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Should GPs commission out-of-hours services?

GPs on the front-line are much better placed than PCTs to monitor out-of-hours care, argues Dr Charles Alessi. But Dr Ravi Mene disagrees, warning that if GPs take back out-of-hours it is bound to be underfunded.

Change is inevitable, growth is intentional... without doubt, the NHS is coming to terms with the fact that change is inevitable. We remain poised on the brink of a further acceleration of the pace of change. But then, growth requires change and involves risk - stepping from the known to the unknown.

The NHS has not stood still since the early nineties - but the pace and scale of change that is now being attempted goes far beyond what had been attempted before. The significant efforts being made to downsize the role played by acute hospitals and transform the district general hospitals to intermediate care community hospitals will combine primary, community and the less specialised aspects of acute care in one setting.

Access to urgent care is also in the process of transition, with a need for the multiplicity of access points to care to begin to converge. At present patients can access care via traditional out-of-hours GP services, accident and emergency, GP-led health centres, walk-in and urgent care centres. Clearly this is unsustainable. The multiplicity of these routes of entry with separate funding streams may well be economically unsustainable in the new environment of cost containment.

A further fundamental change which makes the input of primary care in out-of-hours services compelling lies with the development of polysystems. There is renewed urgency to ensure that leverage by GPs in commissioning is increased and made much more robust. A new world is emerging where primary care is expected to be more consistent in the way it offers services to patients and more predictable in the quality it offers.

There is also the near certainty that hard budgets for polysystems will become a reality - likely to happen sooner than many anticipate. If the patients of polysystems are going to benefit and general practice is going to be engaged, there seems to be no option but for practices to be the prime commissioner of out-of-hours services, given it is their money that is being spent in their operation and that if any efficiencies are to be realised it is to their populations that these will accrue.

So how to move from where we are now to where we need to be? Some practices have made a choice and opted out of the provision of out-of-hours services, giving the responsibility to PCTs to manage this aspect of patients care. There certainly seemed at the time to be minimal financial disadvantage to practices in doing so, as well as major reductions in risk and workload.

But it is now becoming clearer that primary care is much better placed to a more distant PCT to commission and manage these services. The role of PCTs needs to evolve into one where they need to ensure the services are delivered to a consistent and high-quality standard. Their role should be limited to performance-managing polysystems, which then commission services.

There is further change in the offing, which may make GP input in commissioning of out-of-hours services even more compelling. The new primary care choice agenda, with the potential for patients to have access to multiple entry points into primary care services, is a significant structural challenge. The potential exists for significant medico-legal risks, which need to be actively managed. Sharing of the care record is likely to be fundamental both in and out of hours, if risk is going to be managed effectively. How can we achieve all this without GPs taking a role in the commissioning and performance-management of out of hours care?

Dr Charles Alessi is a GP in Kingston upon Thames, Surrey, and medical director of the Kingston Co-operative Initiative

When the handover of responsibility for out-of-hours care was agreed with the Government of the time, it had broad support supported among all parties, although there were some exceptions even at that time who argued that it was our responsibility to provide out-of-hours cover. Some indeed continued to do so.

The Department of Health then started raising the quality thresholds to nudge out these providers, with the process of gaining approval for out-of-hours services increasingly becoming a tick-box exercise. The co-operatives were priced out of the game, and more and more private providers muscled in with the offer of a cheaper service – to the joy of PCT managers.

The rules of the game changed to suit the managers. The calls were screened and the decision to visit was taken from a remote place by anonymous people who did not even know the geography of the area. We had to part with £6K for no longer providing the service and responsibility was with PCTs. They soon realised it was not easy to provide the service with skeleton staff. If we had taken some of the decisions they make not to visit (triaging, as it is now known) we would have been hauled in front of the disciplinary panel. Now, staff are covered by the Government indemnity scheme, no one is responsible for their actions and every mistake is masked as a ‘significant event'.

Out-of-hours care was being run efficiently by GP co-ops, using local doctors who provided a local service for local people. This Government is hell-bent on destroying the ethos of primary care and has largely succeeded with the help of its friends in the media. Having made out-of-hours an emotive issue, ministers would no doubt like to pass it back to us.

Whether it will be backed by adequate financial resources is doubtful, however, given that the media has already softened public opinion by portraying GPs as fat cats doing no work. GP leaders have been ineffective in defending the hard work all of us do. If you say yes to Government requests, there is no guarantee that the pressure will cease.

If we were to be handed back the responsibility the round the clock care, we would be starting from scratch again, as most of the Co-op-type organisations have been extinct for several years. The organisation of an immensely complex service in a short time would be a big task. If we GPs accept the commissioning responsibility, mistakes are likely to happen in an underfunded service (which it will be) and this will give the politicians and the GP bashing media another stick to beat us with.

What guarantees would we need to take back out-of-hours? Would they reinstate the per visit fee as an item of service, or we will be expected to do on- call cover for a pittance, or commission it from others from our own pocket? This is anybody's guess in the current economic downturn. It is more than likely some of your funding will be based on patients' perception of how you respond to out of hours calls - a perfect ploy to obtain a service for free? The losers will be our patients, who will be left with an unsafe service in the name of an economy drive.

Dr Ravi Mene is a GP in Trafford, Manchester and a member of Salford and Trafford LMC.

Yes No Out-of-hours services have been under intense scrutiny recently