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What practices should be doing right now about out-of-hours

Under the new GMS contract, all GPs except those in extreme rural and remote areas can opt out of out-of-hours care for their patients from January 1, 2005. Indeed, where it can be agreed locally with the PCO, practices can opt out from April 1 next year.

After this the PCO will be responsible for providing or securing out-of-hours services for primary care.

Out-of-hours is defined as after 6.30pm and before 8am weekdays and all day weekends and bank holidays. It could be argued that this is the most radical change in British general practice since the foundation of the NHS. It was probably the single most important factor in securing GPs' votes for the new contract, and of course it applies to PMS GPs as well as GMS.

It was seen as a necessary step to attract to general practice a generation of doctors who are unwilling to take on 24/7 care in their contracts.

This reflects the increasingly female and part-time make up of the GP workforce.

Key considerations

Opt-out of out-of-hours must occur at practice level, so it must be the partners who decide what action to take. If practices choose to keep their out-of-hours commitment they will have to satisfy stringent national standards for call answering and audit. This means it will be very difficult for practices to achieve this without using co operatives or commercial organisations to assist them.

What an opt-out will cost

The cost of opting out will be 6 per cent of the global sum or MPIG for GMS practices, but practices will not know this as a true cost until the final global sums are agreed ­possibly in July next year. Indicative global sums will be available as a good guide in January 2004.

For PMS practices this will be an equivalent cost of about £6,000 per partner, but final details on this calculation have yet to be announced. A possible date mentioned is later this month.

What should practices be doing?

As a practice, you should immediately discuss as partners your intentions and establish what everybody wants to do. You should find out how critical loss of income is to individuals. You should then try to establish a consensus decision on opting out.

Having done this, inform your PCO of your intentions 'without prejudice' to help its planning. Remember PCOs will be responsible for out-of-hours after December 31, 2004.

You cannot be expected to make a final decision until you know the definite cost but you can decide to go 'on spec' and opt out early.

You should certainly talk to your PCO. Ask whether it might they be ready to accept responsibility for out-of-hours before the end of 2004. It will need your help to achieve this, so see if you can make it happen.

You should check with any current provider what its intentions are. Check too that it will continue to assist you up to the end of December next year.

This is what you should do immediately. During the period from next month to March 2004 you should look at the cost implications for partners and at how much you might regain from other financial streams, for example the quality framework or enhanced services or additional services.

You should project an income and expenditure stream for 2004/5 and beyond.

You should explore possibilities of earning money working for an out-of-hours provider in future (and remember this will be superannuable).

You should remember ­ although it is likely there will be plenty of work here ­ that this work is not guaranteed and may change in the future. Aim to at least break even after opting out. You should then prepare your practice for the opt-out (see table on the left).

What if you choose to opt in?

If you choose to opt in, talk to your PCO and make sure you understand the accreditation requirements. Also be sure you will fulfill them. In most cases a co-op arrangement will be needed.

Think about whether you will attract

new partners in the future if you decide to

opt in!

Community hospital cover

This is a separate contract you hold and you have no similar right to opt out except by terminating the contract.

The PCO could feasibly commission all the hospital cover from another provider if you do this.

Talk to your PCT early and find win/win solutions. In most cases the new out-of-hours service can cover this too but the PCO will want to claw money back to cover the cost.

You should also negotiate and involve your local LMC.

Who will provide out-of-hours

care in future?

 · Practices by themselves, but probably only in extremely remote areas

 · Co-ops ­ run by practices that choose to

opt in

 · PCOs may provide them directly

 · Commercial organisations

 · Public bodies (for example former co-ops run by GPs)

There will be an open tendering process for these bodies to provide services but co-ops may be given some preferential treatmentt in the short-term to ensure continuous cover.

Remember if you are unsure what to do look to your local LMC and PCO and check out the BMA website

Preparing your practice for opt-out

Remember to discuss with all the staff the fact that you are opting out. They may not realise what your intentions are. You should then:

 · Inform your patients of your intentions well in advance. You should do this by newsletter, surgery notices and so on. Patients do

need to know.

 · Consider altering your opening hours to match national definition.

 · Consider stopping Saturday surgeries in advance so that not all changes happen at once. Discuss this with your PCO and out-of-hours provider.

 · Think about whether you wish to offer a personal service for terminal patients.

 · Establish good systems for sharing information both ways with out-of-hours provider.

What practices should do right now

 · Discuss your intentions as partners

 · Find out how critical loss of income is to individuals.

 · Inform your PCO of your intentions

 · Decide whether you want to go 'on spec' and opt out early

 · Talk to your PCO ­ ask whether it might be ready to accept responsibility before the

end of 2004

 · Check with any current provider what its intentions are

What practices should do from

next month to March 2004

 · Look at cost implications for partners

 · Check how much you might regain from

other financial streams such as quality framework, enhanced services or

additional services

 · Project an income and expenditure stream for 2004/5 and beyond

 · Explore possibilities of earning money working for an out-of-hours provider in future

 · Remember this work is not guaranteed and may change in future

 · Aim to at least break even after opting out

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