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What does the future hold for out-of-hours?

Private providers, telephone triage, urgent care centres and the advent of polyclinics will all shape the future of out-of-hours care. So where will GPs fit in? Steve Nowottny investigates

Private providers, telephone triage, urgent care centres and the advent of polyclinics will all shape the future of out-of-hours care. So where will GPs fit in? Steve Nowottny investigates

When GPs first gave up responsibility for out-of-hours provision, the profession breathed a collective sigh of relief.

No more sleepless nights, no more squinting for door numbers at 2am, no more broken weekends tearing round the practice area with the spouse on phone-answering duties.

But since that watershed moment, out-of-hours care has changed beyond all recognition, with the rise of private providers, call centre services and alternatives such as walk-in centres all leaving their mark.

GPs who are involved in out-of-hours care – and those glad to be shot of it – have been left wondering: what next?

The most obvious change to date has been in the provider landscape.

When PCTs were handed responsibility for out-of-hours care in 2004, in many areas there was no immediate noticeable difference, with local GP co-operatives continuing as before.

But as PCTs began to flex their tendering muscles, different models of provision soon emerged. Private companies such as Serco and Primecare began coming to the fore, as did NHS provider arms, while many co-operatives moved to a social enterprise or profit-sharing structure (see box).

Provider numbers falling

Experts estimate the total number of providers has now shrunk from about 150 to around 100 – and could fall further.

Nigel Wylie, chief executive of Liverpool-based provider Urgent Care 24, says: ‘The service has matured beyond anyone's imaginable vision in four years.'

He believes increasing regulation and the sheer administrative challenge of putting together tenders will ensure only providers with a sufficient ‘critical mass' will survive.

‘I do envisage the contracts being held by fewer companies,' he says. ‘We have three-quarters of a million patients, which I think is viable. I think at half a million it starts to become a viable number.'

Part of the challenge faced by out-of-hours providers in coming years will be maintaining that critical mass, as PCTs increasingly look to commission different aspects of out-of-hours care, with separate providers for call-handling, walk-in treatment and visiting.

Dr Ray Montague, chief executive of the Brisdoc service in Bristol, says: ‘Traditionally, GP out-of-hours have provided a linear care pathway – if someone's in our patch then basically they're your responsibility.

If I believe in anything in terms of out-of-hours, that's what I believe in – I think hand-offs don't work. But there's an enormous momentum towards dividing that up the other way.'

One way in which out-of-hours providers are responding to this challenge is by bidding to run the new wave of Darzi polyclinics.

For many practices, polyclinics are seen as a threat because they will look to poach patients from existing practice lists.

But for out-of-hours providers the walk-in element is potentially even more threatening, with polyclinics poised to operate as de facto providers of out-of-hours care from 8am to 8pm, seven days a week.

One GP working for an out-of-hours company, who asked not to be named, told Pulse that for many out-of-hours providers it was a simple matter of survival: expand or die.

‘If we're not successful with a Darzi centre, then when our contract runs out, we're potentially out of the picture,' he said. ‘But if we've got the Darzi centre, we've got a chance.'

Either way, polyclinics look poised to radically alter the shape of out-of-hours care.

A series of SHA vision documents published ahead of Lord Darzi's NHS Next Stage Review called for the rollout of urgent care centres – a centralised GP-led gateway to emergency and urgent care.

In some areas, separate urgent care centres are being built. West Hertfordshire is due to open one of the first of these next month, to replace an A&E department at Hemel Hempstead hospital.

But in other areas, polyclinics procured under Lord Darzi's Equitable Access in Primary Care programme will be deployed as de facto urgent care centres, acting as a hub for most urgent and unscheduled care.

Regardless of their exact title, Rick Stern, out-of-hours lead for the NHS Alliance and

a partner in the Primary Care Foundation, believes the future will be distinctly polyclinic-shaped. ‘I think you'll see much greater integration with service,' he says.

‘I would hope that in five to 10 years' time you're not talking about out-of-hours any more, but talking about urgent primary care and how that's managed.

‘Out-of-hours is effectively one part of a complex chain and increasingly providers are looking at how they can integrate with everything from GP community services, ambulance services, A&E and beyond.'

A similar kind of integration of skills is likely to be seen within providers themselves. A Pulse investigation in April 2007 found more than half of PCTs had cut the number of GPs covering out-of-hours shifts or had plans to do so – some by as much as 50%.

And a new Pulse survey finds what many GPs see as a dumbing down of the skill mix in out-of-hours care – with two-thirds of those aware of their local situation saying their trust is replacing GP shifts with cover by nurses and emergency care practitioners.

Out-of-hours providers acknowledge this is a trend that is likely to continue, but insist that increasing regulation will maintain or even improve the quality of care.

Underpinning all the predictions about the future of out-of-hours, however, is the elephant in the room. Having gratefully given up responsibility for out-of-hours, could GPs ever be persuaded to take it back?

In a knife-edge vote at this year's LMCs conference, to the surprise of many, LMCs narrowly backed a motion calling on the GPC to consider moves for GPs to take on commissioning of out-of-hours services.

GPC leaders were quick to play down the long-term implications of the vote, and current out-of-hours providers remain sceptical.

‘The scale of GP out-of-hours services is big and PBC groups aren't that big,' says Dr Montague. ‘So they're not going to be allowed to dismantle PCT-wide services.'

Back in driving seat

But giving the profession responsibility for commissioning out-of-hours is official Conservative party policy and a Pulse poll this week shows a surprising 56% of GPs would support the move – although only 31% would actually be prepared to take on commissioning responsibility themselves.

Dr Krishna Korlipara, founder of the now-defunct National Association of GP Co-operatives, believes a return may very much be on the cards.

‘Some GPs may think it is a poisoned chalice to take back out-of-hours, but taking back responsibility does not hark back to the days where each individual doctor had to work every night.

‘Once GPs do not feel they are in the driving seat, and that standards are going to slip, the lack of confidence of the public in the system will persuade the Government that there is no alternative other than to give doctors responsibility for the standards of care provided to patients. There's no alternative.'

GPs who hoped they had shed responsibility for out-of-hours for good may have to think again.

What does the future hold for out of hours? Changing face of out-of-hours care

of PCTs employing not-for-profit organisations

employing private providers

employing PCT provider arms/NHS bodies

employing GP co-operatives

Source: FOI survey of PCTs

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