The urgent care muddle may mean more nights to forget

It is perhaps not surprising that the Commons public accounts committee concluded last week that NHS attempts to transfer responsibility for out-of-hours services from GPs to primary care trusts were 'shambolic'.

Three years since the policy was introduced, stories about failures in care at evenings and weekends continue to be picked up by the media and at least one provider is being closely monitored by its primary care trust after well-publicised problems. The government is currently reviewing urgent care and many PCT contracts with out-of-hours providers are up for renewal later this year. Is change on the cards yet again?

Nigel Wylie, chief executive of Liverpool-based Urgent Care 24, says plans to move out-of-hours services forward over the last three years have been tempered by PCT reconfiguration and developments in government policy. 'We have had 12-18 months of planning blight,' he says. 'Many aspirations of some out-of-hours providers and some commissioners have been stifled.'

NHS Alliance urgent care spokesman Rick Stern says services have probably improved and become more professional but that it can be hard to demonstrate progress.

A National Audit Office report on out-of-hours care last year showed many providers not meeting government targets for answering phones and seeing patients: these should be written into contracts and may have improved since the report was published. But there is no central monitoring of these quality standards.

The NHS will be commissioning in a different environment to three years ago: money has become tighter, government policy has shifted towards care in the community and the acute sector has started to reconfigure. NHS Confederation deputy policy director Jo Webber says commissioners will be looking at different solutions in light of their overall strategy for urgent care.

There could be an increased emphasis on providing services that keep people with long-term conditions in their own homes rather than admitting them to hospital as emergencies. In Oxfordshire, the ambulance service is providing such care using primary care practitioners who treat patients at home. This can dramatically reduce admission rates.

Public perception

But out-of-hours providers sometimes struggle to persuade patients that they are the most appropriate service to access. 'The public perception is that the point of least resistance is either 999 or to turn up at accident and emergency,' says one doctor.

NHS Alliance spokesman Dr David Jenner says the way forward is to site primary care units alongside emergency departments. 'It would be under primary care governance with staff from primary care to deal with a lot of the walk-ins who are not emergencies,' he says. 'If they get into A&E they start racking up the tariff and impact on the four-hour waits.'

Hospital trusts would not complain because they would have a better chance of meeting the four-hour target if they did not have to deal with such patients.

Improving access to diagnostic facilities for primary care out-of-hours providers - which could result from co-location - could be another benefit. Currently, some patients are directed to the emergency department because that is the only way to get x-rays done outside office hours.

If GP practices were open for longer hours that would help reduce demand. Many mourn the loss of the Saturday morning surgery and see it as contributing to increased demand throughout the weekend - including from working people who find it hard to access normal GP services without taking time off.

'We have all struggled since the demise of the Saturday morning surgery - that was like the pressure valve for the whole weekend,' says South Western Ambulance Service trust clinical director Norma Lane.

The government says it wants to encourage GPs to offer longer opening hours but whether hard-pressed PCTs will want to pay for it is far from certain.

Practice-based commissioners may be one driver of change for out-of-hours care: much of practices' indicative budgets are spent on non-elective care but three-quarters of this is initiated outside the practice - through contacts with the out-of-hours services, walk-in centres and so forth. They will want to stop unnecessary admissions - an expensive part of care - and may push for better primary care-based services.

Feeling alienated

In Cornwall, where private provider of out-of-hours care Serco Health has been heavily criticised, this process may have already started among groups of practice-based commissioners.

Dr Jon Tilbury, vice-chair of Cornwall and the Isles of Scilly PCT's professional executive committee, says: 'Some of them have said they would like to have the out-of-hours commissioning budget devolved to them so they could commission the services themselves.'

This may reflect the history of out-of-hours care in the county over the past three years: when a popular co-operative lost the out-of-hours contract, some GPs were left feeling alienated and did not want to work for the new provider.

But there is a danger that practice-based commissioning could lead to a duplication or fragmentation of care, or simply expensive services where areas are wedded to having their 'own' out-of-hours centre or minor injuries unit...

However, making GPs feel they have a stake in the out-of-hours system's success could improve services and reduce costs. Dr Jenner contrasts the position in Cornwall with Devon, where there is still heavy involvement from local GPs.

The new GP contract with its opt-out clause on 24-hour responsibility meant GPs lost any incentive to keep the cost of out-of-hours care down: previously they had to pay for it out of their own budgets and, even if they worked as a co-operative, controlling the costs of providing the service was in their own interests..

One of the immediate effects was that GPs had to be paid more to entice them to work out-of-hours shifts and some decided not to do them at all. Costs have since soared so rates of£100 an hour are not unusual and some areas have resorted to flying in doctors from the Continent to provide weekend cover.

Increased use of other staff - especially highly trained nurses - has been the response of many services to both the cost and shortages of GPs. Typically, a caller may be initially triaged by a call handler, then speak to a nurse and may then speak to or visit a GP if the condition demands it.

But there is now a debate about whether this is the right way ahead: nurses are cheaper than doctors but a proportion of the cases they deal with will also need a doctor's involvement. Urgent Care 24 in Liverpool is one of a number of providers looking at whether a doctor should be the first clinical contact and decide who a patient needs to see.

Mr Stern says: 'The best systems for assessing patients have the most expensive practitioners at the front.'

Slowing investment

The new round of negotiations with providers will take place against a backdrop of slowing investment in the NHS and some PCTs with severe financial problems. The NAO report last year suggested there were substantial savings to be made if all PCTs commissioned services as cost-effectively as the top performers.

This is likely to lead to demands for reduced-cost services. East of England Ambulance Service trust, which runs out-of-hours services in Norfolk and part of Suffolk, expects to have to reduce its tender this year by 20 per cent to meet PCT expectations.

'It is not going to be the same service that we currently provide,' says assistant medical director Dr Scott Turner. 'It will mean the patient will have to put more in to get something out of the system - they will have to go further to be seen in an out-of-hours centre. But whatever system we put in will be safe.'

With quality standards to meet as well, can PCTs push too hard? Costs can be extremely variable: areas with a high proportion of older patients are likely to have more home visits (the most expensive sort of contact), for example, while rural areas may see fewer demands on services but still need staff to be on call and have long travelling times when a visit is needed.

The obvious route to lower costs is better integration with other services; but the NAO highlighted how little of this was happening. Changes to emergency medicine services may force the pace of integration.

Where emergency departments are centralised, some form of urgent care centres are likely to be set up in other acute hospitals. They will not deal with major trauma and possibly not acute medical cases. Will their case-mix be that much different from primary care - or could many of these cases be dealt with by nurse practitioners and GPs, with diagnostic backup?

Another area of integration may be minor injuries and illness units which are often nurse practitioner-led but run alongside GP-led services. Although they can do much to reduce emergency department visits, some see low numbers of patients, especially at night, and they tend to be relatively expensive, as they require nursing staff capable of working independently. Could there be opportunities for staff to work across both services and reduce costs, while still stopping people joining the A&E stream?

One problem with imaginative solutions is that they will require organisations to cede sovereignty. Aligning incentives so that everyone benefits will be challenging in some places. Emergency departments may see minor cases as clogging up their systems and forcing them to miss targets; but could they also see them as a useful source of revenue?.

By the end of the year, the out-of-hours landscape could look very different: but the danger is the current financial problems could drive PCTs to seek solutions based more on cost than quality. If that happens, expect to see more of those critical headlines as the cracks start to show.

Case study: view from the successful service

South Western Ambulance Service trust runs the out-of-hours service in Dorset and Somerset - including 22 treatment centres, usually located with minor injuries units or emergency departments.

It also has contracts for urgent care services for the armed forces and prisons in the area and runs the emergency dental care line, as well as some call handling for other organisations. Its emergency care practitioners will also treat people at home, if appropriate.

Together these allow it to benefit from economies of scale and shift staff around the two counties as needed to meet unexpected peaks in demand.

Clinical director Norma Lane says running out-of-hours services can help divert 999 callers to more appropriate services: call handlers will spend time with patients who do not need a blue-light ambulance to find out what service they need.

'The vast majority of ambulance service work is more about people with long-term conditions or falls - a lot of primary care-type urgent care. It has fitted in well for us to get engaged in urgent care. It is about becoming experts in urgent care regardless of what the setting is,' she says.

'If you have a district nurse who is out there at 2am who you can link with rather than sending a GP out, that is a better use of your resources.'

She adds that, like many other providers, the service is finding it difficult to deal with rising demand. Patients get to know how to work the system and end up accessing out-of-hours services because they are convenient, she says.