Take Care Now set for takeover

Posted on February 18, 2010. Filed under: News stories, Providers | Tags: , , |

Healthcare Republic | Susie Sell | 18 February 2010

Private out-of-hours provider Take Care Now is set to be taken over by larger private firm Harmoni, after heads of agreement have been signed between the two companies.

David Cocks, chief executive of TCN, suggested the future of the company is ‘best placed with a larger organisation’.

He said: ‘Harmoni is a key operator in the delivery of healthcare services to the NHS in England. They are of a size and scale which enables them to take the work TCN has done in delivering timely and appropriate care forward to the next stage.”

Dr Tony Snell, medical director of Harmoni, said: ‘We are delighted to have the opportunity to provide primary urgent care out of hours services to patients across these new areas of the country for Harmoni.

‘We believe that Harmoni will be able to provide strong business management and leadership, safe systems and processes based on our experience elsewhere, and the right level of support to enable them to deliver the best quality service possible for local people.”

Harmoni currently delivers services to more than 7 million patients on behalf of around 20 PCTs predominately located in south England and the West Midlands. TCN provides health services to around 1.5 million patients.

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Should GPs commission out-of-hours services?

Posted on February 10, 2010. Filed under: News stories | Tags: |

GPs on the front-line are much better placed than PCTs to monitor out-of-hours care, argues Dr Charles Alessi. But Dr Ravi Mene disagrees, warning that if GPs take back out-of-hours it is bound to be underfunded.

Change is inevitable, growth is intentional… without doubt, the NHS is coming to terms with the fact that change is inevitable. We remain poised on the brink of a further acceleration of the pace of change. But then, growth requires change and involves risk – stepping from the known to the unknown.
The NHS has not stood still since the early nineties – but the pace and scale of change that is now being attempted goes far beyond what had been attempted before. The significant efforts being made to downsize the role played by acute hospitals and transform the district general hospitals to intermediate care community hospitals will combine primary, community and the less specialised aspects of acute care in one setting.

Access to urgent care is also in the process of transition, with a need for the multiplicity of access points to care to begin to converge. At present patients can access care via traditional out-of-hours GP services, accident and emergency, GP-led health centres, walk-in and urgent care centres. Clearly this is unsustainable. The multiplicity of these routes of entry with separate funding streams may well be economically unsustainable in the new environment of cost containment.

A further fundamental change which makes the input of primary care in out-of-hours services compelling lies with the development of polysystems. There is renewed urgency to ensure that leverage by GPs in commissioning is increased and made much more robust. A new world is emerging where primary care is expected to be more consistent in the way it offers services to patients and more predictable in the quality it offers.

There is also the near certainty that hard budgets for polysystems will become a reality – likely to happen sooner than many anticipate. If the patients of polysystems are going to benefit and general practice is going to be engaged, there seems to be no option but for practices to be the prime commissioner of out-of-hours services, given it is their money that is being spent in their operation and that if any efficiencies are to be realised it is to their populations that these will accrue.

So how to move from where we are now to where we need to be? Some practices have made a choice and opted out of the provision of out-of-hours services, giving the responsibility to PCTs to manage this aspect of patients care. There certainly seemed at the time to be minimal financial disadvantage to practices in doing so, as well as major reductions in risk and workload.

But it is now becoming clearer that primary care is much better placed to a more distant PCT to commission and manage these services. The role of PCTs needs to evolve into one where they need to ensure the services are delivered to a consistent and high-quality standard. Their role should be limited to performance-managing polysystems, which then commission services.

There is further change in the offing, which may make GP input in commissioning of out-of-hours services even more compelling. The new primary care choice agenda, with the potential for patients to have access to multiple entry points into primary care services, is a significant structural challenge. The potential exists for significant medico-legal risks, which need to be actively managed. Sharing of the care record is likely to be fundamental both in and out of hours, if risk is going to be managed effectively. How can we achieve all this without GPs taking a role in the commissioning and performance-management of out of hours care?

Dr Charles Alessi is a GP in Kingston upon Thames, Surrey, and medical director of the Kingston Co-operative Initiative

When the handover of responsibility for out-of-hours care was agreed with the Government of the time, it had broad support supported among all parties, although there were some exceptions even at that time who argued that it was our responsibility to provide out-of-hours cover. Some indeed continued to do so.
The Department of Health then started raising the quality thresholds to nudge out these providers, with the process of gaining approval for out-of-hours services increasingly becoming a tick-box exercise. The co-operatives were priced out of the game, and more and more private providers muscled in with the offer of a cheaper service – to the joy of PCT managers.

The rules of the game changed to suit the managers. The calls were screened and the decision to visit was taken from a remote place by anonymous people who did not even know the geography of the area. We had to part with £6K for no longer providing the service and responsibility was with PCTs. They soon realised it was not easy to provide the service with skeleton staff. If we had taken some of the decisions they make not to visit (triaging, as it is now known) we would have been hauled in front of the disciplinary panel. Now, staff are covered by the Government indemnity scheme, no one is responsible for their actions and every mistake is masked as a ‘significant event’.

Out-of-hours care was being run efficiently by GP co-ops, using local doctors who provided a local service for local people. This Government is hell-bent on destroying the ethos of primary care and has largely succeeded with the help of its friends in the media. Having made out-of-hours an emotive issue, ministers would no doubt like to pass it back to us.

Whether it will be backed by adequate financial resources is doubtful, however, given that the media has already softened public opinion by portraying GPs as fat cats doing no work. GP leaders have been ineffective in defending the hard work all of us do. If you say yes to Government requests, there is no guarantee that the pressure will cease.

If we were to be handed back the responsibility the round the clock care, we would be starting from scratch again, as most of the Co-op-type organisations have been extinct for several years. The organisation of an immensely complex service in a short time would be a big task. If we GPs accept the commissioning responsibility, mistakes are likely to happen in an underfunded service (which it will be) and this will give the politicians and the GP bashing media another stick to beat us with.

What guarantees would we need to take back out-of-hours? Would they reinstate the per visit fee as an item of service, or we will be expected to do on- call cover for a pittance, or commission it from others from our own pocket? This is anybody’s guess in the current economic downturn. It is more than likely some of your funding will be based on patients’ perception of how you respond to out of hours calls – a perfect ploy to obtain a service for free? The losers will be our patients, who will be left with an unsafe service in the name of an economy drive.

Dr Ravi Mene is a GP in Trafford, Manchester and a member of Salford and Trafford LMC.

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Government to bring in national model contract for out-of-hours care

Posted on February 5, 2010. Filed under: News stories | Tags: |

Pulse | By Gareth Iacobucci | 5 February 2010

The Government is to introduce a national model contract and tougher minimum standards for PCTs to use when procuring out of hours services, in order to create tighter controls on GPs providing out-of-hours care.

The announcement – which will also create more robust skills and knowledge testing for out-of-hours GPs – comes after a Government-sanctioned report into the standard of GP out-of-hours care revealed ‘unacceptable variation’ in commissioning and service provision around the country.

Launching the report today, health minister Mike O’Brien also pledged to give GPs a bigger role in planning local out-of-hours services, but ruled out making it compulsory for GPs to commission, a central plank of the Conservatives’ health manifesto.

The report, commissioned following the death of a patient given a fatal overdose by out-of-hours German locum GP Dr Daniel Ubani, said that although requirements were in place to provide ‘safe, high quality out-of-hours services’, this was undermined by the ‘unacceptable variation’ in implementation and monitoring by PCTs.

‘General Practice Out-of-hours Services,’ has been published to coincide with the coroner’s verdict on the death of David Gray, who was ruled to have been ‘unlawfully killed’ by Dr Ubani.

In a damning conclusion to the inquest, the coroner said the case amounted to gross negligence and manslaughter, and criticised weaknesses in the out-of-hours system.

It comes just a day after a confidential report leaked to Pulse revealed that patients have been placed at risk of ‘significant harm’ by a series of failings in an out-of-hours system in West Yorkshire.

The Government report – produced following a review by the Department of Health’s primary care tsar Dr David Colin-Thome and RCGP chair Professor Steve Field – makes a series of key recommendations for improving the commissioning and provision of out of hours care.

These include the requirements for PCTs to performance management arrangements in place for their out-of-hours services, and for the DH to issue guidance to PCTs to assist them in making decisions about whether or not a doctor has the necessary launguage skills.

The Department of Health has accepted all the recommendations in the report, but also pledged to go further in creating a model contract and tougher standards, the content of which will be consulted on before being introduced by the end of this year.

Mr O’Brien said: ”I am accepting all the recommendations made in today’s report and setting out new measures that go even further. These will tighten existing controls and ensure that out of hours providers are employing competent clinicians, providing safe and effective care.’

‘I expect all PCTs to act on these recommendations as a matter of urgency. It is unacceptable for any Trust to fail to meet its obligations on safety and quality of care.’

Dr Colin-Thome said: ‘The quality of out of hours care for most people is better than it was in 2004, but there is unacceptable variation in how services are implemented and monitored around the country.’

‘However, I am confident that by implementing the recommendations from our report, the system can be strengthened and vastly improved.’

Professor Field added: ‘The report outlines a number of important recommendations which will remind PCTs of their legal obligation to provide safe, high quality out of hours care.’

THE REPORT’S KEY RECOMMENDATIONS
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• PCTs should review the performance management arrangements in place for their out-of-hours services and ensure they are robust and fit for purpose;
• The Department of Health should issue guidance to PCTs to assist them in making decisions about whether or not a doctor has the necessary knowledge of English;
• The Department of Health should develop and introduce an improvement programme for PCTs to support their commissioning and performance management of out-of-hours services;
• Out-of-hours providers should consider the recruitment and selection processes in place for clinical staff to ensure they are robust and that they are following best practice;
• Strategic Health Authorities should consider how they monitor action taken by PCTs in response to this report and in carrying out appropriate performance management of out-of-hours providers; and
• Providers should co-operate with other local and regional providers (both in and out-of-hours) to share any concerns over staff working excessive hours for their respective services.

Reaction to the report

Click here to read the latest reaction to the Government’s report as it comes in.

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Leaked report damns ‘serious’ out-of-hours failings

Posted on February 3, 2010. Filed under: News stories | Tags: |

Pulse | By Ian Quinn | 3 February 2010

Exclusive: Patients have been placed at risk of ‘significant harm’ by a series of failings in an out-of-hours system spearheaded by NHS Direct, a confidential report leaked to Pulse warns.

An investigation into West Yorkshire Urgent Care Service, by the doctor who drew up the Government’s national standards on out-of-hours care, identifies a catalogue of ‘serious’ errors in the exchange of clinical information between NHS Direct and on-call GPs.

The report, dated 21 December, comes amid intense scrutiny of out-of-hours services, with the inquest into the death of a Cambridgeshire patient at the hands of a German locum set to deliver its verdict this week.

Report author Dr David Carson warns lessons from that tragedy and similar incidents, such as the death of London patient Penny Campbell in 2005, have not been acted upon.

In a disturbing echo of the Campbell case, his review finds the SystmOne mobile communication system used by the service failed to reliably update on-call GPs on patients’ clinical histories or highlight when they had called on multiple occasions.

NHS Direct, which triages calls for the service, provided no way for doctors to see how many cases were being dealt with at any one time, meaning ‘doctors may be passing urgent calls into a system that does not have the capacity to respond’.

NHS Direct was also criticised for classifying as many as 60% of cases as urgent, leaving the system at risk of being overloaded and true emergencies missed.

Dr Carson, director of the Primary Care Foundation and a leading out-of-hours expert, concluded: ‘I cannot emphasise enough the serious concern I have over the issues identified.

‘Any system requiring so many manual workarounds to ensure patients do not get lost must be unfit. If information about previous consultations is not available to clinicians, these are serious risks. The deficiencies are more serious given the complex provider network… I have no doubt there is a risk of significant harm to patients.’

The investigation came after fears were raised by GPs working for Local Care Direct, a non-profit organisation providing out-of-hours care in the area alongside private firm Care UK.

SystmOne is used by more than 1,000 practices covering 14 million patients as part of the national GP Systems of Choice scheme. It is used for out-of-hours across the huge Leeds-Bradford urban centre. The report says the mobile version was prone to freezing and losing data. Logging on in a moving vehicle at night took 15 minutes, while GPs were forced to read tiny laptop screens using a six-point font and could not update records.

Last week, Pulse revealed the Primary Care Foundation’s concerns about out-of-hours services using more than one provider. It warned: ‘We highlight the consequences in areas where the service is split or where misallocation of case type takes place.’

Dr Trefor Roscoe, a GP in Sheffield and long-term campaigner for better IT safety, said: ‘I’m appalled at these findings.’

Dr Mark Napper, out-of-hours clinical commissioning lead for the five PCTs that run the out-of-hours service with NHS Direct, insisted it had been ‘performing well’, but admitted: ‘There is room for improvement’.

He said the system had been updated to ‘red flag’ patients in contact in the previous 72 hours and check whether messages from NHS Direct had got through. But other key issues remain unsolved. Dr Napper said there was ‘no completion date’ for providers to agree on a system to monitor numbers of cases in the system. GPs are still unable to update patient records using the mobile equipment, although this ‘should be resolved by the end of the month’.

Pulse raised the report’s allegations with TPP, which produces the SystmOne software.

A spokesperson said: ‘TPP was pleased to attend the meeting when Dr Carson’s report was received and able to correct errors in it. Where problems were identified TPP was pleased to provide rapid improvements. We are continuing to work with the service to deliver system enhancements.’

Despite requests, TPP did not clarify what the ‘errors’ were.

OOH SAFETY FEARS
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• ‘Serious risk’ information about repeat callers not being passed on to GPs
• GPs unable to update system, meaning a risk ‘up-to-date information not available’
• Mobile computers hard to read and prone to losing data
• Up to 60% of calls classified by NHS Direct as ‘urgent’, placing doctors under ‘significant strain’
• No way for doctors to see how many cases were in system, threatening overload

Source: Report by Dr David Carson commissioned by NHS Kirklees

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Private providers to cover GP extended hours

Posted on January 28, 2010. Filed under: GP-led health centres, News stories, Providers | Tags: , |

Pulse | By Gareth Iacobucci | 28 January 2010

Private firms will be able to cover extended-hours shifts for practices that do not to provide the service, under the next stage of the Government’s controversial drive to widen access to primary care.

Neighbouring practices could also take on the shifts, in a move the GPC has denounced as ‘a terrific recipe for fragmenting care’.

A letter sent to PCTs and SHAs by Gary Belfield, DH head of primary care, sets out how the Government plans to implement prime minister Gordon Brown’s pledge that all patients would have access to evening and weekend appointments.

The letter, providing details on the extension of the extended hours DES for 2010/11, makes clear that practices will not be forced to offer extended opening themselves, but that other providers will be drafted in where a practice does not.

It says: ‘A key priority is to seek to provide access to evening/weekend appointments for patients whose practices are not providing extended opening, for instance by asking other practices to provide this services, or by commissioning out-of-hours providers to offer bookable appointment slots for routine care.’

One firm, the Practice PLC, which has won a string of GP-led health centre contracts, has already indicated its willingness to take on extended-hours shifts.

Dr Jeremy Rose, clinical director and founder GP of The Practice, said: ‘The Government’s proposal is something we support and is a principle already being delivered at GP-led health centres to non-registered patients. The traditional view patients value continuity of care more than convenience is becoming questionable.’

Latest figures show around 77% of practices offering extended hours, but the Government wants access for all patients and has agreed PCTs should plough £161m into commissioning extended opening 2010/11 under the updated DES.

But GPC chair Dr Laurence Buckman attacked the proposal, calling it ‘an aggressive act against general practice’.

‘Patients will be baffled by this, practices will be angered by it,’ he said. ‘It’s deliberately designed to antagonise practices who are not offering extended hours, and I’m not sure it will improve the care of those patients either.’

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Harmoni merger with Thamesdoc

Posted on January 27, 2010. Filed under: GP-led health centres, Press/News Releases, Providers | Tags: , , , |

Harmoni website | accessed 27 January 2010

Harmoni is delighted to announce that Thamesdoc GPs have voted unanimously in favour of their Board’s recommended merger with Harmoni.

Stephen Price, Chief Executive of Thamesdoc, said “The recent Care Quality Commission interim report highlights the importance of delivering a high quality service where patient care and patient experience are the top priority. We believe that this adds further weight to the move for Out of Hours providers to consolidate in order to have the scale to deliver the best patient care. Thamesdoc and Harmoni are a natural fit. We share common roots as GP based Co-Operatives, have a good fit culturally and are geographically adjacent. I am confident that this merger will enhance the ability of both organisations to deliver high quality care to the populations we serve”.

Andrew Gardner, Harmoni’s Chief Executive, said “This merger reinforces Harmoni’s position as the market leader in the provision of Urgent Care services in England, and further enhances our ability to invest in the people, infrastructure, systems and processes required to provide the best possible patient care. We will set up a new Region based on the South East Coast Strategic Health Authority geography made up of the two companies existing services in Surrey and West Sussex and targeting the new opportunities that are emerging across the rest of the SHA. We will retain the Thamesdoc brand in Surrey where it is well respected and continue to use the Harmoni brand elsewhere.””

Harmoni is a leading provider of primary care services to more than 6 million patients across England. Its services are commissioned by over 20 NHS PCTs and include Out of Hours services, GP led Health Centres, Urgent Care Centres, Single Points of Access and Admission Avoidance schemes.

Thamesdoc is a GP co-operative providing Out of Hours and other urgent care services to patients in Surrey and parts of West Sussex and Hampshire.

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Complaints about GPs on OOH shifts soar by 50%

Posted on January 27, 2010. Filed under: News stories | Tags: |

Pulse | By Gareth Iacobucci | 27 January 2010

A leading defence body has warned that complaints against GPs related to out-of-hours consultations are growing in number, with a 50% increase seen in the past two years.

The Medical Defence Union said it had been notified of 517 complaints related to out-of-hours consultations by GP members in 2007 and 2008, compared to 337 in the previous two years, an increase of 53%.

The study follows renewed calls from the Conservatives for GPs to take back responsibility for out-of-hours care, and the on-going inquest into the death of a patient given a fatal overdose by out-of-hours German locum GP Dr Daniel Ubani.

The MDU’s study found that OOH complaints now represented around 10% of the annual total of GP complaints, compared to 8% in the previous two years.

In total, the MDU reported 73 claims related to OOH consultations over the two years of the study, compared to 41 in the previous two years.

It also said only two claims have been settled to date, and in the MDU’s experience, around two-thirds of claims are discontinued or unsuccessful.

Dr Stephen Green, head of risk management at the MDU, said: ‘OOH care continues to represent a significant and growing proportion of the complaints we see. This analysis also highlights the communication challenges associated with OOH consultations which may make a complaint more likely if something goes wrong, compared to consultations within surgery hours.

‘For example, OOH consultations are generally associated with high levels of stress and anxiety for patients and their families: there may have been a wait to be seen by a doctor they have never met before; and they may feel more vulnerable because it is the middle of the night.

He added: ‘We are advising OOH doctors to pay particular attention to the need for clear, unambiguous communication with patients and colleagues, including accurate and comprehensive note-taking and arranging follow-up if necessary.’

Shadow health Minister Mark Simmonds blamed the increase on the Government’s changes to the OOH system back in 2004.

He said: ‘I have no doubt that this increase in complaints is mainly down to Labour’s flawed changes to the GP out-of-hours system, which took responsibility for the service away from GPs and gave it to local bureaucrats.’

KEY FINDINGS IN THE MDU STUDY

- 120 complaints and 52 claims included allegations of apparent failures or delays in diagnosis or referral. Most common conditions involved were myocardial infarction, septicaemia and meningitis. While it is inevitable that diagnoses will occasionally be missed, the MDU advises doctors to undertake and document the patient’s history and examination, including relevant negative and positive findings.

- 75 complaints and 17 claims were made following the death of a patient. It is impossible to rule out a sudden deterioration in a patient’s condition but it is important to review any diagnosis if there is any change and explain to patients and careers what to do if the condition does not improve.

- 71 complaints included allegations of rudeness or that the doctor had an uncaring or off-hand manner. One case featured an allegation that the doctor was chewing gum during the home visit.

- Problems with telephone triage featured in 19 complaints. In one case, a GP assessed a patient with abdominal pain and prescribed medication without visiting the patient, who later developed appendicitis.

- 13 complaints and claims in the study were referred to the General Medical Council (GMC). Four followed the death of a patient; two were sexual allegations and the majority of the rest related to poor performance.

Source: The Medical Defence Union

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OOH providers to be named and shamed in new benchmarking drive

Posted on January 22, 2010. Filed under: News stories | Tags: |

Pulse | By Gareth Iacobucci | 22 January 2010

PCTs and out-of-hours providers who fall short of national benchmarking standards are to be named and shamed under new plans to drive up standards of care.

The Primary Care Foundation is planning to publish names of trusts and out-of-hours providers, and patient feedback, as part of the next phase of its NHS-funded national benchmarking scheme.

The plan is outlined in the group’s latest report, which analyses the lessons learned from the first phases of its benchmarking scheme.

It comes as the inquest into the death of a patient given a fatal overdose by German locum GP Dr Daniel Ubani has prompted renewed calls from the Conservatives for GPs to take back ‘collective responsibility’ for out-of-hours care.

Although benchmarking information has so far been anonymised, it has exposed huge variations in the cost and quality of out-of-hours services.

The latest report warns many providers are missing ‘potentially urgent’ cases and suggests there is an ‘adverse impact’ where out-of-hours services are split between providers: ‘The next benchmark, planned for mid 2010, we expect to be open rather than anonymous. We are confident greater openness will help both commissioners and providers improve their services.’

Henry Clay, director of the Primary Care Foundation, said: ‘[At the moment] you have a PCT and provider doing X, Y and Z but can’t tell who they are. That feels daft.’

GPC chair Dr Laurence Buckman warned the mounting criticism over out-of-hours did not mean GPs should take back responsibility for cover, saying that would be ‘dangerous to patients’.

‘The BMA wants to see PCTs commission out-of-hours care with the involvement of local GPs. There also needs to be better investment and more rigorous monitoring, but there must not be a return to the system we had before the new contract.’

‘That would just mean replacing the current, poor system with a potentially dangerous one.’

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Buckman bites back over out-of-hours care

Posted on January 19, 2010. Filed under: News stories | Tags: |

Pulse | By Steve Nowottny | 19 January 2010

GPC chair Dr Laurence Buckman has issued a robust response to mounting criticism over out-of-hours care, warning that giving back personal responsibility for its delivery to GPs would be ‘dangerous to patients.’

An inquest into the death of a patient given a fatal overdose by German locum GP Dr Daniel Ubani has prompted a storm of negative coverage in recent days, with two highly critical columns in the Independent and in the Times, and renewed calls from Conservative health spokesman Andrew Lansley for GPs to be ‘collectively responsible’ for out-of-hours care.

Independent columnist Mary Dejevsky chided GPs for working ‘office hours’, and questioned whether ‘those who effectively clock on at 9am and off at 5pm really deserve the status the rest of us reserve for committed professionals.’

‘It is surely no coincidence that as GPs have fled out-of-hours working, more and more people have resorted to A&E departments,’ she wrote on Friday. ‘If the NHS wants to improve A&E, it should start by demanding more of GPs.’

But in a letter to the Times, which has yet to be published, and the Independent, published today, Dr Buckman insisted he had ‘never worked a 9-5 day’ and strongly defended the decision of most GPs to opt out of responsibility for out-of-care.

‘The current out-of-hours sytem desperately needs improving, but we can’t go back to where we were before 2004 where doctors were on call 24 hours a day, meaning many were operating in a constantly sleep-deprived state,’ he wrote.

‘We are where we are now with out-of-hours because right from the start of the new contract many primary care trusts were more concerned with cutting costs rather than ensuring patients go the best quality care.’

‘The BMA wants to see primary care trusts commission out-of-hours care with the involvement of local GPs. There also needs to be better investment and more rigorous monitoring, but there must not be a return to the system we had before the new contract.’

‘That would just mean replacing the current, poor system with a potentially dangerous one.’

In the wake of the Ubani case the Conservatives have reiterated their pledge to hand back overall responsibility for out-of-hours care to GPs.

Mr Lansley said: ‘When Labour took responsibility for out-of-hours care away from GPs they made a serious error.’

GPs ‘are best placed to ensure patients are treated properly and that these awful events are never repeated again,’ he added.

Dr Michael Dixon, chairman of the NHS Alliance, has also entered the fray, insisting that GPs are best placed to deliver OOH care.

‘Recent cases have highlighted the importance of local responsibility for out-of-hours services, ideally manned by local doctors and nurses, who are familiar with their communities and the services that support them,’ he said.

BUCKMAN’S LETTERS IN FULL

Letter to the Independent

Dear Sir or Madam,

Like everyone I have great sympathy for all those involved in the Ubani case and I agree with Mary Dejevsky that the current out-of-hours service for patients is nowhere near what it should be, but I am afraid she misses a vital point when she compares GPs to other professionals (Note to GPs: some jobs have to be 24/7, Friday 15 January 2010). As this case highlights, when doctors make mistakes the consequences can be tragic, and a tired doctor is a dangerous doctor.

The current out-of-hours system desperately needs improving, but we can’t go back to where we were before 2004 where doctors were on call 24 hours a day, meaning many were operating in a constantly sleep-deprived state. Ms Dejevsky’s suggestion that we work shifts is not an unreasonable one, but it would make it very difficult for our regular patients, such as the elderly and those with chronic conditions, to see the same GP twice. They tell us, time and time again, that they value continuity of care.

I am afraid I do have to take issue with Ms Dejevsky’s sweeping and unfair generalisation that all GPs work 9 – 5. I have never worked a 9 – 5 day in my surgery and I don’t know any other doctor who has either. All surgeries are open from 8am till 6.30pm, as a minimum, and I (like most GPs) am there from 8 to 8 doing things for patients.

We are where we are now with out-of-hours because right from the start of the new contract many primary care trusts were more concerned with cutting costs rather than ensuring patients got the best quality care. The BMA wants to see primary care trusts commission out-of-hours care with the involvement of local GPs, there also needs to be better investment and more rigorous monitoring, but there must not be a return to the system we had before the new contract. That would just mean replacing the current, poor system with an unsustainable, potentially dangerous one.

Yours faithfully,

Dr Laurence Buckman
Chairman of the BMA’s GPs Committee
BMA House

Letter to the Times

Dear Sir or Madam,

I understand why, as a patient, Libby Purves wants to see a return to ‘the good old days’ when, if you got ill, it was your family doctor who visited you in the early hours of the morning (If you must get ill, make sure it’s before 6pm, Monday 18 January 2010). I also agree that the current system needs changing, however, Ms Purves is viewing the past through rose-tinted glasses. For doctors, being on call twenty four hours a day, seven days a week took its toll; individual GPs were left permanently exhausted and the profession was facing a recruitment crisis. Those nearing retirement were getting out early and those looking to enter general practice were put off when they saw how burnt out they too would become. That is why most family doctors handed over responsibility for out-of-hours care when it was offered them; with the number of out-of-hours calls rising all the time they couldn’t physically do it any more.

The old system meant many doctors were tired and therefore potentially dangerous to patients and it is for that reason that the BMA, and the GPs it represents, would resist a return to doctors taking back personal responsibility for delivering care out-of-hours. However, some sort of middle ground needs to be reached as patients deserve better than they are getting now. The BMA wants to see primary care trusts commissioning out-of-hours care with the involvement of local GPs, better investment and a focus on more rigorous monitoring of out-of-hours services. But we can’t go back to a potentially dangerous old system which would, once again, have an impact on the quality of care patients receive in-hours and was therefore good for no-one.

Yours faithfully,

Dr Laurence Buckman,
Chairman of the BMA’s GPs Committee
British Medical Association

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DoH increases pressure on practices to extend hours

Posted on January 15, 2010. Filed under: News stories | Tags: |

Healthcare Republic | Prisca Middlemiss | 15 January 2010

Patients from practices not offering extended hours will be able to book evening and weekend appointments at neighbouring practices from April.

Alternatively they will be allowed to book routine appointments with their local out-of-hours service.

The two new schemes spearhead health ministers’ drive to increase the population able to access extended hours.

At the last count in July 2009, 77% of practices offered extended hours.

Gary Belfield, acting director of commissioning at the DoH, has told PCTs and SHAs they are expected to spend their full 2010/11 allocation of £161m on improving GP access.

‘We would expect PCTs in the first instance to seek to maximise the number of practices agreeing to provide the extended opening hours DES (or equivalent arrangements) in the run-up to 1 April 2010.’

Practices must sign up for the extended hours designated enhanced service (DES) early in the financial year so PCTs can plan how to spend their spare cash.

Practices already doing extended hours may be asked to open on more evening or weekend slots.

Dr Richard Vautrey, deputy chairman of the GPC, said ‘At a time when PCTs around the country are under severe financial pressure, I suspect that few will have the necessary resources to make either of these suggestions work.’

Dr Laurence Buckman, GPC chairman, said: ‘If the government wants to spend money it doesn’t have on something that a very small minority of patients say they want, but do not necessarily need, that is for it to decide.’

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GPs to be paid to offer extended hours to patients at neighbouring practices

Posted on January 14, 2010. Filed under: GP-led health centres, News stories | Tags: |

Pulse | By Ian Quinn | 14 January 2010

The Government is to allow practices offering extended hours to take over the evening and weekend care of patients from neighbouring GPs who refuse to provide the service.

In a major new drive to give all patients the right to evening and weekend appointments, the Department of Health has ordered PCTs to pay other practices or commission out-of-hours providers to plug gaps in GP take up.

The controversial move, which will mean patients effectively access care from two different practices, was revealed in a letter sent to all PCTs and SHA chiefs by DH head of primary care Gary Belfield, after details were announced of the extension of the extended hours DES for 2010/11.

Under the terms of the deal agreed with the GPC, GP practices are being asked to indicate early in the next financial year if they plan to take up the DES.

The document states: ‘A key priority is to seek to provide access to evening/weekend appointments for patients whose practices are not providing extended opening, for instance by asking other practices to provide this services, or by commissioning out-of-hours providers to offer bookable appointment slots for routine care.’

Health minister Mike O’Brien told MPs this week that the Government planned a system by which ‘neighbouring doctors can apply to be paid for seeing patients of practices that do not offer extended hours.’

The move comes with extended hours policy set to form a key health battleground between Labour and the Conservatives in the run up to the general election, with the Tories having said they would scrap mandatory extended hours targets for GPs.

Around 77% of practices offer extended hours, according to the latest figures, but the Government wants to expand it, after agreeing with GP leaders the DES which will see £161m ploughed in by PCTs for commissioning extended hours in 2010/11.

The Government has told PCTs all that funding must be used to improve to obtain more extended hours appointments and the document says that it would also be open to trusts to offer additional funding to practices already offering extended hours to get them to ramp up the number of appointments further.

Mr O’Brien claimed that the Government’s policy was driving uptake by making GP practices see that if they failed to take part they would lose out financially to their colleagues, claiming further pressure was being put on practices by the rollout of Darzi centres.

‘The new GP-led health centres are providing a real incentive for practices that up to now have not offered extended hours,’ he told the Commons.

‘They can see that GP-led health centres are there, and that some patients will start to use them unless GPs start to offer the extended hours. GPs can also see that, with £161 million available in the coffers of PCTs, additional funding is available for GP practices that offer extended hours.’

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Jump in non-emergency A&E attendances since GP out-of-hours opt-out

Posted on January 11, 2010. Filed under: News stories | Tags: |

Pulse | By Lilian Anekwe | 11 January 2010

The number of patients attending hospital for minor ailments and non-emergencies has leapt by a third since GPs opted out of out-of-hours responsibility, a new study suggests.

But the number of patients presenting with traumatic conditions has remained the same since the 2004 opt-out, found the research, published in January’s Emergency Medicine Journal.

Researchers analysed attendances at an emergency department for a two-month period every year between 1999 and 2006, and compared numbers ‘in hours’ with those occurring between 10pm and 8am.

Between 1999 and 2003 non-trauma attendances increased whereas emergency attendances remained stable. The number of patients attending out of hours for non-emergencies increased after this point ‘above what would be expected from extrapolation from 1999-2003 data’.

During the daytime non-trauma attendances rose, but by less than during the nights. The proportion of night-time non-trauma attendance rose, from 42.7% to 57.3%, a 34% relative increase. In-hours, there was only an 11% relative increase.

The findings add to evidence that the opt-out has left many patients confused about how to access out-of-hours services, and appear to back the Department of Health’s recent decision to pilot a new non-emergency number in three SHAs across England.

The researchers said the rise coincided with the GP opt-out, but that introduction of the four-hour target for admissions following attendance might also have contributed.

Miss Catriona Thompson, an A&E consultant at the Peterborough district hospital, warned: ‘An increase in patients with non-trauma during night shifts, which are necessarily the last well staffed, may lead to increased waiting times and reduced patient satisfaction.’

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NHS South Gloucestershire

Posted on December 30, 2009. Filed under: GP-led health centres, Press/News Releases | Tags: |

GPs over festive season | accessed December 2009

GP out of hours services

Frendoc and Brisdoc are the out of hours GP services that operate from 6.30pm- 8am Monday-Friday, all weekends and bank holidays. This service is provided by GPs and nurses who can offer telephone advice, face-to-face consultations, or home visits for patients who are housebound. This service is available for treating conditions that cannot wait until your GP surgery reopens. Ring your usual surgery where you will be given instructions or diverted to the out of hours service, or ring NHS Direct on 0845 4647.

GP led health centre

The GP led health centre in Kingswood is open from 8am to 8pm 7 days per week including bank holidays. You do not need to be registered at the health centre – you can use the services offered at the centre as well as your GP surgery. You can use the centre by walking in or phoning to make an appointment.

The Orchard Medical Centre
Macdonald Walk
Kingswood
Bristol
BS158NJ
Tel. 0117 9805100

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Take Care Now loses second out-of-hours contract

Posted on December 21, 2009. Filed under: News stories, Providers | Tags: , , |

Pulse | By Gareth Iacobucci | 21 December 2009

An private out-of-hours provider which came under fire over the death of a patient under the care of one of its foreign locum GPs has lost its second contract in a matter of weeks.

NHS Suffolk has announced it will not renew its contract with Take Care Now - which is due to expire in March 2010 – and has chosen Harmoni to take over out-of-hours responsibility in the county.

Take Care Now, which is based in Suffolk, has been under growing pressure following the death of 70-year-old David Gray last year, who died after being given an accidental overdose by German doctor Dr Daniel Ubani, working his first out-of-hours shift in the UK for the company in Cambridgeshire.

The contract is the second lost by the firm in recent weeks, after it had its contract with NHS Cambridgeshire terminated prematurely last month after failing new spot checks.

It follows a damning report on the David Gray case by the Care Quality Commission, which urged PCTs across the country to place closer scrutiny the performance of GP out-of-hours services, or risk failing to spot serious patient safety issues.

Andrew Hassan, medical director at NHS Suffolk, said: ‘The panel felt the arrangements of this provider [Harmoni] for clinical governance were robust and safe, its quality of care arrangements strong, and ideas for improvement and development of a quality service innovative.’

‘We would like to reassure people across Suffolk that during the transition period between service providers, we will make sure that the safety of patients using the service, and their clinical care, remains our top priority.’

A spokesman for Take Care Now said: ‘Take Care Now has expressed disappointment at not having been re-awarded the contract to run the out-of-hours service for NHS Suffolk but has committed to continuing to deliver innovative and patient-centred care in other areas for NHS Suffolk.’

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Frequently asked questions about GP-Led health centres

Posted on December 2, 2009. Filed under: GP-led health centres, News stories | Tags: , |

Eastern & Coastal Kent PCT | FAQ | accessed 2 December 2009

The following questions have been raised by members of the public at stakeholders groups held in Thanet and Swale as part of the process for talking to patients about how we intend to improve access to a GP.

These questions are posted here to help you find answers to any questions you may have. Please contact our public and patient engagement team if you have further questions.

Questions from Thanet Stakeholder meeting.

Will NHS Direct tell people to go to these new services?

Yes. These services will be part of the range of options available to patients to receive care, including your own GP, minor injuries, walk-in-centres or the new GP-led health services.

Will these services affect the out-of-hours services?

No. The current out-of-hours service is provided by South East Health Ltd and runs independently from GP-led health services. These services will continue to run as they do now. For more information, visit the South East Health website.

How many GP’s will be at the centre?

We do not know at this stage, but it is anticipated three to four are required to cover the rota.

How will unregistered patients be treated if they come from out of the area and what will their aftercare be like?

All patients will be assessed and treated according to their needs and will be given the option of receiving the right kind of follow up care if appropriate.

How will you monitor the drug users who may be out of area and asking for repeat prescriptions?

No patient will be treated without the proper procedures and checks being made using standard triage and reference to medical records as required.

How will you monitor the service when it is up and running?

These new GP-led health facilities will be monitored in the same way as existing medical facilities. There are strict clinical protocols to follow and health and safety issues to consider. Fully-trained staff will be required to check the performance of the services provided on a regular basis.

Will the service take into account the needs of drug users?  Will this be a problem?

Drug users will not be excluded from being treated. Any patient who visits the centre will be assessed and treated as appropriate.

Questions from Swale Stakeholder meeting.

How will this project be achieved on time?

The PCT has committed to having new GP-led health services up and running by April 2009. Tight deadlines are in place to ensure this happens. We have also pledged to develop further services beyond April 2009.

Will these services be where we want them?

Yes. Where these new services should be has been fully researched, including taking note of what has been said during public and patient consultation, GPs views and a health needs assessment. The location is one of many factors to be taken into account when looking at providing new services.

Is this over and above existing services or will some services be cut?

Yes. The PCT must clearly demonstrate that GP-led health centre provision is over and above current services. We do not have any plans to cut any existing services in order to progress these plans.

Will the summer visitor element be factored in?

Yes. These services are in addition to what already exists and will better help deal with demand. We are aware that any services we provide will have peaks and troughs in demand.

How were the Expressions of Interest advertised? (to provide these services)

Advertisements asking for expressions of interest in providing services were placed in appropriate press and publications specialising in this field.

How will the transport issues be addressed?

Transport issues will not be ignored. We continue to work closely with our partners to improve transport to and from our services. It is important to locate these new services correctly as one of the aims is to improve patient access to services. The PCT is committed to making more services available locally for patients.

Will patients who are not registered be entitled to home visits?

No. These new services are being designed to provide care on site between 8am and 8pm. It is not safe practice to use resources to visit an unregistered patient at home.

How will you check a GP’s competency?

This is done through stringent performance management, including a GP appraisal process and the PCT monitoring of any complaints.

How can you assure us this consultation is not a token measure?

We have involved patients throughout this process and the comments/thoughts and views of the public and stakeholders have been included in the very essence of the remit of this project – improving patient access. The PCT has a public and patient advocate on the project team handling GP-led health centre services.

Extra general questions posted.:

Is money being taken from existing GP services to fund GP-led health services?

No. Extra funding has been identified by government, specifically for GP-led health services and the PCT will be investing some funding of its own.

Will patients lose their existing GP if they use these new services?

No. Patients can have an existing GP and still use these new services.

What about under-doctored areas such as Swale?

New GP-led health services will help address the under-doctoring issue and provide improved access for patients to a GP. That’s one of the reasons Swale was identified as an area suitable for such a facility.

Will private companies get the business to provide these services?

A carefully managed tendering process will ensure the best provider of healthcare will be asked to provide these services. That could include existing GPs (working with other partners), an NHS organisation or a private company.

Will existing GP services close as a result of these services being provided?

No. These services are additional services designed to improve access to GPs and attract patients who may not normally visit a GP.

Will GPs running the centre be under-qualified?

No. Only fully qualified and experienced staff will be recruited to run these services

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Professor warns of ‘corporatisation’ of UK primary care

Posted on November 11, 2009. Filed under: GP-led health centres, News stories, Polyclinics | Tags: |

Healthcare Republic | By Colin Cooper | 11 November 2009

An international expert on primary care has warned that UK general practice is in danger of following its US counterpart in to ‘intensive care’.

Professor Gordon Moore, who received the President’s International Medal at the conference, said the tradition of general practice here was admirable compared to the ‘dreadful state’ of primary care across the Atlantic.

But he warned that the ‘corporatisation’ of the UK system, the erosion of the continuity of care and loss of established GP skills, were major threats to the future of the profession.

Professor Moore, from the Department of Population Medicine at Harvard Medical School, told the RCGP conference in Glasgow last week: ‘The loss of out-of-hours responsibility, the use of nurses and the emergence of Darzi centres, have all reduced the likelihood that a patient will see their own GP.’

He warned that the over-management of referrals by PCTs could de-skill GPs to the point where the NHS could remove the role completely, and said that the increase in salaried GPs could weaken the quality of general practice.

‘Corporatisation is coming to a place near you, either through private providers or by principals employing salaried doctors. Salaried GPs without a stake in the practice do not show the same drive to keep that practice at the forefront of excellence.

‘The very core of your 60-year story of success could be threatened. The most important things you can do are to remain competitive, alert, and continue to look for the best. General practice in America is on life support and we depend very much on you to lead the way.’

Professor Moore said he had been an admirer of the UK system since spending a year studying general practice in 1988. He highlighted the key strengths of the system as the overarching NHS structure, the product offered to patients, the approach to the selection and training of GPs, and the integrated nature of general practice.

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Minister reveals plans to bring in ‘daytime out of hours’

Posted on November 5, 2009. Filed under: News stories | Tags: |

Pulse | By Gareth Iacobucci | 5 November 2009

The Government is considering introducing a ‘daytime out of hours’ system to get round obstacles to abolishing GP practice boundaries, the health minister has revealed.

Speaking at the RCGP conference in Glasgow, Mike O’Brien said it may be possible for GPs to relinquish responsibility for daytime home visits for patients who chose to register at practices far away from their home.

Responsibility would fall on third party providers such as existing out-of-hours companies.

But the plans came under a barrage of criticism from GPs, who claimed the move is unworkable and will damage patient care.

Mr O’Brien was forced to defend plans to scrap boundaries, after GPs from the audience warned they risked jeopardizing the holistic nature of general practice.

The minister admitted details of how the plans will work in practice still needed much ironing out but attempted to reassure GPs by saying he did not expect many patients to move practices.

Mr O’Brien said: ‘The reason we’re doing this, is not because we believe large numbers of patients are going to start switching from one practice to another. I don’t think that’s likely to happen. Most people will stay with the GP they currently have.

‘But we do know that some people, particularly younger people, who are working in a big city, may want a GP in the centre of the city.

He added: ‘That will produce the issues of how you arrange visits. That will need to be worked through in detail as to how that will be delivered. It could be through a daytime out-of-hours service, there are a number of ways in which this could be delivered. The patients who make those decisions to move GPs will have to bear in mind who they want to visit them at home.

‘I know some people will be concerned, but patients want that element of choice.’

But GPs from the audience were left unimpressed with the claims. Dr Chris Walker, a GP in Wolverhampton, received a round of applause from delegates after expressing his concern at the plans.

Dr Walker said: ‘If we’re going to have a holistic view of patient care, with an emphasis on palliative care, and if we’re really keen on training GPs, part of that is going to be in the home. How will we be able to visit patients if they need, for example, palliative care, if they live 5-10 miles away?’

RCGP chair Professor Steve Field told Pulse that while he was open to discussing the abolition of practice boundaries, he was not in favour of a ‘daytime out-of-hours’ arrangement.

He said: ‘When I was in Australia, I saw GPs give up visits during the day. To me, this was not a good use of local health resources, and fractured the continuity of care that was needed.’

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Large out-of-hours provider merges with GP co-op

Posted on October 21, 2009. Filed under: News stories, Providers | Tags: , , |

Healthcare Republic | By Neil Durham | 21 October 2009

An out-of-hours provider looking after more than a tenth of England’s population has merged with a GP co-operative.

Harmoni is commissioned by over 20 NHS PCTs to provide services for six million people including out-of-hours, GP-led health centres and urgent care centres.

It merges with Thamesdoc, a GP co-operative providing out-of-hours cover and other urgent care services to patients in Surrey and parts of West Sussex and Hampshire.

Andrew Gardner, Harmoni’s chief executive, said: ‘This merger reinforces Harmoni’s position as the market leader in the provision of urgent care services in England.’

Stephen Price, chief executive of Thamesdoc, said: ‘The recent Care Quality Commission interim report highlights the importance of delivering a high quality service where patient care and patient experience are the top priority.

‘We believe that this adds further weight to the move for out-of-hours providers to consolidate in order to have the scale to deliver the best patient care.’ 

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GP–led, seven–days–a–week service, opens at Charing Cross Hospital

Posted on October 19, 2009. Filed under: News stories | Tags: |

Wellbeing Newsline | 19 October 2009

Edited by Nick Adams: Local residents in West London should benefit from easier access to GPs and emergency medical care since a new 24–hour health centre opened at Charing Cross Hospital recently.

The Fulham Centre for Health works alongside the emergency department to provide urgent care for people with minor injuries and illnesses. In addition, it functions like a conventional GP surgery and offers registration to local residents with appointments available between 8am and 8pm, seven–days–a–week. 

Because the Centre is located on a hospital site it can provide quicker access to diagnostic services, such as X–rays. It joins the Hammersmith Centre for Health, opened in April this year, to provide GP and out–of–hour’s services. 

Visit Imperial College Healthcare NHS Trust online at: www.imperial.nhs.uk.

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CQC calls for review of out of hours GP services

Posted on October 2, 2009. Filed under: Journals, Providers | Tags: |

Health Service Journal | 2 October 2009

A Care Quality Commission report has urged healthcare managers to review the quality of their out of hours services over fears that some private GP companies do not meet basic standards.

The CQC recommendation follows the death of 70-year-old David Gray last February, who was accidentally killed by a German doctor on his first out of hours shift in the UK.

Mr Gray died after being injected with a 10-fold strength dose of morphine. The doctor, Daniel Urbani, later told a court he was exhausted at the time and had only slept for a few hours before starting private work for a Cambridgeshire health trust.

The report into Take Care Now, the company that employed Dr Urbani and has additional contracts at trusts in Essex, Worcestershire, Suffolk, Great Yarmouth and Waveney and Cambridgeshire, concluded that all PCTs should scrutinise out of hours services more closely.

The report said: “They should look in detail at the services that they commission, including the efficiency of call handling and triage, the number of unfilled shifts, the proportion of shifts covered by non-local doctors, the induction and training those doctors receive, and the quality of the decisions made by clinical staff.”

CQC chief executive Cynthia Bower added current trust monitoring of Take Care Now’s services was “only scratching the surface”.

The CQC’s advice was backed up by health minister Mike O’Brien, who said patient safety was paramount.

Mr O’Brien said: “Primary care trusts have a clear legal responsibility to provide safe, high quality out of hours care and are required to have in place robust performance management arrangements to ensure their out of hours services are delivering against contractual requirements.”

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