Care Pathways

Out-of-hours GP system confusing and not enough oversight – MPs

There is not enough oversight of out-of-hours GP services or safeguards in place to prevent doctors awarding contracts to companies they have a financial interest in, MPs have warned.

In a report released today the Commons Public Accounts Committee found that CCGs are not managing conflicts of interest when commissioning out-of-hours GP services. Currently GPs can have interests in both the CCG commissioning the service and the company that provides it and this brings an “inherent risk” of conflict of interest.

The Committee highlighted Barnet, Enfield and Haringey CCGs in north London, where it found that eight members of the Barnet group are shareholders in Barndoc Healthcare Limited, which provides the areas out-of-hours services, and one member chairs it. Five members of the CCGs in Enfield and Haringey groups are also shareholders in the company.

Margaret Hodge, chair of the committee, said: “This issue should have been properly addressed before CCGs were introduced. CCGs must demonstrate how they are managing conflicts of interest and NHS England must assure itself that its guidance is being followed.”

The MPs are calling on NHS England to assess whether there are enough safeguards in place to stop conflicts of interest and investigate all out-of-hours contracts awarded after 1 April 2013 to make sure there were no conflicts.

The report also points to problems with significant variations in terms of cost and patient satisfaction with out-of-hours services across the country.

The cost per case can range from less than £29 to more than £134 depending on the area, while the proportion of people in each local area who rated their experience as 'very good' or 'fairly good' ranged from 49% to 86% in July 2014.

Hodge said: “A clear understanding of the reasons for variation and whether it can be justified is essential, but NHS England could not provide information on the specific reasons for variation or on the costs of a key component of the service, the hourly rates paid to GPs.”

The committee is also critical of NHS England’s oversight of the value for money of out-of-hours services. The report says NHS England viewed out-of-hours GP services as low priority and did not collect enough information to provide it with adequate assurance on value for money. In addition, it did not analyse data that was available from the GP Patient Survey to investigate services which were performing poorly or why overall patient satisfaction was falling.

NHS England says the scrutiny of out-of hours services will increase, but the Committee said assurances about future plans “does not excuse the failure to provide proper oversight so far”.

In general the urgent and emergency care system was found by the Committee to be too complex. The different elements, walk-in centres, A&E departments, out-of-hours GP services, were all found to operate independent of each other making the system fragmented.

“NHS England also needs to address the financial incentives which get in the way of different urgent care services working effectively together. Existing contracts provide incentives for A&E to hang onto patients and do not provide incentives to encourage out-of-hours services to take on more patients,” Hodge said.

The Committee is calling on NHS England to expedite the redesign of urgent and emergency care services, and to work with Monitor in addressing the current “mis-aligned incentives and promote the treatment of patients in the most appropriate setting”.

It also discovered that too many people are unaware of and are confused by the different urgent care options available. A third of adults were found to be either unaware of NHS 111 or to not know what is for. A quarter of adults also did not know that out-of-hours GP services were available. This has led to too many people going to A&E unnecessarily and NHS England needs to increase public awareness of the other options available, the Committee said.

Hodge added: “Too many people are unaware of the different urgent care options – such as out-of-hours GP services, walk-in centres, urgent care centres and A&E departments – and of how to contact them.

“This means people may not receive care in the most appropriate setting. As a result of the confusion, too many go to A&E when they do not need to.”

The final recommendation of the report was for NHS England to develop a model to predict how many GPs will be needed in 2020. With many GP places going unfilled and the Department of Health directing Health Education England to increase the number of GP training places by 10,000 there still remains an uncertainty on what the overall impact on GP numbers will be.

The report said: “NHS England does not currently have a model to predict how many GPs will be needed in 2020 and does not intend to develop one until it has more certainty about the NHS budget to the end of the decade. In our view, NHS England cannot afford to wait for budgets to be set given the time it takes to train new GPs.”

Reacting to the report, Dr Maureen Baker, chair of the Royal College of GPs, said: “Out of hours GP services in the main are very good, so it is frustrating that the hard work and commitment of many GPs across the country is once again coming into question.

“What is necessary in order to improve services is more GPs. We desperately need at least 8,000 more GPs in England alone, so we welcome the call by the Public Accounts Committee for NHS England to urgently address this need.

“We also support the recommendation that NHS England promotes public awareness of GP out-of-hours services. People visit their GP when they are vulnerable and in need of care and it is essential that they know where to turn, whatever the time of day.

“Patients want to be cared for by their local family doctors, in their communities, in and out of hours. However, if local GPs are to provide out of hours services, it is difficult to see how conflicts of interest can be avoided; the Committee should be reminded that many GP out of hours services pre-date the establishment of CCGs. 

“What is important is that good governance and transparency around conflicts of interests exists, and that our patients are aware of them.”

A spokesperson for NHS England told NHE that GPs are working incredibly hard, and for less than the cost of a cinema ticket they provide everyone in this country with year-round access to out of hours GP and 111 services.

“What’s more the real terms cost of doing so has been coming down year by year,” she said. “This report, which looks at the position a year ago, is however right to underline the benefits of much greater integration of GP, ambulance, and hospital emergency and urgent care services as proposed in the NHS Five year Forward View.”

(Body Images: Above left, Margaret Hodge c. Dominic Lipinski/PA Wire; Above right, Dr Maureen Baker)

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