“Primary care out-of-hours services”
Item 3 is another report from the Auditor General for Scotland, on primary care out-of-hours services.
Caroline Gardner (Audit Scotland):
I would like briefly to introduce the report to the committee, focusing first on the background, then on planning, cost and quality for the new contracts, and finally on their impacts and future sustainability. Members know that for most people, contact with the NHS begins and ends in primary care, usually during the working day. However, there are more than 1 million contacts with primary care out-of-hours services each year throughout Scotland, in the evenings, at weekends and on holidays. Those contacts affect mainly children, older people and, as we have just been discussing, people with long-term conditions, palliative care needs and mental health problems.
In 2004, a new GP contract was introduced, which aimed to address the increasing commitment to on-call services among GPs and the effect that that was having on recruitment and retention, among other matters. As part of that contract, GPs are able to opt out of providing 24-hour care for their patients. By December 2004, 95 per cent of practices in Scotland had opted out and responsibility for those services had passed to NHS boards.
The changed role of GPs is important, but it is not the only change affecting out-of-hours services in Scotland. There is also the development of NHS 24 as the first point of contact for out-of-hours services and the introduction of new contracts for consultants, nurses and other health professionals, pharmacists and other NHS staff. All that means that the context in which NHS boards plan and manage their out-of-hours services has changed significantly.
On cost and quality, it is important to be clear that it is not possible to make a like-for-like comparison of the cost of out-of-hours services before the introduction of the new contract and following its introduction. That is mainly because the cost of the previous system is unclear. Some payments were made directly to GPs, but GPs picked up some costs themselves within the broader payments to which they were entitled. We highlight in the report that in future the Scottish Government should produce detailed national cost models before implementing major schemes. Such information should be used to inform negotiations around pay deals.
On the effect on individual practices, those who opted out of providing out-of-hours care had their income reduced by 6 per cent—that is known as the clawback. There were often only limited alternatives in particular parts of Scotland in which GP practices opted out, which meant that NHS boards had to buy back, on a sessional basis, the services of the GPs who had opted out. There are no national rates for that work and health boards across Scotland have had to work hard to contain the rates that they pay to individual GPs. Overall, out-of-hours services cost NHS boards about £68 million in 2006-07. Costs are much higher in remote and rural areas because they have had to fund a much higher proportion of the services themselves.
On quality, NHS boards have largely met the NHS Quality Improvement Scotland standards, which is important. However, those standards tend to focus on the processes and policies that are in place rather than on the real impact of the quality of care that patients receive directly. We think that there is more to do to understand that.
The impact of the changes was greater on the more remote and rural boards. That is partly because their patients are more dispersed, but it is also because fewer GPs are available in those areas to provide out-of-hours services under the new arrangements. Generally, fewer GPs are working to provide out-of-hours services across Scotland, but the shortage is particularly acute in remote and rural areas. We think that there is a significant risk that out-of-hours services may become unsustainable in the future in those areas.
There is a downward trend in the number of GPs who want to contract back to provide out-of-hours care, which cannot be allowed to continue indefinitely. One answer must be for boards to consider different ways of providing out-of-hours services, for example linking more with NHS 24 and the Scottish Ambulance Service, and considering extended roles for other health professionals such as nurses and paramedics.
We think that better information is needed throughout Scotland about how staff are being used and how their roles are being developed. We found examples of good practice, but we do not know comprehensively what is happening. We think that the links with NHS 24 and the Ambulance Service must continue to be developed and rolled out to ensure that they are as effective as possible, and that people should understand how integration is working in their area.
As part of the study, we surveyed a large number of patients to get a sense of how the system is working for them. We were pleased to find that more than 80 per cent are satisfied with the services, right through from initial contact to receiving advice from a GP or a local out-of-hours treatment centre. We also surveyed all GPs in Scotland about the impact of the changes on them. Eighty-eight per cent of those who replied to our survey told us that they are relieved that they no longer have 24-hour responsibility for their patients. However, it is significant that only 11 per cent of those GPs felt that patient care had improved as a result.
I will leave it there, convener, but we will do our best to answer members' questions.
Thank you.
This is another meaty report from Audit Scotland. I throw the floor open to members, but I remind them that our discussion of this report will take place under agenda item 7. I ask for questions and comments of a mainly factual nature, please, on issues around the report. We will start with the deputy convener, Murdo Fraser.
Thank you, convener, and good morning. This is an important report that has serious messages for us. I have a couple of questions.
I will start with the comment with which Caroline Gardner finished, which was on the survey of GPs. Your finding that they feel positive about being able to opt out might be called stating the bleeding obvious; I think that we would all have imagined that that would be the case. What work is being done on considering value for money in the new GP contract? Obviously, that will tie in with the wider issue of how out-of-hours services are operating.
I think that our report is the first significant piece of work that has looked at the impact of the contract in terms of cost and quality. It is difficult to make a judgment about value for money for two reasons. First, we do not have a good enough knowledge of the cost of the previous service to be able to make a comparison. Secondly, we are not collecting enough information about the quality of services—we do not have the performance information about how well patients' needs are being met, rather than simply whether the systems are in place, which is the focus of the NHS QIS work. One of the recommendations that we make in the report is that the health service should be doing more of that evaluation on a continuing basis, given how important out-of-hours services are to people across Scotland. We think that that matters.
A particular gap that we highlight is that, although the contract was clearly intended to focus on improving recruitment and retention, information on that is not now being collected centrally. A voluntary survey is done of the number of GPs and the number of vacancies, but there are no firm figures on whether recruitment and retention have improved across Scotland. That is an example of why it is hard for the health directorates to be able to demonstrate that value for money is being achieved.
Are you doing some work on the new GP contract?
We have a study under way on the wider GMS contract, which takes in the GP contract but also examines the other changes that were intended to be brought about, such as the quality and outcomes framework.
I want to pick up on what you said about current models of service delivery not being sustainable in the long term. The report makes a comment about the need for new ways of working. Were you able to identify the extent to which health boards are making progress on that? Are you satisfied that enough work is being done to get new ways of working into place?
The situation is variable. Some boards faced such pressures in the first few years of the new contract that they had no choice but to put in place new models—NHS Borders is a good example of that. It has made significant advances in the number of salaried GPs that it employs, which gives it much more flexibility in the use of GPs across the area.
Similarly, in other parts of Scotland, there have been trials involving paramedics taking on wider roles in the treatment of patients outwith hospital settings, without bringing them into accident and emergency departments. That is another area in which more monitoring is needed nationally. We must examine what the different groups in the workforce are doing, evaluate what works best and roll out good practice.
We are talking about massive and important changes in out-of-hours services, but the same problem arises of a fundamental lack of preparation. The lack of national data means that the overall impact of the change in the provision of out-of-hours services is not clear. We do not seem to have performance measures or baseline information. How doable is it to obtain such measures and information?
We think that that can be done and, more important, that it must be done. If the declining trend in the number of GPs who want to contract back in to provide out-of-hours services continues, it simply will not be possible to keep on providing 24-hour care in the way that we now expect. We need better information about the ways in which health boards are developing their solutions to the problem so that we can identify good practice, and we need to know much more about patients' experience of out-of-hours services when they require to use them. Some of that information could be collected fairly readily, but a national, co-ordinated approach is necessary and there must be agreement on what the key bits of information are so that we do not create a mini-industry in its own right, which none of us wants to do.
What you have said is common sense.
You believe that new ways of working are required, but is it acknowledged by the Scottish Government and NHS boards that such new ways of working exist? In other words, is there consensus about how such a joined-up system would work?
Different solutions are emerging in different parts of Scotland. To some extent, that is entirely appropriate. What works in the Borders or the Highlands will not necessarily be appropriate in Glasgow. However, it is also fair to say that we are not doing enough evaluation to understand what works best and are not collecting enough information about changes in demand and the quality of service that is provided to allow us to make decisions for the future.
We changed the system to try to acknowledge the pressures on recruitment and retention in rural and remote areas, but we are not able to say whether the change has made a difference. We hear anecdotally that it has not made a difference: the GPs who still provide the out-of-hours service still work 24/7, and those who do not are worried about how patients will be provided for. I am concerned that the change has not had the desired effect.
Recently I met GPs in West Lothian who spoke about the way in which their service is now being provided from a central venue. Rather than GPs going out to visit people in the middle of the night, people are asked to come to the central venue. Taxis are ordered to take them to the central venue and then away again. Do you know how much that service costs?
What additional costs have been placed on accident and emergency services and the Ambulance Service? There is a sense that people are not confident in the new, redesigned service and that they simply dial 999.
I will answer the second part of your question and ask Claire Sweeney to answer the first part.
You are right to suggest that we were very interested to know whether the change had affected accident and emergency services, the Ambulance Service and NHS 24. The patterns in the three services appear to be different. We did not find any evidence of increased activity in accident and emergency services as a result of the change to out-of-hours services. However, we noticed that demand for the Ambulance Service had risen quite significantly when the out-of-hours change was introduced. The Ambulance Service does not know why that it is. It is doing more analysis to try to understand what is going on—whether the increase is related to the change in the out-of-hours service, or whether it happened for quite different reasons.
The NHS 24 service had to roll out across Scotland much more quickly than had been planned as the change to the out-of-hours service came in. Evidence suggests that NHS 24 struggled a lot in the early stages, with long delays and high levels of call back. However, during 2006-07, the situation was brought well under control.
Overall, the evidence is mixed, but it all tends to reinforce the need to manage the system as one system rather than as single parts of one system.
Claire Sweeney will answer your question on the costs of local transport.
Claire Sweeney (Audit Scotland):
We collected information from all boards in Scotland and then broke it down into issues such as patient transport services. As Caroline Gardner suggested, the boards provide the services in very different ways.
It is fair to say that it was expected that, because of the change to out-of-hours services, transport issues would lead to financial concerns and to concerns over how the services would be organised. As Mary Mulligan rightly said, many patients are now expected to travel to a centre rather than having someone go out to see them. However, from our detailed work with a sample of boards, that did not seem to have been quite the issue that people had expected it to be. Some areas had put transport services in place, but the services were not being used as much as had been expected.
In our report, we highlight the point that boards worked very hard at the beginning to try to maintain services for patients. Part of that work was consideration of how to address transport issues. The boards took a cautious approach, but the impact on transport has not been as great as they expected. When we did a survey of patients, we asked about transport and it did not come up as a key concern. People seem ready to travel to centres and they understand the need for that.
That is interesting. We appreciate the value of a doctor's time, and we have to weigh that against the cost of the transport, but it is interesting that it does not seem to have been such an issue.
I have a quick supplementary question on NHS 24. We have spoken about recruitment and retention issues for rural and remote GPs. From discussions that I have had, it seems that NHS 24 is also experiencing difficulties with recruitment and retention—because of the workload that NHS 24 now has, and perhaps because of the pressure that is put on it by the media. Did you pick up on that?
We did not examine NHS 24 directly, other than with respect to the pattern of demand that it has picked up as a result of the changes that have been made.
You referred to the links between different services. Some of the studies that were done in the late 1990s clearly demonstrated that up to 40 per cent of accident and emergency cases were more properly primary care matters. You found no increase in A and E cases, but did you find a shift the other way? Has there been a transmission of individuals into the correct service? I refer to linkages between NHS 24 and referrals to A and E or to out-of-hours primary care services. Did you detect anything of that sort?
We did not test that directly. In fact, a full clinical audit would be required to do that. It is a fair assumption that having a single point of contact for out-of-hours services, through NHS 24, is likely to lead to better decisions for individual patients. They might be passed on to telephone advice and then triaged and passed through, or referred to an out-of-hours treatment centre or A and E if required. Having that single point of contact is likely to have improved the situation—although, as I said, we did not test that.
You said at the beginning that quality standards were broadly being met. However, exhibit 13 in your report seems to tell a slightly different story:
"No service has a full set of Key Performance Indicators in place".
You indicated that having key performance indicators is pretty important. Exhibit 13 goes on to mention that four NHS boards are working on that. One would have thought that, three years into the new service, some, if not all, key performance indicators should be in place by now. Did you get any indication from the NHS boards about how much of a priority that is for them?
Understanding the scale of change that has taken place is one of the central issues. When we interviewed service managers, their reactions were quite telling. Following the introduction of the GP opt-out through the new contract, they had a sense of the boards being responsible and they were considering how to implement a safe service for patients. There was a lot of concern among the boards about how to deal with that. As you would expect from such a situation, the focus was very much on maintaining the service.
I sense that the QIS standards, as they were initially developed, intended to reflect the context. Now, consideration needs to be given to the direct impact on patients. Clearer monitoring data are required on what is going on in the new service as it has been sustained so far. In addition, models have been changing over time.
I have a couple of questions for Caroline Gardner about the public perception of the service. Page 27 of the report contains figures that show quite high levels of satisfaction—85 per cent of the 600 people asked were quite happy with their out-of-hours care service. I presume that that very high figure is higher than the previous figure.
The figure seems to contradict some of the experiences that I have heard about. Members of the public sometimes find themselves attending A and E for treatment and, for a number of reasons, they do not enjoy their experiences there. Judging by representations that have been made to me in the past, people have felt almost as if they were waiting to be served at a bank, although they might have turned up bruised and bleeding. They have ended up talking to people through the curtain of their cubicle, giving out their private and personal details. I am surprised that the report makes no mention of that aspect of the patient experience. Is there more detail available that could be shared?
Yes. We have published a report supplement, which contains all the findings from the survey. We employed a market research firm to find 600 patients who had used out-of-hours services over the past year and to trace their experience from first contact to the end of the process. They were asked about the time that they had to wait, the attitude of the staff who dealt with them, the number of times that they had to give their name and address and what the problem was.
Although there were differences between groups of patients, depending on where they were being seen, we were surprised by how happy patients were, overall, with what they were getting. As with most public services, if we ask people how satisfied they are, surprisingly high levels of satisfaction come through. We did not pick up the sorts of concerns that you have mentioned from that large and statistically significant sample of people. Claire Sweeney might be able to add some colour to that.
Given the high profile of the service, we hear regularly about cases in which it has not been satisfactory or from people who are not happy with the care that they have received. As Caroline Gardner said, we expected issues such as transportation to arise. If people had to travel to get somewhere, they were less likely to be happy with the care that they received. We also expected that patients having to get used to people other than GPs treating them would be an issue, but that did not come across in the survey. As Caroline Gardner said, we asked questions about the service from NHS 24 right the way through to accident and emergency; we asked how happy people were with every service with which they had come into contact. We found that the experiences were generally positive.