The Department of Health has signalled that it may allow practice-based commissioning consortiums to take over commissioning out of hours services. Rick Stern explains why this would be good for patients and budgets
I remember well in a former life as a primary care trust chief executive the frustrating experience of going to a contract review meeting with clear concerns about performance, only to be reassured at length that there was really nothing to worry about. I could challenge some of what the provider was saying, but nowhere near as well as a clinician could. I never made that mistake again. Managers are good at lots of things, but they are only really effective when they work hand in hand with clinical colleagues. In future, I came armed with a clinician.
All too often, commissioning out of hours services has been left to middle managers. Yet all aspects of commissioning care need clinical input. This includes developing a specification that will maximise the quality of care, as well as designing broader clinical pathways.
Out of hours services are just one part of the patient's journey and need to fit with the bigger picture for delivering urgent care. So, for example, a patient who has suffered a stroke should be entitled to expect a consistent response in and out of hours. This means in hours and out of hours providers should have equally strong processes for recognising the symptoms and responding quickly and effectively. The job of the specification is to pin down the out of hours services' responsibility in all this and find a clear way of measuring their performance.
GPs on the front line
GPs in particular remain closely connected to out of hours services. Every day, they pick up the consequences of out of hours decisions for their patients. They are ideally placed to reflect on the wider impact of out of hours services, as fellow providers and as practice-based commissioners. Concerns are often raised about conflicts of interest, and these need to be properly addressed, but the bigger risk is that the people most able to challenge and improve the commissioning of out of hours care are excluded from this role. It follows that the NHS Alliance is keen to see PBC groups taking greater responsibility for commissioning out of hours care.
It is important to emphasise the word "commissioning". We are not looking to roll back the clock to the days before GP co-ops, when bleary-eyed GPs took direct responsibility for care around the clock. While we all liked the idea of this continuity of care (though even then it could be a different GP in the practice), stretching GPs too far was bad clinical practice and made a career in general practice look increasingly unattractive to medical students.
There is an equally important role for clinical leadership in out of hours provider services. However you look at it, about two-thirds of all costs are wrapped up in clinical time - GPs , nurses and paramedics - and ensuring that they are effectively supported, challenged and governed is crucial, especially in a predominantly part-time workforce. All of which makes clinical variation and the importance of benchmarking vital in driving up care in all services, including out of hours care. It also provides some real substance to those contract review meetings so that the focus shifts to improving quality and driving improvement in patient care.