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GP out-of-hours services ‘in fragile state’, finds NHS watchdog

A lack of available workforce means GP out-of-hours services are ‘fragile’ across the whole of Wales, a review has found.

In response, an NHS watchdog has recommended changes to GP pay structures and a relaxing of performers list regulations.

There is an increasing demand for out-of-hours services – particularly when patients struggle to get an in-hours appointment – but there are not enough GPs to deliver the service, the review by the Board of Community Health Councils found.

The board, which is the independent oversight body for NHS quality in Wales, said this was the case in all seven health board areas.

The review of health board reports, launched amid concerns raised by members, found that in most cases there were not enough GPs to deliver the service consistently because of GP shortages and changes to the tax system for those who did work shifts.

The report found health boards had taken a number of steps to address the problem including increasing use of other healthcare staff, offering bonuses and one-off payments to encourage GPs to take up shifts and introducing contracts which allowed GPs to do phone assessment from their own homes.

It also welcomed the Welsh NHS 111 service, which was trialled in two pilot areas before the announcement in April that it would be rolled out nationwide over three years.

But the report said: ‘Despite taking a range of actions to address the challenges, health boards have not made any significant and sustained progress and the situation across Wales remains fragile.

‘The proportion of GPs in any area who undertake out-of-hours shifts remains small. Further, in some cases, the actions identified risk shifting the problem to other NHS services or other geographical areas.

‘The solution lies in the NHS in Wales working together to improve GP out-of-hours services in a way that responds to what [is] important to people.’

The Board recommended agreements should be put in place on how GPs are paid to provide out-of-hours services to avoid competition between geographical areas.

And to review the management of the Medical Performers list to enable GPs from England to work in Wales with minimum delay.

In January a BMA Wales survey found exhaustion was the main reason GPs did not sign up for out-of-hours shifts.

Mutale Merrill, chair of the Board of CHCs said that ‘during 2017/18 CHCs across Wales became concerned about the increasing fragility of GP services provided “out of hours” through our continuous engagement with health boards’.

She added: ‘CHCs are concerned that sometimes the actions taken to address one problem can have a negative impact on other services and other geographical areas. We believe the solution lies in the NHS in Wales working together to deliver GP out-of-hours services in a way that responds to what’s important to people.’

The Welsh Government said many of the recommendations, including more regional working and moving from a GP out-of-hours service to a primary care out-of-hours service, making use of a wider range of healthcare staff, were already being put in place.

Dr Charlotte Jones, chair of the BMA Wales GP committee said the report affirmed what they had been saying about out-of-hours pressure for a long time.

She said: ‘The pressure has been brought out by an increase by an increase in workload from a variety of sources and inadequate resources due to years of underinvestment in both the service and workforce.

‘We know that there have been instances in parts of Wales this year where services have been inadequately staffed, or in some cases not staffed at all.’

She added they had put forward a range of solutions to the Government and health boards which need to be implemented urgently for services to be safe and sustainable.

Dr Jane Fenton-May, RCGP Wales vice-chair, said the College had also consistently highlighted this fragility.

She said: ‘It is a symptom of wider workforce shortages but there are also issues very particular to out of hours services.’

She added that measures which should be looked at include a clearer governance framework to help ensure clinicians are comfortable working in these services.

She said: ‘GPs are going above and beyond in difficult circumstances; at present workforce pressures can lead to difficulties in handovers and questions about safety.

‘We need significant improvements in out of hours services to ensure GPs are happy working in them and patients get the round the clock care they need.’