Out-Of-Hours healthcare provision in urgent need of treatment
Out of hours provision is disjointed, confuses the public and must change. CCGs must face the challenges of reducing pressure on hospitals and managing increasing demand.
Have out of hours services become an anachronism in our modern urgent care systems? This week it has been reported that major A&E units have fallen below the 95% target for the past 52 weeks, and as they experience unprecedented levels of pressure it is increasingly unclear the value that the out of hours services are adding.
Out of hours services came about because GP practices originally had responsibility for their patients 24/7. Rather than run individual on call arrangements within each practice, many practices joined together to provide a collective ‘out of hours’ service for their patients. Then the GP contract was changed in 2004, which enabled GPs to ‘opt-out’ of providing out of hours care.
This led to a collection of private companies and GP co-operatives taking on the contract for out of hour’s services. Since then there has been an increase of 4 million people using A&E services. While this growth cannot be laid entirely at the door of the change in out of hours care provision, it is clear that it has not helped to reduce the pressure on A&E services either.
In recent years a number of other changes have also occurred. The most notable of these is the introduction of the 111 call service. This operates 24 hours a day, and as out of hours services traditionally provided a call service functionality the introduction of the 111 service immediately created a duplication in many systems.
‘Core’ general practice hours have been extended in many areas (meaning the required hours for out of hours services have reduced). But the availability of GPs has also reduced.
There has been much talk about the difficulties practices have faced in recruiting GPs, but the knock on effect is that because of the increasing demands on GPs in their own practices, the supply of GPs to out of hour’s providers has become much more limited.
Increasingly common now are primary care ‘streams’ in A&E departments, or more grandly ‘co-located urgent care centres’, where GPs and nurses staff an area that deals with the majority of the patients with a primary care complaint or minor injury/illness. The relationship of these services where they run during the evening or at weekends with the out of hours services to date has not been well defined.
The other major change taking place is the so-called ‘transformation of general practice’. I say so-called as I was talking to a group of GPs last week who told me that anyone who talks about the transformation of general practice cannot possibly understand what general practice is really like!
But there is a trend of practices federating together to provide services and if part of this is looking at the provision of core general practice (such as access), which surely it must, then out of hours services are inevitably part of this mix.
So what is a sensible way forward?
As existing out of hours and 111 contracts expire, as ambulance services put increasing emphasis on non-conveyance rates, and as GP practice federations start to gain some traction, how can services out of hours be developed in a way that is understandable to the public (according to recent reports 1 in 4 of the general public do not understand the provision of out of hours services) and that genuinely reduce demand?
With the increasing movement to outcome based contracts, CCGs may well be tempted to offer a contract that pulls these elements together and requires ambulance services, out of hours general practice and A&E departments to work together. A more obvious, and more easily implementable, next step may be to decommission the out of hours service altogether, and to use the funding to extend the hours of core general practice provision and to provide a service for the remaining hours through an enhanced primary care stream in A&E.
The current arrangements are out of date, disjointed, incomprehensible to the public, and cannot continue. The future model must be effective in enabling more demand to be managed in a way that reduces pressure on hospitals. This presents not only a challenge to CCGs moving forward, but a tremendous opportunity for the developing primary care federations to show just how innovative and effective they can be.
The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of The Information Daily, its parent company or any associated businesses.
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