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Shortage of trained personnel hinders new providers

How will out-of-hours cover be delivered if, as expected, GPs opt out in their droves? Pulse contacted co-operatives and PCTs and found funding and shortage of trained personnel a source of concern ­ Nerys Hairon reports

Out-of-hours services will be delivered using a wide range of models ranging from GP co-operative mergers using skill mix to co-ops integrating with other emergency care providers.

The timescale to implement new services will vary widely across the country, depending on cost, the enthusiasm of both trusts and local GPs to have an early opt-out, and feasibility in reorganisation.

Skill mix has emerged as a major development in plans for future out-of-hours models, as the significantly depleted GP workforce has forced trusts to consider how best to meet patient needs with limited GP input.

Blackburn and District Medical Co-op has produced a model, yet to be agreed by the two PCTs, that would combine nurses and GPs working on-call. But chair Dr Malcolm Ridgway said there would have to be a move away from home visiting due to the reduced numbers of GPs working shifts.

'I don't think there will be a massive change from what we have got now,' Dr Ridgway said, 'but we have got to move away from home visiting as it's going to be quite a huge area in terms of distance.'

The cost of the new model would be at least 25 per cent more than the current service, because of covering a larger, more rural area, higher shift rates for GPs and the provision of a patient transport system.

Dr Gregor Purdie, secretary of Dumfries and Galloway LMC, said the proposed model in his area also faced a similar problem ­ lack of funds meant having only two doctors on-call who would be unable to do home visits due to large distances.

Dumfries and Galloway NHS board also envisaged a multidisciplinary service, he added, but there would be a period where the service would have to depend on GPs while nurses were being trained.

'Our problem is that we need to move from a doctor-delivered service to a multi-professional service with nurse practitioners, but we don't have these people standing waiting to be employed,' Dr Purdie said.

'We will have to go through an initial phase where we seek out and train other professionals. In the meantime we will have to continue to deliver a service that is doctor-led and that will be expensive.'

Co-ops elsewhere are redesigning services to merge with emergency care providers, such as NHS walk-in centres and A&E.

Peterborough Doctors On Call, which has merged with the walk-in centre, said the proposed model would have three tiers ­ nurse triage, nurses doing face-to-face consultation, and GPs for more complex problems.

Chair Dr Richard Withers said: 'At first I couldn't see how we could carry on when a lot of our members don't want to continue. We decided to collaborate with the walk-in centre with the idea of turning it into a nurse-led service, with the doctors providing back-up and consultancy ­ very similar to the way a lot of general practice is becoming in the daytime.'

With nurse practitioners in short supply, Dr Withers said a lot of training and support would be needed to get less-qualified nurses to the position where they can make diagnoses. Decision support software is a likely option, but GP back-up will be essential, he added.

'Chest pain or severe asthma is easy to process, but an elderly person on a lot of medication with vague symptoms is not so easy to assess,' Dr Withers said. 'To get others to step into doctors' shoes is not so easy.'

For home visits, the co-op is considering using either district nurses or paramedics.

Dr Neil Smith, a director of Worth and Aire GP Emergency Centre, said it was likely that the co-op would fold as there was 'barely a flicker of interest in keeping it going'.

The local trust was working on setting

up a new out-of-hours service, which

would be likely to involve more nursing

input and working with A&E, Dr Smith said.

Yorkshire Pennine Doctors on Call is considering two options ­ either the co-op remaining an individual organisation and becoming a limited company, or becoming part of the wider emergency care network, to facilitate joint working with A&E.

'The model will depend on a number of issues, but we are not going to be able to run a service as we do now,' chair Dr John Clarke said.

Co-ops are also considering merging with other co-ops to achieve economies of scale and pool funds, and then integrating with other emergency care providers.

Maldon Doctors on Call in Essex is considering amalgamating with two or three other co-ops to cover the whole of mid-Essex and a large part of north Essex.

Clinical director Dr Mike North said the service would be run by Essex Ambulance but would continue to use primary care centres in each trust area in the evenings and weekends and just one centre overnight.

'We will be using a skill mix of doctors, nurses and community paramedics, and have already performed an analysis of our historical workload to demonstrate that about half our calls could have been dealt with by a nurse.'

A consortium of three co-ops ­ Sussex Doctors on Call, Maidstone Doctors on Call and TTDOC in Tunbridge Wells and Tonbridge ­ is bidding against deputising service Primecare for the out-of-hours contract across three trust areas.

The consortium model would be co-op based using Susdoc's own existing nurse triage system. General manager John Anthony said: 'Small co-ops will not exist in the future ­ they do not have the depth of management of the larger ones.'

North West Wiltshire On-Call Co-operative is set to combine a PCT-run co-op service with Primecare in the short-term.

'We will end up with a co-op run by the PCT. What we are planning to do in the

short-term is put call handling and phone triage out to Primecare, but we will retain

face-to-face patient contact,' chair Dr Andrew Cowie said.

'But we have got a huge area and it's going to cost a lot of money.'

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