Out-of-hours service

Out-of-hours services are the arrangements to provide access to healthcare in the United Kingdom at times when General Practitioner surgeries are closed; normally between 6.30pm and 8am, at weekends, at Bank Holidays and sometimes if the practice is closed for educational sessions.

Most Out-of-hours services in Scotland and Wales are provided directly by Health Boards. In Northern Ireland they are provided by the Health and Social Care Trusts.^[1] In England they are commissioned by Clinical Commissioning Groups, usually working together, as the contracts often cover large areas. Out-of-hours providers in England must be registered with, and are regulated by, the Care Quality Commission.

The contract for General medical services which most GPs work to requires practices to be responsible for their patients between 8 am and 6.30 pm from Monday to Friday. In some cities commercial deputising services were set up employing doctors to cover the out of hour’s period, paid by the practices in the area but these weren’t viable in much of the country.^[2]

The GP Co-operatives prior to 2004

Woodside Health Centre in Glasgow established a successful deputising service before 1973: “. . . twenty general practitioners group together to provide a highly organised system of out-of-hours health care … The telephone” (at the health centre) ” is permanently manned and the patients are not involved in the delays of a post office diversion system. In the evening the telephone is answered by an experienced registered general nurse who can give advice where it is appropriate. In the event of a visit being required the nurse is able to contact the doctor on duty by radiotelephone. . . . . The patient’s previous notes are readily available to the nurse in the health centre and can be passed on to the doctor on duty. . . . Control of the system is exercised by a sub-committee of the health centre committee of management. The system thus has the advantages of a commercial deputising service in allowing doctors to have adequate time off duty, but control is exercised from within the health centre.”^[3]

In 1994 after minor changes to the GP contract many groups of doctors got together and formed cooperative organisations sharing the out of hours calls between a large number of GPs on a rota basis. A minimum of about 40 GPs were needed to set up a successful cooperative. In 1996 the G-Docs out-of-hours cooperative in Grampian became Scotland’s first out-of-hours general practitioner service, financed by 200 GPs who each paid a monthly subscription.^[4]

The Carson Report published by the Department of Health in 2000 proposed quality standards which would apply not only to deputising services and Out-Of-Hours cooperatives but also to individual GPs & practices providing their own cover.^[5] Carson's proposal for “A new model of integrated out-of-hours provision ... accessed by patients via a single telephone call, routed in the first place through NHS Direct and passed, where necessary, to the appropriate provider of out-of-hours services in that locality.” eventually developed into NHS 111 and influenced the formulation of the 2004 GP contract.

Until the 2004 contract most GPs provided care for their patients outside those hours either themselves, or as part of a GP Co-operative.^[6] The total amount earmarked for Out of Hours duties including Night Visit Fees was an average of just under £6000 per GP per year.^[7]

Changes after 2004

The new contract passed the responsibility for organising out-of-hours services from individual doctors to the Primary Care Trusts. Practices could opt out of the provision of out-of-hours services and lose the £6000 and most did. Some PCTs worked with the GP co-operatives, but some gave the contract to a commercial provider, commonly Harmoni or Serco both of which have been the subject of major complaints and of failing to employ sufficient doctors. By 2013 most of the co-operatives had converted to social enterprises.^[8] Many of the co-ops were involved in the provision of contracts to deliver NHS 111 services. According to John Horrocks, chief executive of Urgent Health UK, "It's not the same as it used to be, where everyone took their turn in a co-operative. It's more of a lifestyle choice. Now, you often find GPs who specialise in out-of-hours … typically, a shift rota is available on the internet and the GP is able to sign up to whatever shifts they want to work."

A study by the National Audit Office in July 2014 of people in England found that the urgent care system is complex and many people do not know how to contact out-of-hours GP services or even that such services exist;^[9] that 26% had not heard of out-of-hours GP services, and 19% had not heard of NHS 111.^[10]

Provision of out-of-hours services is a particular problem in remote locations. The Western Isles are an example of a remote area where new models of care are being trialled, with Community Unscheduled Care Nurses being deployed for patients who need to be visited at their place of residence.^[11]

David Cameron introduced plans to enable "hard working people ...to see their GP seven days a week and out of office hours" in September 2013. This promised access to GPs from 8am-8pm, and on Saturday and Sunday and to "test a variety of forward-thinking services to suit modern lifestyles, including greater use of Skype, email and phone consultations for those who would find it easier."^[12] Results from the GP Patient Survey, an independent poll run by Ipsos MORI on behalf of NHS England showed that extending opening hours and weekend opening were not a high priority for many patients. Long waits for appointments and failing to see a preferred, named doctor were more pressing issues. There was variation in demand for weekend opening with the highest demand in Windsor, Ascot and Maidenhead where some 28.1% of patients wanted surgeries open on Saturday but it was lowest in Wigan, where only 13.9% did.^[13]

In October 2014 GPs complained that the NHS 111 service had not been inspected by the Care Quality Commission and that it could jeopardise the safety of Out-of-hours services.^[14]

Commercial providers

Harmoni HS Ltd is a major provider of primary care, including out-of-hours services, which started as a GP co-operative and is now owned by Care UK.^[15] Care UK Clinical Services Limited now provides unscheduled care to over 15m patients.^[16]

IC24 provides services in East Sussex, Brighton & Hove, Kent, East Surrey and West Sussex.^[17]

Medvivo provides services in Wiltshire.^[18]

Nestor Primecare Services Limited provides out of hours services in Mid Essex, Dudley, Sandwell, Heart of Birmingham, South Birmingham, Wolverhampton, Herefordshire, Scarborough, Sunderland in England and Abertawe Bro Morgannwg and Carmarthenshire in Wales.

Serco had a contract to run out-of-hours services in Cornwall but NHS Kernow, the Clinical commissioning group, reached agreement with the firm to end the current contract at the end of May 2015 – 17 months early.^[19]

Take Care Now had contracts for services in Cambridgeshire, Suffolk, Great Yarmouth and Waveney, and Worcester. It was taken over by Harmoni.

Zafash Medical Services Limited provides services in central London on a commercial basis outside the NHS.

Not for profit providers

• Birmingham & District General Practitioner Emergency Rooms (BADGER)
• Brisdoc Bristol
• Central Nottinghamshire Clinical Services
• City Health Care Partnership CIC Hull and Knowsley
• Core Care Links Limited Grimsby
• Devon Doctors
• East Berkshire Primary Care Out Of Hours Services Limited
• East Lancashire Medical Services Limited
• GO To DOC Manchester and Sefton
• Grabadoc Greenwich and Bexley
• Northern Doctors Urgent Care part of Vocare
• Partnership of East London Co-operatives (PELC) Limited
• South East London Doctors' Co-operative (SELDOC)
• Staffordshire Doctors Urgent Care part of Vocare
• Urgent Care 24 Limited Liverpool, Halton and Knowsley

References

External links

• Urgent Health UK- federation of Social Enterprise Unscheduled Primary Care Providers
• The True History of GP Out of Hours Services