgent care.'

So how would the proposals work on the ground?

Dr Dixon says: ‘I think those who have been against the plan have felt we would be trying to put them back into doing out-of-hours, but we are not talking about provision. In most cases the provider will remain the same, but there will be a creative edge in the commissioning. PBC commissioners will challenge them, make sure they are better integrated and that patients get clearer signposting.

‘It's creating that accountability between in hours and out-of-hours, without the GP practice itself having to provide out-of-hours care.'

The push to coordinate in-hours and out-of-hours care intensified last week, with reports that practices could be fined for patients who attended walk-in centres or A&E rather than seeing a GP. Whether such a scheme could ever hold practices to account out of their core contracted hours is still not clear.

What's more certain is that performance management of GPs working out of hours will continue, even if services are commissioned under PBC. But Dr Dixon says: ‘GPs will know that their clinical colleagues are setting the standards and they'll be more likely to make underspend. The solution and problem will be in the same camp.'

Dr James Kingsland, chair of the National Association of Primary Care, says he agrees with the sentiment of the NHS Alliance proposals, but fears that GPs will continue to be prevented from commissioning out of hours care by PCTs.

‘In one respect, it's a bit of rhetoric, we can do it already, but it's just not being allowed.

‘The ability was in place in October 2004. The only thing that's stopping it is PCTs properly developing PBC in the budget. When you get a budget, that includes the out of hours service.'

Dr Chaand Nagpaul, GPC negotiator with responsibility for out of hours care, believes that the proposals have arisen because of ‘the abject failure of PBC'.

He says: ‘The failure of PCTs to devolve commissioning power to GPs has, in a way, brought on this call. The problem has been inadequate incentives, resources and support for GPs, and the failure of PCTs to let go.

Dr Nagpaul said the GPC would support GPs having more commissioning power for out of hours ‘within the wider context of PBC', but that it would fight against any moves that may see GPs taking back full responsibility.

‘GPs are better placed to commission out-of-hours services than PCTs. What we would not support is compelling GPs to take personal responsibility for its provision. We don't want to turn the clock back. We voted very clearly against that.'

For their part, current out-of-hours providers appear open to greater GP involvement in commissioning services, but are sceptical of it working in practice.

Dr Ashish Dwivedi, chief executive of out of hours provider Seldoc, says: ‘This change could be for the better, as it could lead to a more integrated service. We have a patchy service in parts of England.

‘But, this could have very serious side affects. One, GPs might think they'd be going back to the previous out-of-hours situation. And side affect two is that it wouldn't work without economies of scale.

He adds: ‘We know PBC is still wildly misunderstood. It may be that now is not the right time for PBC to commission. It's not mature enough. Is the direction right, Yes. Is the timing right? Probably not.'

Dr David Lloyd, a medical director at out-of-hours provider Harmoni, says GPs face an uphill battle to exert more power over PCTs. ‘It's a tremendous battle, because PCTs don't necessarily feel GPs have the skill to provide everything that's needed. There is a very tall flight of stairs, but at the end you could get an integrated out-of-hours service which is primarily GP run, which could be a very good model.'

But with Lord Darzi planning a huge shake-up of urgent care in his Next State Review, review, some GPs fear commissioning will be just the smokescreen ministers need to force full responsibility back onto GPs.

Dr Mahay believes recent battles over extended hours and pay will make it difficult for the Government to make any moves in this direction without suffering a severe backlash.

‘I think the Government's been found out. It won't get a very sympathetic hearing from the profession,' he says.

Dr Kevin Booth, a GP in Altrincham, warns: ‘Ultimately against as I am sure that the Government would withdraw funds and we would be doing it for free again.'

Four years on from the out-of-hours opt-out and there remains a feeling of trepidation for what the future may hold.

The NHS Alliance insists its plans to dot spell a return to GPs being on call at four in the morning Out of hours Dr James Kingsland Dr James Kingsland

In one respect it's a bit of rhetoric. We can do it already, but it's just not being allowed

Dr Chaand Nagpaul, GPC negotiator Dr Chaand Nagpaul, GPC negotiator

What we would not support is compelling GPs to take personal responsibility for OOH provision.

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