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The term 'out-of-hours care' refers to primary medical care services available from 6.30pm until 08.00am on weekdays, and on all weekends, bank holidays and public holidays. In April 2004 a new general medical services (GMS) contract came into force which allowed GPs to opt out of out-of-hours provision, with the responsibility for provision being taken up by primary care trusts (PCT), GP co-operatives, NHS Direct and private companies. Findings from this NAO report on the quality of out-of-hours services include that there were some shortcomings in the initial commissioning process because PCTs lacked the experience, time and reliable management data, and there was confusion over whether out-of-hours services should be restricted to urgent care. Providers are now beginning to deliver a satisfactory level of service in general, although most have not yet met all the national quality requirements, particularly in relation to speed of response. The costs of providing out-of-hours services in 2005-06, the first full year of the new arrangements, was £392 million, 22 per cent higher than that allocated by the Department of Health.
Approximately 9 million patients receive urgent primary out-of -hours care in England. In April 2004 the Department of Health gave GPs the chance to opt out of providing this service and transfer responsibility to the Primary Care Trust. This report looks at three main issues related to the change: how well did the Department of Health prepare; how did the new service perform and what did it cost. It concludes that the preparation was shambolic both at local and national level and although the new service is starting to improve performance against key access targets is still not good enough. In addition the cost of the new out-of-hours service has been £70 million higher than was foreseen.
This review incorporates the views and visions of 2,000 clinicians and other health and social care professionals from every NHS region in England, and has been developed in discussion with patients, carers and the general public. The changes proposed are locally-led, patient-centred and clinically driven. Chapter 2 identifies the challenges facing the NHS in the 21st century: ever higher expectations; demand driven by demographics as people live longer; health in an age of information and connectivity; the changing nature of disease; advances in treatment; a changing health workplace. Chapter 3 outlines the proposals to deliver high quality care for patients and the public, with an emphasis on helping people to stay healthy, empowering patients, providing the most effective treatments, and keeping patients as safe as possible in healthcare environments. The importance of quality in all aspects of the NHS is reinforced in chapter 4, and must be understood from the perspective of the patient's safety, experience in care received and the effectiveness of that care. Best practice will be widely promoted, with a central role for the National Institute for Health and Clinical Excellence (NICE) in expanding national standards. This will bring clarity to the high standards expected and quality performance will be measured and published. The review outlines the need to put frontline staff in control of this drive for quality (chapter 5), with greater freedom to use their expertise and skill and decision-making to find innovative ways to improve care for patients. Clinical and managerial leadership skills at the local level need further development, and all levels of staff will receive support through education and training (chapter 6). The review recommends the introduction of an NHS Constitution (chapter 7). The final chapter sets out the means of implementation.
People turn to out-of-hours GP services when they are worried about their own health or that of family or friends, and want urgent advice or treatment. However, the urgent and emergency care system is complex and people struggle to know which is the right service to use. Patients' experience of and satisfaction with the out-of-hours services varies significantly and unacceptably across the country, as does the cost. NHS England has not provided effective oversight of whether the services are providing value for money. It lacks the basic information needed to understand what lies behind the variations and identify where it should intervene. It has not dealt adequately with conflicts of interest which inevitably occur when many commissioners are also providers. NHS England also needs to address the perverse financial incentives which get in the way of different urgent care services working effectively together. It needs to examine whether the out-of-hours services are working properly with other services and whether the system encourages duplication when resources are so constrained. At the most basic level, the Department of Health and NHS England must develop information to be able to know whether there will be enough GPs to cope with the growing workload.
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