As this week's leaked report clearly illustrates, handing responsibility for out-of-hours care over to PCTs was never going to work. It's time the system was sorted out once and for all
What goes up must come down. So it is with tennis balls and interest rates, so also with the costs of NHS management. The salary costs of NHS managers have been under the microscope ever since Pulse revealed they had increased by 25% in just two years, and over the last week the first trusts were set targets to bring them right back down again, by a similar amount.
But the prospect of job losses isn't the only reason why it hasn't been the best of weeks to be a PCT manager. It wasn't just the vast increase in salary costs that so annoyed GPs, but the fact that the increase has done so little to strengthen the ability of trusts to commission care effectively. Vascular screening – hotchpotch mess that it is – provides one vivid illustration of how PCT-delivered schemes can go askew. Last week's report by MPs on chlamydia testing provided another, making clear they regarded trusts as simply not up to the job of delivering a national screening programme.
If PCTs can't persuade young men and women to urinate in a pot when required, they were always going to struggle when faced with the infinitely more complicated challenge of delivering a GP out-of-hours service. And struggle they have – as the report leaked to Pulse on safety concerns at the West Yorkshire Urgent Care Service is just the latest to illustrate.
In fairness to PCTs, the job they were handed after the 2004 opt-out was not an easy one. Trusts didn't have the money to do the job properly, with the Government grossly underestimating the true value of the service GPs had been providing. Managers have also had to cope with a primary care landscape the Government has made ever more complex and fragmented. GP out-of-hours services compete not only with A&E, as they always have, but also NHS Direct, extended hours, walk-in centres, urgent care centres, Darzi centres and doubtless other kinds of centres besides. It is not only patients who are confused about who should access what kind of service when.
That fragmentation is one of the key messages to come out of the West Yorkshire report, which details a service split between NHS Direct, not-for-profit organisation Local Care Direct and private firm Care UK. Such complexity brings communication problems, and it is these that have been implicated in previous out-of-hours tragedies, such as the death of Penny Campbell in 2006. There is a sense PCTs are simply too distant from delivery of care on the ground to manage the contracts of out-of-hours providers and ensure they communicate with each other effectively. So it is hardly surprising politicians are asking whether GPs would be better placed to do the job.
GP opinion remains split, but it is most probably time to accept the return of some responsibility for out-of-hours is inevitable. But it is essential that responsibility is transferred only for commissioning, not for provision, so doctors never again have to face a working day after a night spent on call. Out-of-hours care must receive the funding it requires for delivery of a safe service, so GPs are not left desperately trying to plug the funding gap. And finally, the Government must tackle the muddle of urgent care provision, not only with a single phone number, but with clear guidance demarcating the responsibilities of different providers.
Then, and only then, it will be right for commissioning of out-of-hours to return to GPs. Responsibility must lie with a profession capable of shouldering it.
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