05 May 2006
Night-time medical provision lacks guidelines on care to be provided
New arrangements for out-of-hours GP services have been condemned as 'shambolic' following a watchdog report that found lengthy waiting times and a 22% cost overrun.
The May 5 National Audit Office report into changes that have enabled GPs in England to 'opt out' of out-of-hours provision since last year found that alternative providers cost the NHS £392m in 2005/06 – 'considerably more' than the planned £322m.
The overrun means that the average cost of replacing each GP's out-of-hours service was £11,600 rather than the allocated £9,500. The NAO found the impact of the shortfall 'has been considerable' for primary care trusts.
Although savings could be made in many PCTs in the immediate future, 'for some PCTs [this] will not be possible', the report said, forcing cuts elsewhere.
Ninety per cent of all GPs have now opted out of their out-of-hours care. Since April 2005 services have been provided either directly by PCTs (17%) or by commercial providers (12%), GP co-operatives (17%), NHS trusts (16%) and other organisations.
However, two-thirds of these providers have no contract as they are still arguing with their PCTs over costs. Such providers could walk away at any point, said NAO health audit manager Tim McDonald. Many were providing the service only in the hope that negotiations would finally yield a higher payment, which would further increase the cost overrun.
'It's unsatisfactory on both sides,' he said. 'The PCTs don't have the contractual levers to demand improvements… and it puts the providers at financial risk.'
Although the NAO found 'no evidence' that patient safety might be jeopardised, it said that no one provider was meeting all the quality targets set by the Department of Health.
NAO director of health audit Chris Shapcott said that performance on waiting and response times was 'worrying'. Fewer than 10% of PCTs were sure that urgent cases were addressed within 20 minutes of a phone call and only 15% were certain that urgent cases were seen within two hours.
Health auditor Shamail Ahmad said that 'a significant proportion of PCTs were unable to provide the data, possibly over half. They do not have the means to monitor it.'
The NAO also criticised the continued 'confusion' over what the out-of-hours services were supposed to provide. The £9,500-per-GP cost estimate had been based on urgent care provision only. However, mixed messages from the DoH around 'patient choice' had led many PCTs to believe they were also expected to provide non-urgent treatment.
This ambiguity was criticised by Commons' Public Accounts Committee chair Edward Leigh. Describing the situation as 'shambolic' and 'a costly mess', he said: 'The DoH has still to clarify for all PCTs the absolutely basic point whether an out-of-hours service should respond to just urgent cases or any requests for help at all.'
A spokesman for the DoH said the department 'took a very clear position' that such services were for urgent needs only but that it would be looking to see if further clarification was needed. He added that PCTs and service providers would be invited to 'master classes' later this year 'to help ensure the NHS grasps the changes required' to improve costs and performance.
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