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OOH benchmarks carry no credibility

The fact that most PCTs are compliant with national standards on out-of-hours service provision would be good news – if the interpretation of those standards didn't vary wildly

The fact that most PCTs are compliant with national standards on out-of-hours service provision would be good news – if the interpretation of those standards didn't vary wildly



Out-of-hours care is the unloved ugly duckling of the NHS. It may be the negative headlines or just bad memories of midnight callouts, but it struggles to shed its image as a dimly lit backwater of primary care. Not only that, but out-of-hours services have proved to be the profession's Achilles heel in recent years, with GPs forced to carry the can by the national media for the failure of primary care organisations to put proper services in place following the 2004 opt-out.

So let's start with the good news from a new benchmarking review of out-of-hours services, conducted for the Department of Health by the Primary Care Foundation. The great majority of PCOs are, apparently, compliant with national standards. That would be terrific if those standards had any credibility. Unfortunately, the very same review reveals that they do not.

Among the national standards are two targets for the time taken to clinically assess patients who call out-of-hours services. The first requires that patients making urgent calls are assessed within 20 minutes, the second that non-urgent callers are assessed within the hour. That's all fine, except for one problem. Who is responsible for deciding whether a call is urgent or not? That would be the out-of-hours service.

The benchmarking review found the proportion of callers classified as urgent varied from 60% in some PCOs to less than 2% in others. It's going to be a whole lot easier to hit the 20-minute target if you reduce the number of patients to whom it applies to just a handful of the most seriously ill.

But that's not the only flaw in the national standards revealed by the new review. We already knew there were huge variations in expenditure on out-of-hours care in different parts of the country – something Pulse first revealed more than a year ago. What the new report shows, though, is the stark differences in level of service provided by PCOs as a result of that variation in funding. The proportion of patients who receive home visits varies from more than 20% at some PCOs to just 2% at others. And although the national standards specify speed of response for home visits, they have nothing to say about how many patients should get such care nor whether geographical factors might justify at least part of the variation.

Highlighting flaws in the standards is not the same as being in a position to do anything about them. The real problem is we simply don't know the best way to run an out-of-hours service. There is very little evidence on how many patients who call a service ought to be classed as urgent. Similarly, it's not clear how many calls can be dealt with over the phone and what proportion of patients need to see a doctor. The DH must do more than comparing PCOs against each other. It must rigorously assess the models on offer and provide guidance on how to provide high-quality services, rather a simplistic and flawed set of targets.

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