CCGs must work hard writing out of hours contracts that deliver exactly what they want. By Alison Moore

GP out of hours services are a key part of the broader urgent and emergency care picture: get provision right and the numbers of people attending A&E inappropriately may start to fall.

Get it wrong and not only will A&E departments be flooded but some patients will receive poor quality and even dangerous service.

With the demise of PCTs, clinical commissioning groups have taken on the responsibility of commissioning out of hours services.

‘People will spend a lot of money on the front end of the contract but not look at the specifications at the back of the contract’

“One would think that this is ideal ground for clinical commissioners to make real improvement,” says Rick Stern, a director of the Primary Care Foundation. But he points out that it has coincided with the troublesome implementation of NHS 111.

With contracts coming up for renewal, some PCTs and CCGs chose to roll them over for a few additional months to allow the new bodies time to think about what they wanted - and potentially to look at the interface with the NHS 111 service.

In Sussex, for example, contracts were originally to be extended for six months to avoid them expiring as CCGs took over, but it became clear that different CCGs wanted different specifications and contracts were extended for 12 months to allow extra time to develop and commission these.

Safety first

But what should be at the forefront of CCG leaders’ minds as they start to contract for these services?

They are almost certainly thinking of the two pillars of quality and cost - and how they reconcile them. While good quality care may be costly, so are services which fail to meet people’s needs - and lead to them attending A&E instead. In those cases, the CCG will be paying twice. Making use of this opportunity to further integrate urgent care is also likely to be prominent.

The advice from James Reynolds, head of primary care at healthcare law firm Capsticks, is that service design and specification is crucial. A well written specification will help to deliver a quality service.

“The first consideration should be what constitutes a safe service and then how do you achieve the aim of treating more people in primary care,” he says.

Part of this is likely to be through proper triage, good telephone advice for those patients with more minor conditions, and then access to healthcare professionals, for example through attending an out of hours centre or a home visit.

“People will spend a lot of money on the front end of the contract but not look at the specifications at the back of the contract,” says his colleague Duncan Gordon-Smith. “They don’t make it work for them.”

One example of this is that there can be a perverse incentive for out of hours providers to send people to A&E rather than treating them themselves - unless the contract and specifications are well written. And specifications need to be enforceable and have consequences if achieved or not achieved.

Mr Gordon-Smith recommends involving other stakeholders in thinking about the specification of services and how this can drive better integration.

Right incentives

Some of these specifications can be designed to incentivise the behaviour the CCG wants to see, he suggests. These can include specifying who provides care - such as that any doctors employed by the provider should always be familiar with the NHS and staff should have undergone a detailed induction process.

This could help avoid disasters such as the Ubani case - when a doctor who was not familiar with the NHS gave a patient a fatal overdose.

Out of hours services already have national quality requirements, covering everything from how quickly triage should start in urgent cases to auditing patient experience. Providers should be reporting to the commissioners on how they are doing against these.

Some commissioners may want to add in additional performance indicators based on their local situation. But should these be process or outcome based? Process based indicators can be easy to measure - how quickly phones are answered, for example, which is already in the national requirements. But they may not be a good proxy for the ultimate goal of high quality services.

Contracts with demands for too much information can also be an issue, according to Capsticks’ James Clarke. Collecting information increases the cost of a contract and if that information is not used by the commissioner to drive improvements it is money wasted.

But measuring outcomes may be harder and can be a blunt instrument - a drop in the number of people attending A&E can be hard to link to changes in the out of hours service, for example, and may only be meaningful if the people who are not going to A&E are those who can be treated more appropriately elsewhere.

In practice, many contracts will include a range of performance indicators covering both process and outcome.

Contract on a plate

The Primary Care Foundation recently suggested additional ones could include how long patients wait in an out of hours centre; how long it takes for them to be assessed or managed over the phone; and how many cases are identified as urgent or emergency, and how quickly they are responded to.

CCGs may also be concerned about the process for procuring out of hours services. Although such contracts may be exempt from full European procurement, CCGs are still likely to have to go through an extensive procurement process including advertising the contract through Supply2Health and assessing responses against set criteria, says Mr Clarke.

There’s nothing to stop local GPs applying for the contract - and they may be in a good position to do so. But there is no guarantee that they will win and they certainly can’t be handed the contract on a plate. This can lead to some frustration among GPs, suggests Mr Reynolds.

And, of course, those involved in the decision making process on the CCG side will need to ensure that any conflicts of interest are managed.

But, more generally, CCGs may want to ensure that procurement aids rather than hinders integration. The interface with NHS 111 is likely to be important, together with the need to share information and to ensure that patients don’t have to repeat basic details and information without cause. In some areas, procurement of the two services has been run in parallel, allowing for greater integration: but that is not universal.

So there are opportunities for CCGs to seek to improve services through good contract management. The worry for many of them will be the uncertainty around the future shape of out of hours.

Health secretary Jeremy Hunt has not ruled out a return to GP responsibility for out of hours care of their patients. And Sir Bruce Keogh has been examining out of hours as part of his wider review of urgent and emergency care. CCGs contracting for new services will be doing so in a rapidly changing environment.

Read the out of hours case studies

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James Clarke on uncertainty

With the long term future of commissioning arrangements for out of hours services uncertain, clinical commissioning groups are faced with the task of commissioning services that may be the subject of significant policy and regulatory change during their term.

Against the backdrop of discharging statutory responsibilities and pressure to achieve greater levels of integration with other services and a reduction in A&E attendances, what does success look like for a CCG approaching procurement and contracting for historically difficult services facing significant change?

The decision to procure should be an easy one, although some wishing to set up their own out of hours services struggle to accept that at present there is no lawful mechanism for GPs to “opt back in” to the 24 hour provision of patient care.

Procurement, although an unavoidable duty, should not be seen as an obstacle to progress or a compliance “tick box” exercise, but as a key tool for a CCG to employ in order to secure precisely the services that patients need at a price that demonstrates value in compliance with statutory duties.

Impenetrable language

The inherent flexibility in APMS (Alternative Provider Medical Services) contracts means that, with careful specification, it is possible to seek the highest quality and contractual performance whilst securing bids from the widest possible pool of providers.

Some of the better known APMS contract forms of the past, however, have been beset with real practical difficulties. For example, we have seen agreements in impenetrable language, with unenforceable terms, seldom read by those with operational responsibility for services.

CCGs now have an opportunity to take a new and positive approach to out of hours contracting by taking control of the commissioning process and making it serve the precise outcomes that they wish to deliver for patients. This means:

  • careful specification design, encouraging best behaviours from providers in terms of quality, value, outcomes and integration;
  • clear drafting of contractual terms, using the flexibility offered by APMS contracts to the advantage of patients to include appropriate performance management provisions, incentives and enforceable sanctions; and
  • making the procurement process work for each unique situation - avoiding the unsatisfactory and often legally problematic “off the shelf” approach to procurement peddled by unqualified procurement “experts”.

There is everything to play for in improving out of hours services right now. Adopting a holistic, quality driven approach to procurement and contracting processes gives CCGs a unique opportunity to make a positive impact for patients.

James Clarke is partner in the commercial department at Capsticks