Sharing the burden of out-of-hours care

No comments

From next month, providers of out-of-hours services will have a new set of standards to comply with. Dr Gerard Panting explains what this will mean for GPs

Gone are the days when GPs were obliged to take responsibility for their patients’ care 24 hours a day, 365 days a year. The new primary care contracts introduced earlier this year allow GP practices to opt out of out-of-hours care and pass the responsibility for ensuring that patients have access to 24-hour care to the primary care organisation.

Since November 2002, all organised providers of these services have had to comply with quality standards set down by the Department of Health. These are now to be replaced by national quality requirements in the delivery of out-of-hours services, which will come into effect on 1 January 2005 (Box 1, below).¹

Box 1: National quality requirements in the delivery of out-of-hours services

Providers must report regularly to PCTs on compliance with the quality requirements.
Providers must send details of all OOH consultations to the practice where the patient is registered by 8 am the following working day.
Providers must have systems in place to support regular exchange of up-to-date information including anticipatory care plans between different agencies providing care to patients with pre-defined needs (including, for example, patients with terminal illness).
Providers must regularly audit a random sample of patient contacts, take action on the basis of those results and provide reports of the audits to the contracting PCT. Providers must co-operate fully with PCTs in ensuring that these audits include clinical consultations with patients whose episode of care involved more than one provider organisation.
Providers must perform regular audits on a random sample of patients' experiences of the service (for example 1% per quarter) and take appropriate action on the results.These audits should also include cases where more than one provider organisation is involved.
A complaints procedure must be in place and anonymised reports detailing individual complaints and how they have been dealt with submitted to the PCT. All complaints must be audited in relation to individual staff so that appropriate action can be taken if necessary.
Capacity must be matched to predictable fluctuations in demand.
For initial telephone calls, no more than 0.1% of calls should be engaged and no more than 5% of calls should be abandoned. All calls must be answered within 60 seconds of the end of the introductory message, which should normally be no longer than 30 seconds in length. If there is no introductory message, calls must be answered within 30 seconds.
Telephone clinical assessment: robust systems for identifying all immediate life-threatening conditions must be in place. Calls about such conditions should be passed to the ambulance service within 3 minutes. Providers using a clinically safe and effective system for prioritising calls must start definitive clinical assessment for urgent calls within 20 minutes of the call being answered by a person and start definitive clinical assessment for all other calls within 60 minutes of the call being answered by a person.Where no such system operates, definitive clinical assessment must commence within 20 minutes of the call being answered by a person. At the end of the assessment, the patient must be clear of the outcome including, where appropriate, the timescale within which further action will be taken and the location of any face-to-face consultation.
Face-to-face clinical assessment: the requirement for this is the same as that for telephone clinical assessment.
Patients must be treated by the clinician best equipped to meet their needs in the most appropriate location. This includes, where necessary, the patient's residence.
Face-to-face consultations must be started within set timescales after definitive clinical assessment has been completed:
- Emergency: within 1 hour
- Urgent: within 2 hours
- Less urgent: within 6 hours.
Patients unable to communicate effectively in English will be provided with an interpretation service within 15 minutes of initial contact. Provision must also be made for patients with impaired hearing or sight.

Alternative models

There are four models for delivering out-of-hours services:

The PCT commissions services direct from providers (APMS), which must comply with the quality requirements and report regularly to the PCT on their compliance with them.
The PCT provides its own out-of-hours services (PCTMS). The PCT must comply with the same requirements as the model above, so the part of the PCT that provides the service will be required to report regularly on its compliance to a different part of the PCT that is responsible for the quality of services.
The practice provides its own out-of-hours services. These practices will also have to comply with the quality requirements and report on their compliance in the format agreed with the PCT. This is an acknowledgement that detailed reporting as required of other providers would be too onerous for individual practices, and PCTs should ensure that they do not impose too burdensome a regime on the practice.
The practice subcontracts its out-of-hours services direct to another provider, in which case, the GP practice itself is responsible for meeting the quality requirements. Practices can enter into their own arrangements only with the agreement of the PCT, and again, the PCT and practice will have to agree on exactly what regular reports should be made to the PCT.

National quality requirements

The 13 requirements listed in the Department of Health’s paper (see Box 1) put in place performance measurement of out-of-hours services and, with the exception of reporting requirements, will apply to all four types of arrangements of out-of-hours services.

The requirements set out a number of standards designed to promote continuity of care. These include giving the patient’s usual practice details of any out-of-hours consultation by 8 am the next working day and coordinating with out-of-hours providers over the care likely to be needed by particular patients.

Next, the requirements stipulate that patient experience must be audited regularly and action taken on the results. This may appear onerous, but audit should be undertaken by the provider’s administrative staff and not increase the workload of clinical staff.

All providers of care to NHS patients must have a complaints procedure in place, so anyone providing an out-of-hours service should already comply with requirement 6.

As patient demand varies from day to day, resource requirements fluctuate. The DoH document recognises that although these fluctuations are predictable – for example the third day of bank holiday weekends and Saturday and Sunday mornings are invariably busier – providers are expected to anticipate periods of peak demand and staff the service to meet the urgent needs of patients that cannot safely be deferred until routine service is resumed.

Requirement numbers 9-12 are all about ensuring that patients who require urgent treatment are suitably prioritised, including being seen by the clinician best equipped to meet their needs in the most appropriate location – obviously, including the patient’s home.

Requirement 13 seems aptly numbered, requiring as it does the provision of an interpreter within 15 minutes of initial contact for any patient unable to communicate in English. This seems an impossible target to set, requiring virtually instantaneous access to interpreters for every language on earth.

Conclusion

Performance measurement and management are common practice in virtually all types of enterprise and clearly can be very constructive provided care is taken to measure the right things. Looking at the burden placed on out-of-hours providers, many GPs who no longer have this responsibility may be heard to take a deep sigh of relief.