There are three major disconnects causing problems with the quality of out-of-hours care provision (outside funding and staffing levels) that call on GPs to provide leadership. In the long term, GPs working exclusively in out-of-hours care shouldn’t be revalidated as GPs unless they demonstrate keeping up to date with chronic disease management. Equally GPs mainly working in hours can be challenged by unscheduled care shifts. An out-of-hours session in is not equivalent to one in hours.
Disconnect two: no coherent clinical governance. Some private companies delivering out-of-hours care are designated bodies with their own responsible officers. However, most require their GPs to be on a performers list which will have its own responsible officer taking priority for their revalidation: why? Within many out-of-hours providers there are no regular peer-to-peer meetings to discuss significant events. Confidentiality clauses also stymie transparency. The report by Colin-Thome & Fields on general practice out-of-hours services in England noted supervision of out-of-hours GPs was mainly through medical directors and indeed urged commissioners to separate discussions on service delivery from quality with providers to maintain focus. The National Out-of-Hours Operations Group meets monthly to interconnect the service in Scotland, but in England only a small number of providers share significant events confidentially and compulsory national quality markers are benchmarked by non-government organisations such as the Primary Care Foundation.
Out-of-hours care is now provided by many professions who are discretely trained, such as unscheduled care nurses via a range of routes, paramedics with different guidelines and drugs in their kit, and BASICS trained doctors, anaesthetists, and emergency care clinicians all with stakes in unscheduled care. Coordination is needed.
What to be done? Creating a national quality spine/contract running through all providers of NHS patient care (both private and public) would answer these points. Such a contract signed by all providers and their employees would preclude any access to NHS patients. This would necessitate regular significant event meetings with a duty of candour with all interprofessional same-sector peers contracted and paid to attend, linked to appraisal, chaired by experienced outside monitors. National standards are also required for provision of equipment and drugs in out-of-hours care. The seeds are there following the Francis and Berwick reports and the College can lead the debate.
Conscription of practice-based GPs again into 24/7 practice? (‘Oh! we don’t want to lose you, but we think you ought to go ...’, as the WWI recruiting song had it). No, a better solution would be to buddy-up willing out-of-hours GPs with practices to embed them locally to maintain their all-round practice and allow them to be link workers between the services, particularly with reference to vulnerable patients. And funding to achieve this public purpose.
- © British Journal of General Practice 2013