Out-of-hours GP services in England

NHS England’s oversight of the value for money of out-of-hours GP services has been inadequate. Out-of-hours GP services are commissioned locally by clinical commissioning groups or NHS England’s local area teams. During 2013-14, NHS England viewed out-of-hours GP services as low priority and did not collect enough information to provide it with adequate assurance on value for money. In addition, it did not analyse data that was available from the GP Patient Survey to investigate services which were performing poorly or why overall patient satisfaction was falling. No up-to-date information is available to allow clinical commissioning groups to benchmark the cost of their services and how they perform against the national quality requirements. Available data is over 2 years old. NHS England said that scrutiny of out-of-hours GP services will increase in the future and that the Care Quality Commission would be inspecting the quality and safety of all services. However, assurances about future plans does not excuse the failure to provide proper oversight so far. Recommendation: NHS England should adopt a proportionate oversight regime which provides it with assurance on the value for money of out-of-hours GP services and allows it to identify poorly performing services and make targeted interventions.

NHS England should do more to understand the reasons for the significant variations in cost and patient satisfaction. There is significant variation across the country in both the cost of out-of-hours GP services and patient satisfaction with these services. For example, the cost per case ranged from less than £29 to more than £134 in 2013-14. The proportion of people in each local area who rated their experience as ‘very good’ or ‘fairly good’ ranged from 49% to 86% in July 2014. NHS England demonstrated a general understanding of what may drive the variation in cost and patient satisfaction, but it appeared to have little specific information. In 5 evidence to us, it relied almost entirely on the cost data collected by the National Audit Office and could not provide information on the specific reasons for variation or on the costs of a key component of the service, the hourly rates paid to GPs. A clear understanding of the reasons for variation and whether it can be justified is essential. This will help patients, NHS England, commissioners and providers to understand what good performance and an efficient service look like, and to drive improvements in value for money. Recommendation: NHS England should take responsibility for developing an understanding of the significant variations across England in the cost of out-of- hours GP services and in the level of patient satisfaction with these services.

Clinical commissioning groups are not presently managing conflicts of interest when commissioning out-of-hours GP services. They should be able to demonstrate that they are. The design of the current system, where GPs can have interests in both the clinical commissioning groups that commission out-of-hours services and in the organisations that provide these services, brings an inherent risk of conflicts of interest. This issue should have been properly addressed before clinical commissioning groups were introduced. For example, in Barnet, Enfield and Haringey, a large number of GPs who work for the clinical commissioning groups also have shareholdings in the organisation that provides out-of-hours care. The National Audit Office found that clinical commissioning groups understood these risks and were acting to manage them, the potential for problems arising from conflicts of interest are considerable. However, where the number of GPs with conflicts is significant, this is not a practical solution. Some clinical commissioning groups have awarded out-of-hours contracts without a competitive procurement process which, when coupled with the potential for conflicts of interest, increases the risk to propriety and value for money. NHS England confirmed that it had issued guidance to clinical commissioning groups on how to handle conflicts of interest and that its local area teams would be seeking more assurance on this issue this year. Recommendation: NHS England should test whether its guidance on conflicts of interest is being followed and assess whether it offers enough safeguards. Where contracts for out-of-hours GP services have been awarded since 1 April 2013, it should seek documentary evidence that no one with an interest in the successful provider organisation was involved in the procurement process.

The urgent and emergency care system is complex and fragmented and the present financial incentives run the risk of undermining effective integration of the different elements. The urgent and emergency care system includes out-of- hours GP services, walk-in centres, urgent care centres and A&E departments. The Government also has an ongoing £50 million initiative to encourage GPs to extend their opening hours. These elements have largely operated independently of each other and the system is fragmented as a result. NHS England accepts that a great deal needs to be done to redesign out-of-hours and emergency services. NHS England’s review of urgent and emergency care has identified that the financial incentives are an important barrier to encouraging integration and ensuring patients are treated in the best place. Existing contracts provide incentives for A&E to hang onto patients and do not provide incentives to encourage out-of-hours services to take on more 6 patients. This is because A&E departments tend to be paid on the basis of activity, while out-of-hours services tend to have block contracts where payments are not based on the number of cases handled. NHS England and Monitor are consulting on reforms to the payment frameworks for urgent and emergency care. Recommendation: Given the pressures on the NHS budget it is important that NHS England should expedite the redesign of urgent and emergency care services. NHS England, working with Monitor, should urgently identify solutions for paying for urgent and emergency care that address the current mis-aligned incentives and promote the treatment of patients in the most appropriate setting and the most effective use of NHS resources.

Too many people are unaware of the different urgent care options and of how to contact them, meaning they may not receive care in the most appropriate setting. There are many ways to access urgent care which can leave people confused about what is the most appropriate service for them. As a result, too many go to A&E when they do not need to. NHS 111 is intended to provide a single entry point to urgent care, but about a third of adults in England have either not heard of NHS 111 or have heard of it but do not know what it is for. In addition, a quarter of adults have not heard of out-of-hours GP services. Awareness was lower still among certain groups including younger people and people from black and minority ethnic communities. While increasing awareness does not necessarily lead people to change their behaviour, NHS England acknowledged that it had a responsibility to improve public awareness of urgent care services so that NHS resources are used more efficiently. Recommendation: NHS England should set targets to increase public awareness of out-of-hours GP services and NHS 111, and collect data to monitor progress. As well as general public awareness, it should focus particularly on those groups with the lowest levels of awareness.

NHS England cannot at present assess how many GPs will be needed over the coming years. Having enough GPs is crucial to providing a safe and responsive out- of-hours service and minimising expenditure on more expensive hospital services. The National Audit Office found that, although only 6% of GP shifts were filled by agency GPs, out-of-hours providers are finding it harder to attract enough GPs. The Department has commissioned Health Education England to increase the number of GP training places by 10,000. However, it is uncertain what the overall impact on GP numbers will be, as existing GPs will be retiring at the same time. NHS England does not currently have a model to predict how many GPs will be needed in 2020 and does not intend to develop one until it has more certainty about the NHS budget to the end of the decade. In our view, NHS England cannot afford to wait for budgets to be set given the time it takes to train new GPs. Recommendation: The Department and NHS England should develop a model for the GP workforce now, and use the results to inform discussions about the budget the NHS needs and decisions about the number of GP training places required. 7 1 Oversight and Assurance

NHS England also highlighted that the Care Quality Commission will be inspecting all out-of-hours GP services, under its new inspection regime. The results of each inspection will be published.13 During its first wave of inspections, covering 30 out-of-hours GP services, the Care Quality Commission found that most were providing ‘safe, effective, caring, responsive and well-led care’.14

The National Audit Office estimated that out-of-hours GP services in England cost some £400 million in 2013-14, equivalent to £7.50 per person on average. The total cost was some £75 million less than in 2005-06, after adjusting for inflation.15 However, there was wide variation across the country in the cost per person and the cost per case. For example, 95% of contracts fell within a range of £28.30 and £134.30 per case in 2013-14, with the average cost being £68.30.16 NHS England told us that it was hard to draw conclusions on variation because the comparisons were not necessarily like-for-like. In general terms, it considered that some of the difference could be explained by the age, deprivation and mix of local populations. Variation could also be caused by geographic factors, which affect travel distances, and differences in what was included within the scope of different out-of- hours contracts.17 However NHS England had not carried out the analysis to support its assertions.

NHS England told us that, on the basis of the available data, it could not say whether out-of-hours GP services were more efficient now than they had been. We asked about the cost of hiring GPs, which is one of the main drivers of cost. NHS England noted that this cost varied widely across the country. However, it could not tell us what the cost per hour 9 Qq 16, 64, 94 10 Q 95 11 HC Committee of Public Accounts, The provision of the out-of-hours GP service in Cornwall, Fifteenth Report of Session 2013-14, June 2013 12 C&AG’s Report, para 2.10 13 Qq 16, 62-63 14 Q 92; C&AG’s Report, para 2.15 15 C&AG’s Report, para 7 16 C&AG’s report, para 1.17, Figure 2 17 Qq 23, 91 9 was, or how the cost now compared with the cost in 2008 when it ranged between £50 and £70.18

There is also significant variation in patient satisfaction with out-of-hours GP services across the country. The GP Patient Survey in July 2014 found that 66% of people rated their overall experience as ‘very good’ or ‘fairly good’. However, the proportion in each clinical commissioning group ranged from 86% to 49%.19 NHS England noted that the variation in satisfaction related to a variety of factors such as patient characteristics and geography. Younger people and people from minority ethnic backgrounds tend to be less positive about their experience, and levels of satisfaction with out-of-hours GP services are lower in London. In these respects, the position on out-of-hours GP services is consistent with other NHS services.20

The reforms to the health system, which took effect in April 2013, put GP-led clinical commissioning groups in charge of commissioning healthcare locally, including out-of- hours GP services.21 The design of the system brings an inherent risk of conflicts of interest as GPs can be part of both clinical commissioning groups and organisations that provide, or bid to provide, out-of-hours care.22 We highlighted the case of Barnet, Enfield and Haringey clinical commissioning groups where Barnet takes the lead in managing the contract with the provider, Barndoc Limited. We understand that eight members of Barnet clinical commissioning group are also shareholders in Barndoc Limited, with one member acting as the chair of Barndoc. In addition, across Enfield and Haringey, five members of the clinical commissioning groups are shareholders in Barndoc.23

NHS England told us that, if the aim was for local GPs to provide out-of-hours care, then by definition they could also be involved in the local clinical commissioning group. Nevertheless, there had to be ‘clear daylight’ between the people making commissioning decisions and the people who would benefit from those decisions.24 It confirmed that it had issued guidance to clinical commissioning groups on how to manage conflicts of interest, including in circumstances where a significant number of clinical commissioning group members have a conflict. The guidance sets out possible alternative arrangements such as the NHS England local area team awarding the contract, or another clinical commissioning group running the procurement process, where it is not feasible for the conflicts of interest to be managed by members of the clinical commissioning group excusing themselves from discussions.25

The National Audit Office found that clinical commissioning groups understood the risk of conflicts of interest and were acting to manage them. However, the safeguards relied 18 Qq 23-25, 37-39 19 C&AG’s Report, paras 2.19, 2.21 20 Qq 89-90 21 C&AG’s Report, paras 1.5-1.6 22 Q 78, C&AG’s Report, para 3.19 23 Q 65 24 Q 73 25 Q 75 10 on the people concerned disclosing their interests.26 NHS England told us that it planned to assess compliance with the requirements that people involved in bidding exempt themselves from any involvement in the procurement process. As part of the quarterly assurance process in September 2014, it would be asking clinical commissioning groups to demonstrate how they were managing conflicts of interest.27

NHS England also noted that transparent processes to test value for money, including competitive procurement where that made sense, should help to address the risk of conflicts of interest. However, the National Audit Office found that not all services were being competitively tendered: in five of the eight cases examined, contracts had been re- awarded without a competitive procurement process. NHS England said that, in a number of these cases, the contract had been rolled forward for a period to allow a combined, integrated contract covering, for example, out-of-hours GP services and NHS 111, to be procured at a later date.28 2 The wider urgent and emergency care system

The urgent and emergency care system is complex and includes a variety of different services, including out-of-hours GPs, NHS 111, walk-in centres, urgent care centres and A&E departments.29 The Government also has yet another initiative costing £50 million to encourage longer opening hours by GP surgeries. NHS England acknowledged that the system has been too fragmented, with the different services operating separately from each other.30 In January 2013, it began a comprehensive review of how urgent and emergency care services are provided. A key aim of the review over the next 18 to 30 months would be to join up different parts of the system and to simplify how people access urgent and emergency care.31

Different parts of the urgent and emergency care system are currently provided under different payment mechanisms and financial incentives are not aligned. For example, out- of-hours GP services tend to use block contracts where payments are not based on the number of cases handled, whereas A&E departments are paid on the basis of activity using ‘payment by results’ tariffs.32 Evidence from the urgent and emergency care review is that, even when local commissioners and providers come together and agree an integrated solution, it remains financially difficult for A&E departments to give up activity and for services in the community, such as out-of-hours GP services, to take on activity.33 NHS 26 Qq 65-67; C&AG’s Report, para 3.19 27 Qq 76-77 28 Qq 68-70; C&AG’s Report, para 3.17 29 C&AG’s Report, para 18, Figure 12 30 Q 4 31 Qq 4, 7; C&AG’s Report, paragraph 4.18 32 C&AG’s Report, paras 4.14-4.15 33 Q 19 11 England described the current system of financial incentives as ‘absolutely wrong’ and told us that the strongest message coming out of the urgent and emergency care review is that the way different services are paid for is a barrier to integration and needs to be reformed.34

NHS England has recently published a consultation document with Monitor on how hospitals, GPs, out-of-hours GP services and ambulance services are paid for urgent and emergency care. It is seeking views from the NHS on several different proposed models. It has also asked different parts of the country to work with it to test these new models during the course of 2015, with a view to rolling out broader payment reform in 2016.35 NHS England told us there was clearly a desire to reform the payment system. It envisaged a more uniform system of funding, with core elements that are there irrespective of the amount of work and activity components which help move patients through the care system in the desired way. The arrangements may differ to reflect different local priorities, for example in rural areas compared with urban areas. While recognising the need for national steering of reforms, NHS England also stressed that it could not simply impose changes, as local service planning is needed.36

People have been able to access urgent and emergency care through a variety of routes. However, the National Audit Office found that too many patients choose to go straight to A&E departments, increasing the pressure on these services.37 NHS England told us that it could not expect patients to understand precisely which service they need, for example whether they need to go to hospital or whether out-of-hours GP care is appropriate. The aim is for patients to be directed to the right place as quickly as possible however they approach the NHS.38

NHS England explained that the NHS 111 telephone number is designed to provide a single ‘gateway’ to urgent care. It highlighted that NHS 111 is a short, memorable number through which people can access any urgent care service in their local area.39 It said that new contracts for NHS 111 will start next year with revised specifications that will allow people to speak directly to a clinician if required. In addition, call-handlers will be able to book appointments for patients, for example at an urgent care centre, or arrange for patients to be called back by their own GP the following morning.40

However, the National Audit Office found that significant numbers of people are unaware of NHS 111—19% of the public had not heard of NHS 111, and a further 11% had heard of NHS 111 but did not know what it was for.41 In addition, 26% of the public had not heard of out-of-hours GP services. Awareness among certain groups, including younger people and people from black and minority ethnic communities, was considerably 34 Q 17, 20 35 Qq 17 36 Qq 19-21 37 Q4; C&AG’s Report, Figure 14 38 Qq 3, 55, 57 39 Qq 88; C&AG’s Report, paras 4.10-4.11 40 Q 56 41 Qq 1-2 12 lower than among other groups. For example, only 49% of black and minority ethnic people had heard of GP out-of-hours services.42

NHS England told us that, while public education is generally a poor way of changing people’s behaviour, it is responsible for increasing awareness and making it less confusing for people about what is the responsible thing to do when they or their family want urgent medical advice or treatment. In addition, NHS England suggested that evidence indicates that the way to change public behaviour is by learning through experience. If someone uses a service and it gives them what they want, they will use it again and they will also tell their friends and family about their experience.43

We asked NHS England about the supply of GPs to provide out-of-hours care. The National Audit Office found that, during September and December 2013, out-of-hours GP service providers filled 98% of their rota hours. The vast majority of hours were covered by directly employed or contracted GPs, with 6% of hours filled by agency GPs.44 However, providers are finding it harder to attract GPs to out-of-hours work for a range of reasons, including the rise in GPs’ in-hours workload.45

NHS England acknowledged that GPs are under pressure and that more GPs are needed to cover the increased workload in in-hours surgeries, out-of-hours services and A&E departments, and the predicted increase in the population. It told us that the number of GPs had increased by 20% in the last decade and was higher than ever. In addition, the Department has commissioned Health Education England to increase the number of GP training places by 10,000 and Health Education England has published a strategy for training places, including GPs, over the next 15 years.46 NHS England acknowledged that it needs to make GP training more attractive, including relative to hospital medicine. It told us that, in the last 10 years, the number of hospital consultants had increased by 76% compared with a rise of between a fifth and a quarter in the number of GPs.47

NHS England noted that, while the number of newly trained GPs was increasing, GPs were also retiring at the same time and there was no single forecast for how many GPs there would be in total by the end of the decade.48 It told us that there are a range of models to predict the number of GPs required to meet the increased workload. It looks at some of these models but does not have a single model to predict the number of GPs needed by