The Provision of Out-of-Hours Care in England

Transcription

1 The Provisio of Out-of-Hours Care i Eglad REPORT BY THE COMPTROLLER AND AUDITOR GENERAL HC 1041 Sessio May 2006

2 The Natioal Audit Office scrutiises public spedig o behalf of Parliamet. The Comptroller ad Auditor Geeral, Sir Joh Bour, is a Officer of the House of Commos. He is the head of the Natioal Audit Office, which employs some 800 staff. He, ad the Natioal Audit Office, are totally idepedet of Govermet. He certifies the accouts of all Govermet departmets ad a wide rage of other public sector bodies; ad he has statutory authority to report to Parliamet o the ecoomy, efficiecy ad effectiveess with which departmets ad other bodies have used their resources. Our work saves the taxpayer millios of pouds every year. At least 8 for every 1 spet ruig the Office.

3 The Provisio of Out-of-Hours Care i Eglad LONDON: The Statioery Office Ordered by the House of Commos to be prited o 2 May 2006 REPORT BY THE COMPTROLLER AND AUDITOR GENERAL HC 1041 Sessio May 2006

4 cotets summary 4 This report has bee prepared uder Sectio 6 of the Natioal Audit Act 1983 for presetatio to the House of Commos i accordace with Sectio 9 of the Act. Joh Bour Comptroller ad Auditor Geeral Natioal Audit Office 21 April 2006 The Natioal Audit Office study team cosisted of: Tom McDoald ad Shamail Ahmad, with assistace from Rebecca Lych, Naomi Lock ad Kaja Nithiaatha, uder the directio of Chris Shapcott This report ca be foud o the Natioal Audit Office web site at Part 1 The previous out-of-hours service 8 was usustaiable The Carso Review ad other strategic documets 9 set out a visio for chage A ew system of out-of-hours arragemets was 10 implemeted durig Part 2 There were some shortcomigs i the 12 commissioig process A lack of time ad expertise resulted i 13 patchy preparatios There were widespread problems with cotracts 14 Various factors udermied the rigours of 15 competitive tederig processes For further iformatio about the Natioal Audit Office please cotact: Natioal Audit Office Press Office Buckigham Palace Road Victoria Lodo SW1W 9SP Tel: equiries@ao.gsi.gov.uk Natioal Audit Office 2006

5 Part 3 Out-of-hours providers are begiig 18 to deliver a satisfactory stadard of service Access problems do ot seem to have 19 compromised safety Providers are ot meetig all the Quality 20 Requiremets yet, especially those relatig to speed of respose Patiet experiece is geerally good, but oe i 22 five are dissatisfied Maagemet iformatio is still poor 24 There is limited progress toward itegratio 25 with other services Part 4 Costs are higher tha aticipated 26 There were misuderstadigs about fudig, 27 i particular the 6,000 foregoe by GPs The Departmet made provisio of 322m to 28 reflect the kow costs of the existig service, but the costs of the ew service were higher Part 5 Commissioers are eterig ito 34 cotracts with multiple providers ad the market is maturig The provider market is diversifyig ad maturig 35 Case studies ad visits reveal much good practice 37 Commissioers are begiig to make 38 tough decisios Eglad performs well agaist UK ad 38 iteratioal comparisos Appedices 1 Methodology 39 2 Case Examples 41 3 Out-of-hours arragemets i 43 Scotlad, Wales ad Norther Irelad 4 Out-of-hours arragemets i Demark, 45 Netherlads, USA ad Australia 5 Quality Requiremets 47 Costs are 22 per cet higher overall 29 There is scope to reduce costs i future by up 30 to 134 millio GP pay rates remai the key driver of costs 32 Cover courtesy of Mary Evas/Roger Maye Photographs, iside photographs courtesy of Alamy.com ad

6 summary summary 1 Most primary medical care takes place durig the workig day, but patiets sometimes eed care at other times as well. Such care is kow as out-of-hours care, the term curretly beig used to describe the period from 6:30pm util 8:00am o weekdays, ad all weekeds, bak holidays ad public holidays. 2 Out-of-hours services have udergoe sigificat chage sice 2000, whe the Departmet of Health (the Departmet) commissioed a review of these services i order to cosider issues such as quality of care ad liks with wider NHS services. This review, kow as the Carso Review 1, made recommedatios which, combied with the NHS Pla, set the foudatios for curret out-of-hours services. 3 May Geeral Practitioers (GPs) had already used powers grated i the mid-1990s to delegate out-of hours provisio to a third party. However, a ew Geeral Medical Services (GMS) cotract came ito force i 2004, which allowed GPs to opt out of the resposibility of orgaisig out-of-hours care etirely from 1 April Where GPs opted out, they gave up a average of 6,000 per aum ad passed o resposibility to their Primary Care Trust (PCT). 4 This report examies whether the Departmet is o the right track towards providig high-quality out-of-hours services. Appedix 1 sets out our methodology. Our work has foud that: There were some shortcomigs i the iitial commissioig process because PCTs lacked experiece, time ad reliable maagemet data. There is also cofusio over whether out-of-hours services should be restricted to urget care. Out-of-hours providers are begiig to deliver a satisfactory stadard of service but most are ot yet meetig all the atioal Quality Requiremets, particularly o speed of respose. I a survey of PCTs we foud that the actual costs of providig out-of-hours are 392 millio, cosiderably more tha the 322 millio allocated by the Departmet. Commissioers are eterig ito cotracts with multiple providers ad the market is maturig. 1 Named after the review pael s Chairma, Dr David Carso, a GP, who was head of primary care strategy ad performace at East Lodo & the City Health Authority at the time of his appoitmet, ad who had already assisted the Departmet of Health with its reviews of GP pay ad GP postgraduate educatio. 4 The Provisio of Out-of-Hours Care i Eglad

7 summary 5 Our more detailed fidigs are as follows. There were some shortcomigs i the commissioig process 6 I 2005, may PCTs had ot previously maaged or delivered out-of-hours services ad so lacked both kowledge ad experiece i this area. There was little, if ay, reliable maagemet iformatio, for example o demad, activity ad cost. This shortfall i iformatio made it very difficult for PCTs to write service specificatios ad commissio effectively. Some PCTs were, ad remai, cofused as to whether the out-of-hours service should be restricted to urget care, or should respod to ay request for medical care from members of the public. I additio, may PCTs allowed isufficiet time for commissioig out-of-hours services, reducig the quality of the process. 7 May cotracts were siged late or ot at all, with sigificat legal implicatios. This was due to poor service specificatios, disagreemets betwee commissioers ad providers over risk-sharig, ad the iability to recocile PCTs limited budgets with providers estimated costs of meetig all the Quality Requiremets. Our survey of PCTs, carried out joitly with the Audit Commissio, foud that, where exteral providers deliver services, siged cotracts were i place i oly ie per cet of cases by the time the service bega. This icreased to 34 per cet by 30 September Whilst services cotiued to be provided despite the lack of siged cotracts, several providers told us that the lack of a formal cotractual agreemet forced them to carry extremely high operatioal ad legal risks. 8 Our survey foud that 39 per cet of PCTs ra a competitive tederig process to award a cotract. Those that did ot ofte cited departmetal guidace, which stated that there was o requiremet to udertake a formal teder exercise. Our survey foud that the more rural a PCT was, the less likely it was to have udertake formal teders. The lack of competitio from commercial providers i rural areas stems from the difficulty of achievig ecoomies of scale. However, overall we foud that services which had bee subject to a tederig process were o cheaper or better tha those which had ot. Out-of-hours providers are begiig to deliver a satisfactory stadard of service 9 Aecdotal evidece suggests that patiets suffered loger waits i at least 50 per cet of Eglad durig the first few days of the ew service, but there is o idicatio that safety was compromised. Providers are ot yet meetig all the Quality Requiremets, particularly o Saturday morigs whe demad peaks. Patiet surveys ru by PCTs show extremely high levels of satisfactio with the service provided. However, our survey of patiets views of out-of-hours ad other urget care services foud that they had had broadly good experieces, but oe i five were dissatisfied. This suggests that there may be shortcomigs i patiet experieces that are curretly ot beig captured by PCTs. The Provisio of Out-of-Hours Care i Eglad 5

8 summary 10 Despite upgrades ad improvemets to IT systems, maagemet iformatio is still poor, as demostrated by the difficulties PCTs experieced i obtaiig maagemet data to complete our survey. This is ot helped by iadequate call maagemet techology i some areas or difficulties i usig the Departmet s reportig template. There is also some cofusio over the defiitio of compliace with the Quality Requiremets, despite clear explaatios i the accompayig commetary. 11 Limited progress has bee made towards itegratio with other parts of the NHS, such as local Accidet & Emergecy Departmets ad ambulace services, but there are some idividual examples of strog efforts to joi up services. Further plaig ad commissioig of itegrated services should reduce duplicatio ad improve value for moey. Costs of providig out-of-hours services are higher tha aticipated 12 Prior to the coclusio of the ew GMS cotract egotiatios, the Departmet coducted a ecoomic aalysis of GP co-operatives to estimate the cost to GPs of providig the service ad arrived at a approximate average figure of 9,500 per GP. The outcome of the egotiatios for the ew GMS cotract was a agreed average opt-out figure of 6,000, although the precise amout for idividual GPs varied depedig o list size. The Departmet icreased its out-of-hours developmet fudig to aroud 3,500 per GP to help establish the ew service, givig a average total of 9,500 for every GP optig out. Some 90 per cet of GPs decided to opt out, i lie with what the Departmet told us were their expectatios. 13 The Departmet established a programme for PCTs to support the implemetatio of the ew out-of-hours arragemets. The programme set out the expected average cost - of 9,500 per GP to provide out-of-hours services usig the aalysis that was completed i advace of the ew GMS cotract egotiatios. The Departmet also explaied their resource support package, which totalled a average of 9,500 per GP. Despite this, some PCTs failed to uderstad that the 6,000 opt-out sum was ot iteded to represet the true cost of the service, which led to may uderestimatig their costs. Our survey foud that the actual costs of providig out-of-hours for , the first full year of the ew arragemets, were 392 millio, 22 per cet more tha the 322 millio allocated by the Departmet, ad a average of 13,000 per whole-time equivalet GP. 14 The above fudig gap may impact o ivestmet i out-of-hours ifrastructure ad staff traiig i the short term, but there is sigificat scope to reduce costs i future. Our aalysis idetified the best performig PCTs for each rural/urba classificatio i terms of quality levels ad cost per head. Bechmarkig PCTs i each category agaist the best suggested that if all PCTs matched the best, a savig of 134 millio could be achieved without compromisig quality. PCTs could make savigs through a umber of actios, icludig bechmarkig themselves agaist similar PCTs ad aalysig local demad patters to help patiets access the service more appropriately. Commissioers are eterig ito cotracts with multiple providers ad the market is maturig 15 There is ow a wide array of ew out-of-hours providers, icludig GP co-operatives, NHS Direct, PCTs themselves ad private sector compaies, ad it is commo for commissioers to eter ito cotracts with multiple providers to provide differet elemets of the service. 16 Whilst the GP-led model still predomiates i both PCT-provided ad commissioed services, we have see evidece of various differet models of skill mix, i.e. the employmet of health professioals other tha doctors i out-of-hours primary care. Providers tell us that chagig skill mix icreases the cost of the service i the short term, for example due to traiig costs, but savigs are expected to materialise i the loger term. May of the emergig staffig models are still quite small-scale ad it is ot yet clear how successful they will be i providig cost effective performace. Our survey aalysis foud that the most cost-effective models varied depedig o the rural classificatio of the PCT. 17 Providers are becomig more resposive to commissioers, who ow have better maagemet iformatio ad are takig decisios to pealise poor providers. Eglad compares well both withi the UK ad iteratioally i terms of service structure ad quality moitorig. 6 The Provisio of Out-of-Hours Care i Eglad

9 recommedatios 18 The Departmet should: Although PCTs have the primary resposibility for out-of-hours services, the Departmet should oetheless use all the levers at its disposal to ecourage PCTs to improve the cost-effectiveess of the service through bechmarkig of costs, improvemets to local commissioig processes, ad makig available traiig ad best practice. Esure that commissioers ad providers uderstad the Quality Requiremets ad that they are aware that full compliace is a average performace of 95 per cet rather tha 100 per cet, as set out i the Departmet s guidace. The Departmet should also clarify the term defiitive cliical assessmet ad cosider how to focus the Quality Requiremets further o quality ad patiet experiece. Provide adequate traiig to esure that providers ca use its reportig template effectively, ad work i partership with Adastra 2 to improve the maagemet iformatio which its various systems are producig to support performace maagemet. 19 PCTs should: Bechmark their costs agaist those of other geographically comparable PCTs to idetify areas for improvemet. Improve commissioers capacity i terms of writig service specificatios ad market maagemet i preparatio for subsequet rouds of commissioig. Esure that they uderstad local drivers of demad to see if they ca help patiets to access the service more appropriately. They should coduct a thorough aalysis of patiet flows ito all uscheduled care services i order to see the detail of case-mix ad socio-ecoomic groups usig the differet services. Esure that they, or their providers, improve the quality of their patiet questioaires ad make the most of best practice from pilot ad academic work to esure realistic patiet feedback. Use all the cotractual ad performace maagemet levers at their disposal to esure that they or their providers meet the access requiremets withi the atioal Quality Requiremets. 2 The mai commercial IT supplier for out-of-hours operatios. The Provisio of Out-of-Hours Care i Eglad

10 part oe Part oe The previous out-of-hours service was usustaiable The Provisio of Out-of-Hours Care i Eglad

11 part oe Before 2004, GPs were resposible for esurig the provisio of out-of-hours services, although this was mostly delegated to GP co-operatives or the private sector. I respose to public ad Ombudsma cocers, ad cocer at the impact of this resposibility o the recruitmet ad retetio of GPs, the Departmet commissioed a review of out-of-hours services i The review, kow as the Carso Review, ad the NHS Pla, helped set the foudatios for curret out-of-hours services, for which Primary Care Trusts are ow usually resposible. The Carso Review ad other strategic documets set out a visio for chage Before 2004 GPs were resposible for esurig the provisio of out-of-hours services for their patiets 1.1 Most primary medical care takes place durig the day, but prior to April 2004, Geeral Practitioers (GPs) also had a resposibility to provide urget medical care durig the out-of-hours period, which is ow defied as from 6:30 pm util 8:00 am o weekdays, ad all weekeds, bak holidays ad public holidays. Approximately ie millio patiets aually receive urget primary care out-of-hours i Eglad. 1.2 I recet decades, the resposibility for out-of-hours has become icreasigly upopular ad GPs have sought ways to reduce the burde of out-of-hours cover, while still dischargig their duty of care. Uder arragemets itroduced i 1995, the Departmet ecouraged GPs to co-operate more ad to focus o premises-based care i providig out-of-hours services. Apart from providig the service themselves, GPs could joi a practice rota or area co-operative, uder which they could pool their resposibility through a rota system. I additio, GPs could employ a commercial deputisig service. As a result, by the begiig of 2004, approximately 70 per cet of GPs had delegated the resposibility to a GP co-operative, ad aroud 25 per cet to a commercial provider. 1.3 These treds helped reduce the scale of GPs persoal ivolvemet but, oetheless, persoal resposibility for the service remaied upopular amog GPs, particularly amog the growig umbers of female GPs. The Departmet respoded to public, Ombudsma & media cocers 1.4 Uder the historic patter of provisio, either the public or the Departmet of Health (the Departmet) kew very much about the overall quality, costs or outcomes of out-of-hours provisio. However, there is aecdotal evidece that the quality of care varied cosiderably betwee differet provider types ad differet geographical areas, ad i early 2000, a risig umber of complaits ad egative reports i the media led the Health Service Commissioer (Ombudsma) to raise cocers about out-of-hours services with the Departmet. The Provisio of Out-of-Hours Care i Eglad

12 part oe 1.5 This evidece led the Departmet to coclude that the existig model of out-of-hours was ot sustaiable. As a result, i March 2000 the Departmet aouced a review of the arragemets for out-of-hours cover across Eglad. The aim of the review was to idetify ways of assurig quality ad to make recommedatios to improve services. The review was chaired by Dr. David Carso ad the Carso Review 3 was published i October The Carso Review made 22 recommedatios, which were all accepted i full by the Departmet. It idetified a future model of out-of-hours care i which Primary Care Trusts (PCTs) would develop a itegrated etwork of uscheduled care provisio, brigig together providers of out-of-hours services to work collaboratively with other health ad social care providers such as Accidet ad Emergecy departmets ad ambulace services. The review also idetified some core quality stadards, to which all out-of-hours services should be delivered i the future. Uder a ew accreditatio scheme, the Departmet requested that all providers of out-of-hours should achieve compliace with these stadards by March The stadards were reviewed i 2004 ad the re-cast as the Natioal Quality Requiremets from 1 Jauary The NHS Pla 4 was published mid-way through the work for the Carso Review, ad built o its prelimiary fidigs, whilst the 2001 report o Reformig Emergecy Care 5 helped clarify the Departmet s policy objectives for emergecy services operatig i the out-of-hours period. These three documets formed the backgroud to curret out-of-hours provisio. A ew system of out-of-hours arragemets was implemeted durig GPs were relieved of the obligatio to esure provisio of out-of-hours services 1.8 The ew Geeral Medical Services cotract was egotiated betwee the NHS Cofederatio (the NHS employer s orgaisatio) ad the Geeral Practitioers Committee (GPC) of the British Medical Associatio durig 2002 ad The Departmet acted as a observer. The ew cotract allowed GPs to opt out of resposibility for out-of-hours from 1 April 2004, at a average cost of 6,000 a year. Where GPs opted out, the resposibility for out-of-hours passed to the PCT with immediate effect, although PCTs who were uable to accept the resposibility could defer the trasfer. The fial deadlie for deferral was 1 Jauary PCTs were give the opportuity to re-desig services uder Shiftig the Balace of Power 1.9 I takig over resposibility for out-of-hours, PCTs were give the task of developig itegrated etworks of urget care services. The Departmet had bee workig with PCTs sice the publicatio of the Carso Review, with the aim of ecouragig them to use their icreased autoomy uder Shiftig the Balace of Power 6 to make the Carso Review s aspiratios of itegrated care a reality. The Carso Review also developed a support programme which icluded work with the Natioal Associatio of GP Co-operatives to idetify best practice, support for wider commissioig ad a Exemplar scheme which was desiged to help sites coverig aroud 20 per cet of the populatio of Eglad itegrate their services with NHS Direct. 3 Raisig Stadards for Patiets: New Parterships i Out-of-Hours Care. A Idepedet Review of GP Out-of-Hours Services i Eglad, The NHS Pla, Departmet of Health, Reformig Emergecy Care, Departmet of Health, Shiftig the Balace of Power withi the NHS, Departmet of Health, The Provisio of Out-of-Hours Care i Eglad

13 part oe 1.10 Followig publicatio of the ew GMS cotract, the Departmet issued guidace to PCTs to help them i commissioig out-of-hours services. The guidace provided for out-of-hours services to be delivered uder oe of four cotractual frameworks ad stipulated that: either GPs or PCTs would have resposibility for out of-hours, depedig o whether the GP opted out; i both cases, the service would either be delivered i-house or cotracted out to a exteral provider; ad resposibility for compliace with the Quality Requiremets 7 would remai with whoever was resposible for the out-of-hours services i.e. either the GP or the PCT The fial date for the trasfer of resposibility for out-of-hours services from GPs to PCTs was 1 Jauary By this poit the 90 per cet of GP practices which wished to trasfer had doe so. As at April 2005, the Departmet s uderstadig, based o data gathered from Strategic Health Authorities, was that some 75 per cet of service provisio was PCT-orgaised or cotracted through co-operatives of various types, with the remaiig 25 per cet provided by commercial providers, ambulace trusts ad others, with NHS Direct supplyig iitial call hadlig ad triage for may providers. 7 See Appedix 5 for the full set of Natioal Quality Requiremets. The Provisio of Out-of-Hours Care i Eglad 11

14 part two Part two There were some shortcomigs i the commissioig process 12 The Provisio of Out-of-Hours Care i Eglad

15 part two PCTs were ew to the resposibility of providig out-of-hours services. This lack of experiece, combied with a busy ageda ad poor maagemet iformatio o which to base commissioig decisios, reduced the quality of the process. Poor service specificatios, budget costraits ad disagreemets betwee commissioers ad providers over risk-sharig ofte resulted i services beig commissioed ad provided without a siged cotract i place. Commissioers did ot always ru competitive tederig processes ad competitio was ofte udermied by immature markets or commissioers prefereces for particular providers. A lack of time ad expertise resulted i patchy preparatios May PCTs took o a service for which there was little reliable data, which udermied specificatios 2.1 Because out-of-hours services were ot previously delivered or maaged by PCTs, they teded to kow relatively little about it. I a survey we coducted of PCTs 8 ad from visits to PCTs, we foud that 91 per cet of PCTs did coduct some aalysis of how the service was provided prior to hadover ad that 78 per cet coducted some form of eeds assessmet prior to specifyig a ew service. However, whilst may PCTs made efforts to gather what maagemet iformatio they could, whe we spoke to those who did, two thirds said that this iformatio was of poor quality or was simply ot available. I some cases, the lack of iformatio was due to providers reluctace to provide too much detail i case they were challeged to make savigs as a result. 2.2 Examples of where good data were uavailable iclude: records of demad data, such as case ad morbidity mix; records of activity levels, icludig for peak periods; ad operatig costs. Although the lack of good data was ot as problematic for PCTs who were takig a existig service i-house or commissioig from existig providers, it did make it difficult for ew providers ad commissioers to pla ew services. There was cofusio over whether the out of hours service should be restricted to urget care 2.3 May providers ad commissioers told us that there was ogoig cofusio about whether out-of-hours was supposed to be a urget or uscheduled care service, ad that the differece was ot merely liguistic. 8 Survey coducted i cojuctio with the Audit Commissio see Appedix 1 for more detail. The Provisio of Out-of-Hours Care i Eglad 13

16 part two 2.4 They explaied the differece as follows. A truly urget primary care service would likely treat patiets classified as either emergecy or urget ad all others would be asked to make a appoitmet to see a GP i hours the ext workig day. Demad would be cut ad providers could focus o meetig Quality Requiremets for patiets requirig advice or care withi short time frames. A uscheduled care service, however, would be more resposive to patiets ad would ot seek to restrict access, o matter how mior the ijury or illess. Sice access would be urestricted, this service could be more costly, but might provide more flexibility for patiets ad could iteract better with existig daytime primary care services by allowig cotiuity of care. 2.5 Commissioers ad providers would like the Departmet to decide which kid of service they should provide, as they feel that curretly they are providig a hybrid model, with resultig cofusio for commissioers, providers ad patiets. For example, we foud aecdotal evidece of patiets usig out-of-hours services for o urget purposes ad providers beig uwillig to tur them away i case they complaied. The recet primary care White Paper 9 does ot clarify whether out-of hours services should be urget or uscheduled. It does, however, put forward the possibility that out-of-hours providers could ru eveig surgeries ad take o booked appoitmets ad registered patiets, suggestig a move away from strictly urget care provisio. Some PCTs did ot leave eough time for the process 2.6 Durig 2004 PCTs had a extremely busy ageda. Alogside their core work of commissioig ad ruig a wide rage of care through primary ad secodary providers, they were also dealig with the ew Geeral Medical Services cotract, the Ageda for Chage programme, preparatios for Paymet by Results ad Patiet Choice, the itroductio of icreasig private sector provisio ad other major iitiatives. 2.7 May PCTs told us that these issues took priority over out-of-hours i terms of maagemet time ad attetio. As a result, some PCTs did ot leave eough time to pla ad commissio or provide what was for may a ew ad ukow service. This led to the rage of problems set out below, may of which reduced the quality of the commissioig process. The few PCTs who egaged early with GPs reaped beefits 2.8 It is clear from the evidece we gathered from providers ad commissioers that those few PCTs who had the foresight to egage early with their GP commuities reaped beefits i several ways. Hereford PCT (see Case Example 1, Appedix 2) was a example of a commissioer who saw the possibilities of improvig their out-of-hours service ad who egaged with GPs ad other providers early to good effect. Early egagemet with GPs ofte gave commissioers ad providers a better chace of keepig them ivolved i the provisio of the service. There were widespread problems with cotracts May cotracts were siged late or ot at all, with legal implicatios 2.9 Respodig to cocers raised by the Natioal Associatio of GP Co-operatives i Jauary 2005 that may cotracts had ot bee siged, the Departmet stated that this was ideed true for some PCTs. Cocered that, where this was the case, PCTs would have o cotractual levers to esure Quality Requiremets were beig met or to recocile difficulties with providers where o eforceable dispute procedures were i place, the Departmet therefore used its established performace maagemet route through the Recovery ad Support Uit ad Strategic Health Authorities to try ad esure that cotracts were i place. 9 Our Health, Our care, Our Say: a ew directio for commuity services, Departmet of Health, The Provisio of Out-of-Hours Care i Eglad

17 part two 2.10 However, our evidece below shows that this was ot wholly successful. Resposes to our survey suggest that, where exteral providers deliver services, siged cotracts were i place i oly ie per cet of cases i time for the service to begi. This figure icreased to 34 per cet by 30 September 2005, the date o which they submitted their returs to us Accordig to commissioers ad providers that we iterviewed, the two most commo reasos for the lack of siged cotracts were egotiatios over cost ad quality, ad situatios where PCTs were joitly commissioig i cosortia. The egotiatios over cost ad quality mostly reflected a iability to recocile a PCT s limited out of hours budget with the provider s estimates of ruig a service that would meet all the Quality Requiremets. I the other sceario, the mai difficulty was obtaiig timely ad co-ordiated decisios from all the relevat committees i the cosortium Several providers told us that the lack of cotract sigatures meat that they had to carry extremely high operatioal ad legal risks, eve if there was a heads of agreemet or some other temporary arragemet i place. They also stated that they felt compelled to ru the service, eve where cotracts had ot bee siged, i order ot to go bakrupt or fall out of favour with their commissioers. Various factors udermied the rigours of competitive tederig processes Markets were ot mature i some places so competitio was difficult 2.13 The legacy of previous out-of-hours services ad the geographical differeces betwee various PCT areas meat that it was more difficult to hold a competitive tederig process i some areas tha i others. For example, rural areas may i the past have had a GP co operative made up of local doctors which might ot be easily replaced with a ew provider, sice the latter might fid it harder to cover a wide area at a similar cost Eve i urba or semi-urba areas, it was ot ecessarily possible to hold competitive tederig processes, sice may providers were amalgamatig, dissolvig or re-cosiderig their market positio ad might ot have wated to bid for a particular cotract Departmetal guidace o implemetig the ew GMS cotract stated that udertakig a formal teder exercise was ot compulsory uder Europea public procuremet rules. The guidace also left the fial decisio to PCTs as to what the best process might be. Our survey foud that 39 per cet of PCTs ra a competitive tederig process i order to award a cotract. The remaiig 61 per cet did ot for a variety of reasos. Some did ot teder because they did ot have sufficiet time to do so; others because they had a preferred provider i mid; ad the remaider because they wished to provide the service i-house. Sice the majority of PCTs did ot ivite other providers to bid for a cotract, they did ot kow if they struck the best deal O the basis of resposes to our survey, for each PCT we calculated the umber of quality poits achieved per poud spet. Quality poits were awarded for each quality requiremet, or part thereof, that the PCT stated it was meetig. A maximum of 23 poits were available. Figure 1 overleaf shows PCTs quality scores agaist their cost per head for services which were put out to teder ad Figure 2 overleaf shows PCTs quality scores agaist their cost per head which were ot put out to teder. They suggest that there is o correlatio betwee cost ad quality i either case Our survey foud that the more rural the PCT, the fewer cotracts were put out to teder. Of all the cotracts etered ito by PCTs classed as Major Urba (see paragraph 4.18), 70 per cet were awarded followig a formal teder exercise, compared with oly eight per cet of PCTs classed as the most rural. This ca be attributed to the lack of competitio i rural areas due to the relative difficulty i providig a cheaper service tha the oe (usually a GP co-operative) previously i place. Rural PCTs had a much higher cost per head. However this was ot due to the lack of tederig. Lookig at all PCTs who tedered for the service, their average cost was 8.65 per head. This was oly 0.29 per head cheaper tha those who were selected without a teder. The Provisio of Out-of-Hours Care i Eglad 15

18 part two 1 Relatioship of quality scores agaist cost per head for out-of-hours services which were put out to teder. The graph shows o correlatio betwee cost ad quality. 2 Relatioship of quality scores agaist cost per head for out-of-hours services which were ot put out to teder. As i Figure 1, the graph shows o correlatio betwee cost ad quality. Actual cost per head ( ) 20 Actual cost per head ( ) Quality score Quality score Source: Natioal Audit Office Source: Natioal Audit Office 2.18 I terms of average quality scores, there was o variace at all, with both types of provider averagig a score of 10.9 (out of a maximum 23 poits 10 ). This demostrates that a competitive tederig process would ot automatically have helped commissioers strike a better deal with providers i this first roud of commissioig. Some PCTs chose preferred providers or took existig services i-house to deliver quickly but there were some possible coflicts of iterest 2.19 Although a competitive tederig process was ot always ecessary to select the best provider, its absece, or ieffectiveess, sometimes udermied the ew service. Where PCTs did ru competitive tederig processes, we foud some evidece of possible coflicts of iterest which may have udermied those processes. For example, i respose to our survey, 16 per cet of PCTs recogised there had bee a coflict of iterest betwee people resposible for orgaisig the tederig process ad those providig the services I may cases PCTs kew little about the service they were commissioig ad so aturally sought help from those who did. Ufortuately this meat that i some cases the proper separatio which should have existed betwee commissioig ad providig fuctios was breached. We foud isolated examples of: cotract specificatios ad prices beig draw up by providers, who were the awarded the cotracts virtually uchalleged; i 64 per cet of resposes to our PCT survey, the provider gave assistace i drawig up the service specificatio; ad provider staff also sittig o PCT boards or Professioal Executive Committees, which awarded cotracts to their ow orgaisatios While it was uderstadable for commissioers dealig with a ew service to seek advice from those with the expertise, they will have to esure that stricter ad more trasparet processes are followed i future i order to avoid legal challeges from usuccessful bidders ad to protect value for moey. 10 What looks like a low score for average performace ca be partly explaied by PCTs mistake uderstadig that compliace must be 100 per cet. If judged agaist the Departmet s actual compliace level of 95 per cet, some of the scores would be higher. 16 The Provisio of Out-of-Hours Care i Eglad

19 part two The Provisio of Out-of-Hours Care i Eglad 17

20 part three Part three Out-of-hours providers are begiig to deliver a satisfactory stadard of service 18 The Provisio of Out-of-Hours Care i Eglad

21 part three Serious access problems occurred durig the hadover of out-of-hours services, but there is o evidece that safety was compromised. Service has improved, but the vast majority of providers are ot yet meetig all the ew Quality Requiremets. Patiet experiece has geerally bee good, but oe i five are dissatisfied. The mai commercial IT supplier for out-of-hours, Adastra, has made upgrades ad improvemets to IT systems, but maagers ability to produce high quality iformatio is still poor, as demostrated by the difficulties PCTs experieced i obtaiig data to complete our survey. There has bee limited progress towards itegratio with other services, but there are some idividual examples of strog efforts to joi up services. Access problems do ot seem to have compromised safety Patiets i may areas suffered log waits durig the hadover period 3.1 Although some services were haded over to ew providers i the autum of 2004, may ew services bega at the begiig of This had the disadvatage of testig ew services durig a period of high demad which icluded public holidays (whe ormal i-hours GP cover would be limited) ad cold weather. The Departmet told us that it had shared the cocer of a umber of PCTs that delays ad cofusio durig the hadover period might lead to large umbers of adverse patiet icidets. 3.2 Our discussios with providers ad commissioers revealed that some patiets did i fact suffer log waits durig the first few days of the ew service. At least 50 per cet of providers we spoke to about the hadover struggled to meet the Quality Requiremets o access times. However, their view was that there was o evidece that these delays resulted i adverse patiet icidets. Furthermore, they did ot subsequetly receive sigificat umbers of patiet complaits, although they did ackowledge that patiets who were uable to access their services might have goe elsewhere i the NHS for treatmet ad therefore remaied urecorded. 3.3 Specific difficulties reported durig the hadover period icluded: delays for patiets accessig Saturday morig services, because a lack of data or lack of plaig had left providers poorly prepared for those sessios. The Departmet s view was that a large umber of PCTs had failed to iform the public adequately about the chage i Saturday morig provisio; mixed results for public egagemet. I some cases, local publicity campaigs had successfully reassured ad educated patiets about how to access local services. I other cases, similar kids of campaigs simply icreased demad by raisig awareess of the service; delays i respodig to telephoe calls led to patiets makig repeat calls ad further blockig the system; ad widespread difficulties i meetig access targets set out by the Quality Requiremets. This was eve more challegig for those providers who had ot yet istalled call maagemet equipmet. The Provisio of Out-of-Hours Care i Eglad 19

22 part three Providers are ot meetig all the Quality Requiremets yet, especially those relatig to speed of respose The situatio is a great improvemet from prior arragemets 3.4 Sice 1 Jauary 2005, out-of-hours providers have had to meet the atioal Quality Requiremets as a cotractual obligatio (See Appedix 5 for a full list of the Quality Requiremets). Virtually all providers ad commissioers that we iterviewed agreed that the curret set of Quality Requiremets was better tha its predecessors, helped them to assess performace over time ad was focused o the right elemets of the service. 3.5 However, may also said that real improvemets could, ad should, be made to the Quality Requiremets. There was geeral agreemet from our meetigs ad from our expert pael that further work should be udertake to measure the quality of service delivered to the patiet. Our iterviewees recogised that this would be challegig ad would require a mixture of umerical ad softer, qualitative aalysis, but that this should be the focus for future improvemets to the Quality Requiremets. 3.6 There is, however, some ucertaity as to what is curretly required, despite clear defiitios i the Departmet s guidace o the Quality Requiremets ad their performace maagemet. I this guidace, the Departmet states that providers should aim to be 100 per cet compliat with the Quality Requiremets. However, the guidace also says that average performace of 95 per cet ad above would i fact represet full compliace ad that average performace of betwee 90 per cet ad 94.9 per cet would represet partial compliace. 3.7 Our meetigs with providers ad commissioers revealed some cofusio i this area. Aroud 80 per cet of those we spoke to about the Quality Requiremets believed that they should be aimig for 100 per cet compliace with all the Requiremets ad they did ot seem to be aware of the Departmet s more uaced view of performace. This has i tur led to argumets about acceptable levels of performace, particularly where the service is the subject of a formal cotract. Some providers have oted that if they meet a particular stadard 98 per cet of the time for a give period, they will be deemed as ot havig met it ad ca be pealised, especially if the PCT is takig a rigid approach to performace maagemet. The provider s view i this kid of case seems closer to the Departmet s guidace i allowig for variatio with reasoable bouds. Whatever the merits of idividual situatios, it is clear that there is some cofusio here which requires clarificatio. 3.8 Aother area of cofusio which emerged durig our meetigs was the defiitio of defiitive cliical assessmet. We foud that some providers recorded their performace agaist Quality Requiremets differetly to others, meaig that some patiets are beig give lower stadards of care tha others. For example, where oe provider might regard the decisio to refer a patiet o to a doctor as defiitive cliical assessmet, aother would regard the subsequet coversatio betwee doctor ad patiet as beig the defiitive assessmet poit. 3.9 The Royal College of Geeral Practitioers told us that it was cocered about the quality of out-of-hours care, particularly where a service is delivered by a umber of providers ad also i relatio to the traiig ad accreditatio of health care professioals other tha GPs. The College was cocered that Quality Requiremets were ot adequately moitored or eforced. Oe area of particular cocer was Quality Requiremet 11, where the College felt it was particularly importat for patiets to have access to a GP where cliically appropriate. The College also oted that traiig for GP Registrars i urget care was essetial ad that all GPs should be competet i this area of medicie. 20 The Provisio of Out-of-Hours Care i Eglad

23 part three Performace agaist the Quality Requiremets is patchy 3.10 Our detailed aalysis of PCT resposes to our survey reveals some good performace, but also some iterestig shortfalls i performace. Figure 3 sets out PCTs overall performace agaist 100 per cet compliace with the Quality Requiremets. Clearly, Quality Requiremets 8, 9, 10 ad 12, which set out a series of targets for telephoe ad face-to-face access, are the most challegig to meet. This data is supported by fidigs from our iterviews ad expert pael Performace agaist some of the more importat Quality Requiremets are as follows. 94 per cet of respodets said they esured that their provider reported to them regularly o performace, i.e. weekly, mothly or quarterly (Quality Requiremet 1). However, 39 per cet of respodets stated that they were able to sed details of all cosultatios to the patiets registered practices by 8am the followig day (Quality Requiremet 2). 3 Performace of PCTs agaist Natioal Quality Requiremets Quality Requiremets (See Appedix 5 for further detail) Percetage of PCTs Meetig Each Requiremet 1 Providers report regularly to PCTs 94 2 Providers sed details of all cosultatios to the patiet s practice by 8am 39 3 Providers have systems i place to support the exchage of iformatio 97 4a Providers regularly audit patiet cotacts 82 4b The audit reports (4a) are made available to PCTs 60 5 Providers regularly audit patiet experieces 82 6 Providers operate a complaits procedure cosistet with that of the NHS 99 7 Providers demostrate a ability to match capacity to demad 94 8a No more tha 0.1% of calls are egaged 50 8b No more tha 5% of calls are abadoed 27 8c Calls aswered withi 60 secods of the ed of the itroductory message 2 8d Where there is o itroductory message, all calls aswered withi 30 secods 5 9a Start defiitive cliical assessmet for urget calls withi 20 miutes of call 8 9b Start defiitive cliical assessmet for all other calls withi 60 miutes of call 9 9c No prioritisatio system - start defiitive cliical assessmet withi 20 miutes of call 13 10a Start defiitive cliical assessmet for urget patiets withi 20 miutes of arrival 23 10b Start defiitive cliical assessmet for all other patiets withi 60 miutes of arrival 19 10c No prioritisatio system - start defiitive cliical assessmet withi 20 miutes of patiet arrival GP is available where a cosultatio is cliically appropriate 98 12a Emergecy face-to-face cosultatio at the cetre withi 1 hour 15 12b Urget face-to-face cosultatio at the cetre withi 2 hours 15 12c Less urget face-to-face cosultatio at the cetre withi 6 hours 24 12d Emergecy face-to-face cosultatio at patiet s home withi 1 hour 21 12e Urget face-to-face cosultatio at patiet s home withi 2 hours 13 12f Less urget face-to-face cosultatio at patiet s home withi 6 hours Iterpretatio service provided withi 15 miutes of iitial cotact 96 Source: Natioal Audit Office The Provisio of Out-of-Hours Care i Eglad 21

24 part three 3.12 Eighty-two per cet of respodets reported that their provider regularly audited a radom sample of patiet cotacts ad took appropriate actio o the results, however oly 60 per cet of respodets had these reports made available to them (Quality Requiremet 4). Eighty-two per cet of respodets cofirmed that their provider regularly audited a radom sample of patiet experieces ad took appropriate actio o the results (Quality Requiremet 5), whilst 99 per cet cofirmed that they have complaits procedures i place (Quality Requiremet 6) Fifty per cet of respodets met the Quality Requiremet for egaged calls (less tha 0.1 per cet of calls should be egaged) ad 27 per cet of respodets met the Quality Requiremet for abadoed calls (less tha five per cet of calls should be abadoed). Two per cet of respodets aswered calls withi 60 secods of the itroductory message fiishig, if they had a recorded message. This rose to five per cet for calls which had to be aswered withi 30 secods (i the absece of a recorded message). These low scores agaist the telephoe-related targets of Quality Requiremet 8 may be explaied partly by the demadig ature of the targets ad partly by some istaces of providers simply lackig the call maagemet techology with which to measure it Just uder 10 per cet of respodets fully met the targets for telephoe cliical assessmet (Quality Requiremet 9), whilst just over 20 per cet of respodets met the targets for face to face cliical assessmet (Quality Requiremet 10). The resposes for face to face cosultatios were margially better for home visits (a average of 19 per cet across the three classificatios) tha for primary care cetres (a average of 18 per cet). Saturday morigs are particularly difficult 3.15 All providers agreed that demad was particularly strog o Saturday morigs ad that it was frequetly difficult to meet the access targets. May thought that Saturday morigs should ot have bee icluded i the out-of-hours period as defied by the ew GMS cotract ad that GPs should still coduct their ow Saturday morig surgeries. However, some PCTs have bee makig imagiative use of their commissioig optios to put alterative Saturday morig arragemets i place, as is illustrated by Case Example 2 (i Appedix 2) Quality Requiremet 7 relates to the provider s ability to meet service peaks such as Saturday morigs. It also metios Suday morigs ad Bak Holidays as other demad peaks ad may providers ad commissioers cofirmed to us that it was also difficult to meet the access targets o these days. However, providers also told us that they were already plaig for the Christmas holidays (i August ad September) ad felt much better placed to cope havig bee through oe Christmas/New Year period already. Patiet experiece is geerally good, but oe i five are dissatisfied Patiets had broadly good experieces across a represetative NAO survey sample 3.17 The Natioal Audit Office commissioed MORI to udertake a survey of the public to ascertai their views ad experieces of out-of-hours services. The objectives of the survey were to ascertai awareess ad usage of out-of-hours services ad to measure satisfactio with various aspects of the service. Further detail o the survey scope ad methods ca be foud i Appedix 1 ad the complete MORI report ca be foud at uk. Whe surveyig respodets, MORI did ot clarify what was meat by the term out-of-hours services ad it is therefore likely that, i at least some of their aswers, respodets are referrig to services other tha their GP-led out-of-hours service. Other services might iclude walk-i cetres or Accidet ad Emergecy departmets The survey foud that 81 per cet of respodets had ot tried to obtai out-of-hours medical care i the last six moths, either for themselves or someoe they were carig for. Of those that had tried, 12 per cet had doe so oce, four per cet had doe so twice ad the remaiig three per cet three or more times For the six-moth period covered by the survey, usage of out-of-hours care was more commo amogst some groups tha others, i particular: wome - 22 per cet of those questioed have used the service oce or more, compared to 19 per cet of respodets as a whole; those aged per cet have used the service oce or more; ad those with a child aged uder 16 i their household - 26 per cet had used the service. This icreased to 33 per cet for those with two or more childre. 22 The Provisio of Out-of-Hours Care i Eglad

25 part three 3.20 Those respodets who had ot required out of hours care were asked how they would go about tryig to obtai it if they did eed it. Just uder half (47 per cet) said that they would call their local GP surgery ad a further 13 per cet said that they would call NHS Direct. Other suggestios were: goig to Accidet ad Emergecy departmets (te per cet), callig a umber give by a GP surgery (seve per cet) ad callig 999 or callig the local hospital (four per cet each). These figures suggest that, eve people who have ot tried to access the service recetly, ad who may ot kow much about it, will ormally try ad telephoe before travellig somewhere Of the 19 per cet of respodets who had accessed some form of out-of-hours service, 44 per cet had i fact travelled somewhere to see a doctor or urse. 23 per cet had had a telephoe coversatio with a doctor, 18 per cet had had a telephoe coversatio with a urse, 13 per cet had received a home visit from a doctor ad two per cet had received a home visit from a urse Quality Requiremet 12 states that followig a defiitive cliical assessmet, face to face cosultatio should commece, either i a cetre or the patiet s place of residece withi oe hour for emergecies, two hours for urget cases ad six hours for less urget cases. Those respodets receivig home visits reported a wide rage of waitig times, with the mea legth of wait beig five hours ad 39 miutes. 61 per cet of respodets visited by a doctor or urse waited less tha two hours ad 40 per cet waited less tha oe hour (Figure 4). A small umber of respodets waited a extremely log time for their visits, although for some there were exteuatig circumstaces, such as patiets themselves requestig a delay I terms of satisfactio with the service, 63 per cet of users rate the quality of care as good or excellet. However, 19 per cet thik the quality of care is quite poor or very poor (Figure 6 overleaf). 4 Percetage of respodets Source: MORI poll for Natioal Audit Office 5 Waitig times to see a doctor or urse Less tha 1 hour 1 to 2 hours Percetage of respodets to 3 hours Time 3 to 4 hours 4 or more hours Waitig times for a doctor or urse to call back 3.23 Service users who had telephoe cotact oly with a doctor or urse (icludig NHS Direct) were asked how log it took before the healthcare professioal called them back. Quality Requiremet 9 states that defiitive cliical assessmet must start withi 20 miutes of a urget call beig aswered ad 60 miutes for all other calls. Where calls caot be safely ad effectively prioritised, the provider s target must be 20 miutes. Overall, our survey foud that two thirds (65 per cet) of respodets were called back withi 60 miutes ad 30 per cet withi 20 miutes (Figure 5). This leaves 35 per cet of all call-backs failig the quality requiremet, eve if the call is classed as o-urget Less tha10 miutes 10 to 20 miutes 20 to 30 miutes Time Source: MORI poll for Natioal Audit Office 30 miutes to a hour 1 to 2 hours 2 or more hours The Provisio of Out-of-Hours Care i Eglad 23

26 part three 6 Percetage of respodets Quality of out-of-hours care Excellet Good Fair Quite poor Quality Source: MORI poll for Natioal Audit Office Very poor 3.25 Most users appear satisfied with the advice they have received, with 72 per cet sayig that the advice was fairly good or excellet. Fiftee per cet said the advice made o differece whilst fewer tha oe i te thik the advice they received was wrog to some extet or totally wrog. Shortcomigs i patiet experieces from the NAO survey are ot mirrored by PCT views 3.26 Whilst our survey of patiet experieces paits a largely positive picture of out-of-hours services, it does reveal some dissatisfactio. However, PCTs views of patiet experieces are slightly differet. Both commissioers ad providers patiet experiece data show extremely high satisfactio ratigs i the various patiet surveys they have udertake. There seems therefore to be a discrepacy betwee what patiets have told us ad the messages service providers have received, suggestig that providers are curretly ot capturig egative feedback Oe reaso for this discrepacy might be that providers have bee cotiuig to record satisfactio levels (as required uder the old Quality Stadard), rather tha the actual patiet experiece, as the ew Quality Requiremet demads. Aother reaso might be that, for some questios at least, patiets i our survey were givig their views of both out-of-hours providers ad other services, as oted above. Maagemet iformatio is still poor Systems are gradually beig upgraded but it ca still be difficult to extract the required iformatio 3.28 Although IT systems i use at providers are beig upgraded ad improved, there are still a umber of specific areas that we idetified through our visits ad i discussio with Adastra, the mai commercial IT provider for out-of-hours, which make it difficult to extract the iformatio required for the purposes of effective maagemet. They are as follows: some providers report to a umber of differet commissioers, with differet degrees of detail or frequecy. This ca mea that, although they may ot possess advaced IT or aalytical fuctios, they have to sped large amouts of time tryig to cut their data i differet formats; while Adastra software is capable of producig good maagemet iformatio, it does deped o the provider uderstadig how to cofigure their database to eter relevat iformatio ad the doig so i a cosistet fashio; there are some difficulties i matchig local omeclature (activity types, priorities etc.) to commissioers reportig requiremets; where a call is first take by NHS Direct (ad the quality requiremet clock has started), but the haded o to a dedicated out-of-hours provider, the latter does ot ecessarily kow how log the patiet has already bee waitig. Not kowig whe the patiet first etered the system makes it difficult to tell whether or ot Quality Requiremets have bee met; reasoable ad routie exceptios to respose time stadards are curretly pealised. This would cover situatios where there is o-oe at home whe a call is retured, or where a caller elects to delay a appoitmet because they are waitig for childcare arragemets. Curretly these situatios are see as shortfalls i provider performace; 24 The Provisio of Out-of-Hours Care i Eglad

27 part three may providers complaied that the Departmet s ow reportig template, a electroic spreadsheet desiged to simplify the reportig process, was difficult to use. The view of our expert pael was that, although techical improvemets to the template could be made, the Departmet eeded to cosider further traiig for users; it is ot clear how robust local protocols for categorisig emergecy, urget ad other calls are. Work doe by the Healthcare Foudatio 11 has show cosiderable variace i both iitial categorisatio ad evetual outcomes which may have serious implicatios for patiet safety; ad a umber of providers have iadequate call maagemet techology. This meas that they are simply uable to report o those Quality Requiremets relatig to telephoe access. May PCTs had difficulty i sourcig basic data for our survey 3.29 It is revealig of the difficulties commissioers ad providers have with maagemet iformatio that may PCTs foud it difficult to gather meaigful data for our joit survey Respodets told us that they had particular difficulties where they commissioed from several differet providers. For example, where their iitial call hadlig ad their cosultatios were provided by two completely separate orgaisatios, commissioers struggled to amalgamate the two sets of data. I additio, where PCTs commissio i cosortia, they told us that it was ofte impossible to split out activity data or quality requiremet performace by PCT. The implicatio of this is that some PCTs may ot actually kow what level of service their ow patiets are receivig. There is limited progress toward itegratio with other services There are may idividual examples of efforts to joi up uscheduled care 3.31 As a result of the Carso Review s recommedatios ad Techical Liks programmes ru by the Departmet, there is ow a etwork of local commuicatios hubs across out-of-hours providers i Eglad, which is helpig to itegrate providers systems ad eable data sharig. I additio, providers i various parts of Eglad have bee developig more itegrated arragemets with other members of their emergecy care etworks We foud from our visits ad survey that oe model some providers use is to itroduce some form of physical itegratio with the Accidet ad Emergecy departmet. This could take the form simply of a GP sittig i a Accidet ad Emergecy departmet ad treatig those patiets who are ot acute or emergecy cases i order to reduce the flow ito the trust. A more developed versio of this is for the out-of-hours provider to build or lease cosultig rooms adjacet to Accidet ad Emergecy departmets i order to triage patiets requirig primary or o-emergecy care. These efforts do ot add up to full itegratio from the patiet s perspective yet 3.33 However, the umbers of PCTs ivolved i such arragemets are small. Most of these arragemets are still i their early stages ad do ot yet represet full itegratio from the patiet s perspective. This meas that the Carso Review s visio of a seamless care pathway iitiated by a sigle telephoe call has ot bee realised i most places ad that the pace of itegratio is slower tha the Departmet would have liked. As well as improvig the patiet s experiece, further plaig ad commissioig of itegrated services should reduce duplicatio ad improve value for moey. 11 The Healthcare Foudatio - a cosultig firm specialisig i best practice, leadership ad bechmarkig for primary ad commuity care providers. The Provisio of Out-of-Hours Care i Eglad 25

28 part four Part four Costs are higher tha aticipated 26 The Provisio of Out-of-Hours Care i Eglad

29 part four The iclusio of the out-of-hours opt-out i the ew GMS cotract cotributed to the success of the egotiatios. The 6,000 foregoe by GPs optig out of out-of-hours was close to the average cost to GPs from their icome, before accoutig for PCT out-of-hours developmet fuds. Usig ecoomic aalysis, the Departmet calculated the average cost of the existig service at 9,500 per GP, from a combiatio of out-of-hours ad GP fuds, ad esured that this resource was available to the service. However, may PCTs did ot uderstad this ad by basig the cost of out-of-hours o the 6,000 opt out sum, sigificatly uderestimated their costs. Our survey of PCTs foud that the cost of providig ew out-of-hours services is 22 per cet greater tha the combiatio of the fuds allocated by the Departmet ad those fuds give up by GPs. This may be due to a umber of factors, icludig the failure to geerate efficiecies, uderestimates of costs ad icreases i GP pay rates. However, there is sigificat scope to reduce costs i future commissioig rouds. There were misuderstadigs about fudig, i particular the 6,000 foregoe by GPs The Departmet wated to make geeral practice more attractive to doctors 4.1 Twety-four-hour patiet resposibility was deeply upopular amogst GPs ad the Departmet told us that it believed that the opportuity to opt out was a key lever i the egotiatio of the ew cotract. It also cosidered the wideig of the defiitio of the out-of-hours period to iclude Saturday morigs to be a attractive feature of the egotiatios for GPs. 4.2 The Royal College of Geeral Practitioers told us that they did ot collect data o the effect of the opt out o recruitmet ad retetio but that there was a widespread feelig of relief amog GPs that they o loger had a 24-hour cotractual resposibility. The College thought that this had udoubtedly had a positive effect o morale ad believes that it will make a career i geeral practice more attractive. The College was also kee to stress that the opt-out was oly from the cotractual resposibility ad that, i may areas, GPs cotiue to support ad develop GP co-operatives ad participate i other PCT arragemets. The Provisio of Out-of-Hours Care i Eglad 27

30 part four The 6,000 figure was the outcome of the ew Geeral Medical Services cotract egotiatios 4.3 Out-of-hours services had bee fuded from a combiatio of GP cotributios ad cetral developmet fuds sice I decidig o a aual sum for GPs to forego if they wated to opt out of out-of-hours, the Departmet s primary aim was to ecourage GPs to accept the ew GMS cotract. The cost of the opt-out was therefore a egotiatig sum for this purpose ad was ot iteded to be a precise reflectio of the cost of providig out-of-hours services. As oted i Part 1, the Departmet was a observer at these egotiatios, which were coducted betwee the NHS Cofederatio ad the British Medical Associatio. 4.4 Prior to the egotiatios, the Departmet coducted some ecoomic aalysis of GP co-operatives, aalysig figures for urba, rural ad mixed areas, to estimate the cost to GPs of providig the service. The costs, icludig fuds specifically allocated to PCTs for ivestmet i GP practices, varied from 7,000 per year to 14,000 per year per GP, with a mea of approximately 9,500. This figure iformed the cotract egotiatios with the outcome of those egotiatios beig agreemet of a amout of about 6,000 to be foregoe by GPs from their icome, but which did ot iclude out-of-hours fudig from PCTs. However, the precise sum varied betwee GPs, depedig o list size ad other factors. I lie with what the Departmet told us were their expectatios, aroud 90 per cet of GPs were prepared to forego this amout ad opted out. 4.5 I additio to the 6,000 sum refuded by GPs, the Departmet provided developmet fudig to PCTs of some 3,500 per GP to help establish the ew service. The Departmet told us that this package of developmet fuds ad the fuds give up by GPs, givig a average allocatio of 9,500 per GP who opted out, would be sufficiet o average to deliver services. Their expectatio was that they would make additioal fudig available for areas i which this was ot the case. However, the Departmet also hoped that icreased itegratio with other services would drive costs dow i due course. The breakdow of fudig available is set out below. The 6,000 opt-out figure led may PCTs to uderestimate their ow costs 4.6 The Departmet is clear that it fuded the service based o the average costs per GP of 9,500. It also set up a programme to support PCTs i implemetig the ew out-of-hours arragemets. This icluded providig iformatio o the aticipated costs ad the additioal resources available to meet the cost. Despite this, some PCTs did ot uderstad that the 6,000 opt-out sum was ot the full cost of the service. The view of the Natioal Associatio of GP Co-operatives ad aecdotal evidece from our visits to providers ad commissioers suggests that there was a widespread misuderstadig that the sum would be eough to cover the costs of out-of-hours. The Departmet made provisio of 322m to reflect the kow costs of the existig service, but the costs of the ew service were higher Extra moey was made available through out-of-hours developmet ad rural fuds 4.7 The Departmet established the followig set of fudig arragemets, i order to esure that commissioers would be able to provide out-of-hours oce GPs had opted out. For the fiacial year , the Departmet provided the followig fuds: the opt-out moies which would total 180 millio if all 30,000 GPs opted out; a rig-feced developmet fud of 92 millio; 14 millio to support PCTs facig the biggest challeges i developig out-of-hours services, such as those coverig highly rural or highly urba areas; ad 30 millio ( 100,000 for every PCT) i capital icetives to reward PCTs for havig robust arragemets i place for the hadover of out of hours ad, subsequetly for providig high quality, sustaiable services. The Departmet told us that all of the capital icetive fuds were disbursed to PCTs o the basis of Strategic Health 28 The Provisio of Out-of-Hours Care i Eglad

31 part four Authority judgemets that their PCTs complied with the coditios. Give our fidigs that providers are ot yet meetig all the Quality Requiremets, we believe that this moey was ot spet o the basis of prove performace. 4.8 Take together, up to 316 millio was available for the provisio of out-of-hours services i I additio, a cetrally held fud of 4 millio was available to support the Techical Liks programme. 4.9 However, i additio to this, the Departmet was kee for PCTs to use their uified budgets to commissio care i a ew, itegrated fashio. These uified budgets amouted to a total of 49.3 billio ad the Departmet wated PCTs to use some of this moey to establish itegrated etworks of high quality out-of-hours ad urget care provisio For the fiacial year , similar fuds were available with the followig chages: there were some chages to the allocatio formula for the 92 millio developmet fud. However, the Departmet stated that o PCTs would receive less tha they did i ; the 30 millio capital icetives were o recurret ad were therefore ot available for this period; a additioal 33.4 millio was available for PCTs for out-of-hours ad urget care developmet; 3 millio was made available to the 53 PCTs ivolved i the Exemplar Programme for itegrated out-of-hours services; ad the Departmet made additioal out-of-hours fudig available to PCTs i , followig ew arragemets for commissioig NHS Direct. PCTs were allocated fudig for NHS Direct ehaced services, icludig call hadlig ad triagig out of-hours GP calls. However, these services were cotestable, i.e. commissioers could choose ot to commissio these services from NHS Direct ad commissio a differet provider istead. Costs are 22 per cet higher overall Survey aalysis shows a cotracted cost of 380 millio ad likely actual cost of 392 millio 4.11 The Departmet has ot sought to calculate the actual costs of out-of-hours services. We therefore asked PCTs a umber of questios about their costs through our survey. We asked PCTs what their cotractual cost (or budgeted cost i the case of i-house services) was for the curret fiacial year. We also asked them for the actual cost of the most recet quarter for which they had iformatio. 12 For aroud 95 per cet of respodets, this was April-Jue We the extrapolated the costs of this quarter to derive a estimated cost for the whole year. 95 per cet of PCTs respoded to our survey Our survey aalysis shows that the actual costs of providig out-of-hours services are cosiderably more tha the 322m allocated by the Departmet. PCTs respodig to our survey reported that the cotractual cost of providig out-of-hours services for was 369 millio ad the actual cost was 380 millio. Whe this was extrapolated over the etire PCT populatio, cotract ad actual costs of 380 millio ad 392 millio respectively were derived, givig fiacial commitmets of 18 ad 22 per cet over ad above the fuds provided by the Departmet. The Departmet s view was that icreases i GP pay rates may have cotributed to cost pressures i may areas. Aecdotal evidece from our iterviews suggests that this is correct, although we were uable to quatify the scale of ay rises. There are cosiderable fiacial implicatios for PCTs 4.13 Eve for those PCTs who foresaw the eed to top up the Departmet s allocatios, the fiacial impact of this icrease i cost has bee cosiderable. All PCTs with whom we discussed costs have bee forced to look for additioal fudig from other budgets or have etered ito egotiatios with their providers about how to reduce costs. I total, up to 322 millio was made available to PCTs for out-of-hours services i PCTs told us that actual costs ofte exceeded cotractual costs because the lack of activity data oted i Part 2 meat that providers uder-estimated demad. The Provisio of Out-of-Hours Care i Eglad 29

32 part four There is a likelihood of a fudig gap while the market matures 4.14 For some PCTs, therefore, it will ot be possible to reduce actual costs to the allocated fudig level i the short term. We describe below how PCTs ca reduce their costs i future, but for some, the combied effects of immature markets, high demad ad high costs will mea that they will have to draw o their uified budgets to top up their out-of-hours fudig before the impact of improvemets kicks i. Cotracts based o cost aloe are ot allowig ivestmet i traiig, facilities or iovatio 4.15 May providers complaied that these shortfalls i fudig were leadig PCTs to let cotracts that were largely drive by cost. This was particularly true for small co-operatives ad mutual orgaisatios. Providers told us that this focus o cost was ot allowig them to sped moey o ay sped-to-save measures, such as experimetig with skill mix, upgradig facilities or iovative itegratio pilots. PCTs desire to let short-term cotracts may have also mitigated agaist ivestmets for the medium term i some istaces. There is scope to reduce costs i future by up to 134 millio Bechmarkig suggests that the costeffectiveess of particular services is iflueced by rural classificatio 4.16 Evidece from our visits to PCTs ad the views of our expert paellists shows that there is scope for PCTs to reduce the costs of out-of-hours i future by: drivig value for moey from future tederig processes based o real competitio; cotiuig to test the cost-effective use of other health professioals alogside GPs i out-of-hours teams; developig activity ad cost data so as to improve provider performace; aalysig case-mix to see if particular patiet groups ca be targeted by specialist primary or secodary care teams i order to reduce those patiets reliace o the out-of-hours service; commissioig itegrated urget ad uscheduled care services i order to reduce duplicatio; ad providers makig further operatioal improvemets to deliver more effective utilisatio of ifrastructure ad staff I additio, aalysis of data from our survey suggests that further savigs could be made across the etire PCT commuity. We split PCTs ito six categories by rural classificatio 13 ad the assessed their performace i each category. Usig the PCT survey data, we calculated the cost per head of the service, based o the total actual costs ad the opt-out populatio of the PCT, ad a overall quality score (see paragraph 2.16). Cost ad quality were the combied by calculatig the umber of quality poits achieved for each poud spet per head. Fially, PCTs were raked withi their urba/rural class o the basis of their score, with the highest score beig the best (i.e. most cost-effective) out-of-hours service i a give class. We the idetified the best-performig PCTs i each category. These are show i Figure As Figure 8 shows, the cost of out-of-hours icreases the more rural a PCT is, whilst quality scores remai broadly the same. This correlatio betwee rurality ad cost meas that a model which works well i a sigificatly urba area may ot ecessarily be a suitable model for a sigificatly rural area. It is also worth otig that, while costs ad scores have bee calculated for idividual PCTs, both factors ca be affected where PCTs commissio services joitly. Bechmarkig agaist the best services could geerate savigs of up to 134 millio 4.19 Usig the services idetified as the best for each PCT classificatio, we calculated the savigs that could be made if each PCT i that classificatio provided its service at the same cost as the best. The potetial savigs totalled 134 millio, ad the breakdow of these savigs ca be see i Figure DEFRA Classificatio of Primary Care Trusts i Eglad, Departmet for the Eviromet, Food ad Rural Affairs, The Provisio of Out-of-Hours Care i Eglad

33 part four 7 Most cost-effective out-of-hours services i Eglad Classificatio PCT Actual cost Quality score Quality poits per head ( ) per spet Major urba Bexley Care Trust Large urba South Gloucestershire PCT Other urba Milto Keyes PCT Sigificat rural Bath ad North East Somerset PCT Rural-50 (i.e. largely rural) Cotswold ad Vale PCT Rural-80 (i.e. major rural) Cetral Suffolk PCT Source: Natioal Audit Office 8 Average cost ad quality scores for each rural classificatio Classificatio Average Average Average actual cost quality quality poits per head ( ) score per spet Major urba Large urba Other urba Sigificat rural Rural Rural Source: Natioal Audit Office 9 Savigs (to the earest m) achievable usig the best service i each classificatio of PCT Classificatio Total actual Total cost at Savig cost ( m) best rate ( m) ( m) Major urba Large urba It is urealistic to expect all PCTs to achieve as good a performace as the best i each category, so we also examied what savigs might be made if the most expesive 50 per cet of PCTs could reach the average performace level i each category. After rakig all PCTs withi the same category by their combied cost/quality score, the media-rakig PCT was selected. We the calculated the savigs that could be made if all PCTs with a cost per head greater tha the media were to reduce their costs dow to the media cost. The potetial savigs totalled 53 millio (Figure 10 overleaf) Our aalysis suggests that it is possible for out of hours services to be provided at lower cost without compromisig quality. However, of our iterviewees who compared costs before ad after the hadover, 100 per cet stated that that the costs of providig the service had goe up. The opt-out of may GPs meas the supply of GPs is ow restricted, icreasig their cost. I additio, costs that were oce absorbed, or ot accurately idetified i relatio to out-of-hours, are ow more trasparet, which also makes the service appear more expesive. Quality moitorig is more rigorous ow tha it was previously, but this also has a iflatioary effect o costs. Other urba Sigificat rural Rural Rural Total Source: Natioal Audit Office The Provisio of Out-of-Hours Care i Eglad 31

34 part four 4.22 There is o sigle model which will work best for all PCTs. Commissioers are at a experimetatio stage at the momet ad should cotiue to experimet with differet arragemets to idetify a model which works well for them. However, the models idetified below should serve as a basic set of cost-effective bechmarks for providers operatig i a urba, mixed or rural area: 10 Savigs (to the earest m) achievable usig the media service i each classificatio of PCT Classificatio Total actual Total cost at Savig cost ( m) media rate ( m) ( m) Major urba Large urba Other urba Sigificat rural Rural Rural Total Source: Natioal Audit Office Bexley Care Trust (largely urba PCT): the out of hours service is provided by GPs with support from urse practitioers i call hadlig ad cosultatios. There is oe primary care cetre at the orth-west ed of the borough. It is maed by admiistrative staff as the operatioal base all week, icludig durig the day. A additioal outreach service operates at weekeds i a large GP practice. GPs complete home visits durig the eveigs while other GPs ma the primary care cetre; durig the ight shift admiistrative staff ma the base, while the GP is out. The service also statios GPs i the Accidet ad Emergecy departmets of two local hospitals durig periods of peak demad. The out-of-hours provider has achieved a good level of itegratio with other services, such as commuity ursig, mior ijury uit, Accidet ad Emergecy departmets, ad a primary care ursig team at oe Accidet ad Emergecy uit, ad diverts patiets as appropriate; Cetral Suffolk PCT (largely rural PCT): out-of-hours care is provided by GPs ad urses. Call hadlers perform telephoe triage ad good itegratio with local mior ijury uits allows may calls to be diverted away. Patiets requirig GP attetio ca be treated at a base or a home visit is arraged; ad Bath ad North East Somerset PCT (rural-urba mix): out-of-hours care is provided by a mix of GPs ad urses. Telephoe triage is cotracted out to a larger, eighbourig PCT, sice it is ot cost effective to perform i-house. There are two primary care cetres, each located withi a hospital ad each staffed by oe GP ad a team of urses with a additioal GP o stad-by. Primary care cetre cosultatios are performed by the GP or urses ad home visits completed by GPs. If the GP is ot due to retur from a home visit for some time ad patiets preset at the primary care cetre requirig GP attetio (followig urse assessmet), the stadby doctor is called Sigificatly, all of these providers are itegrated with other services such as commuity ursig, mior ijuries uits, walk-i cetres or Accidet ad Emergecy departmets ad divert patiets as appropriate. GP pay rates remai the key driver of costs PCT survey shows wide distributio of pay rates - ot solely o the basis of rurality 4.24 Our PCT survey shows a wide distributio of pay rates for GPs. The distributio of rural, urba ad mixed PCTs amog the pay rates scale shows that rurality is ot the oly driver behid how expesive the rates are. Figure 11 shows that a average weekday eveig rate of ca be early doubled durig a bak holiday, whe the average rises to The Provisio of Out-of-Hours Care i Eglad

35 part four 11 GP pay rates GP pay rates ( ) Weekday eveig Weekday overight Weeked Weeked overight Public holiday Average rate Maximum Miimum Source: Natioal Audit Office There is some evidece that good workig relatioships keep pay dow 4.25 May PCTs told us that they felt their fiaces were at the mercy of whatever pay rates GPs demaded. However, we also foud evidece of providers ad commissioers takig practical steps to help keep GP pay rates dow, whilst keepig GPs themselves committed to providig a good service The Devo Doctors Co-operative is a particularly good example of effective plaig ad maagemet which allows them to pay their GPs 50 per hour o weekday eveigs ad 70 per hour overight ad at weekeds. This provider is over-subscribed with GPs willig to work out-of-hours shifts, allowig it to keep overall costs dow. The rich supply of local GP pricipals (who cover 70 per cet of shifts) ca be attributed, i part, to good preparatio. Devo Doctors reduced ucertaity by implemetig aspects of the ew cotract such as Saturday morig cover, well i advace of the ew cotract s itroductio. Devo Doctors fills its rotas three moths i advace usig a preferece system to esure it has sufficiet cover. Fillig the rota is assisted by a pioeerig website where shifts ca be booked electroically. The advace plaig also allows doctors greater freedom to pla their schedules. A additioal icetive for GPs is speed of paymet ad reduced superauatio admiistratio Devo Doctors pays its GPs o a weekly basis. The Provisio of Out-of-Hours Care i Eglad 33

36 part five Part five Commissioers are eterig ito cotracts with multiple providers ad the market is maturig 34 The Provisio of Out-of-Hours Care i Eglad