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• Report: Out-of-hours GP services in England
• Report: Out-of-hours GP services in England (PDF)
• Inquiry: Out-of-hours GP services in England
• Public Accounts Committee

The Rt Hon Margaret Hodge MP, Chair of the Committee of Public Accounts, yesterday said:

"People turn to out-of-hours GP services when they are worried about their own health or that of family or friends, and want urgent advice or treatment.

However, the urgent and emergency care system is complex and people struggle to know which is the right service to use.

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.

About a third of adults in England have either not heard of NHS 111 or have heard of it but do not know what it is for. In addition, a quarter of adults have not heard of out-of-hours GP services. Awareness was lower still among certain groups including younger people and people from black and minority ethnic communities.

NHS England should set targets to increase public awareness of out-of-hours GP services and NHS 111.

NHS England has not provided effective oversight of whether out-of-hours GP services are serving patients well and providing value for money.

There is an inherent risk of conflicts of interest in the current system of commissioning out-of-hours GP services, where GPs who are members of CCGs are able to commission services from organisations in which they have a financial interest.

For example, in Barnet, Enfield and Haringey, we understand a number of GPs who work for the CCGs also have shareholdings in the organisation that provides out-of-hours care.

Some clinical commissioning groups have awarded out-of-hours contracts without a competitive procurement process which, when coupled with the potential for conflicts of interest, increases the risk to propriety and value for money.

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.

Patients' experience of, and satisfaction with, the out-of-hours services varies significantly and unacceptably across the country, as does the cost.

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. The cost per case ranged from less than £29 to more than £134 in 2013-14.

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.

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.

Looking to the future, the Department of Health and NHS England must develop information to be able to know whether there will be enough GPs to cope with the growing workload. NHS England cannot afford to wait for budgets to be set to predict how many GPs will be needed given the time it takes to train new GPs."

Margaret Hodge was speaking as the Committee published its 22nd Report of this Session which, on the basis of evidence from Dame Barbara Hakin, National Director of Commissioning Operations, NHS England, Una O'Brien, Permanent Secretary, Department of Health, Simon Stevens, Chief Executive, NHS England and Professor Keith Willett, Director for Acute Care, NHS England, examined Out-of-hours GP services in England.

People turn to out-of-hours GP services when they are worried about their own health or that of family or friends, and want urgent advice or treatment.However, the urgent and emergency care system is complex and people struggle to know which is the right service to use. Patients’ experience of and satisfaction with the out-of-hours services varies significantly and unacceptably across the country, as does the cost. NHS England has not provided effective oversight of whether the services are providing value for money. It lacks the basic information needed to understand what lies behind the variations and identify where it should intervene. It has not dealt adequately with conflicts of interest which inevitably occur when many commissioners are also providers. NHS England also needs to address the perverse financial incentives which get in the way of different urgent care services working effectively together. It needs to examine whether the out-of-hours services are working properly with other services and whether the system encourages duplication when resources are so constrained. At the most basic level, the Department of Health and NHS England must develop information to be able to know whether there will be enough GPs to cope with the growing workload.

Out-of-hours GP services provide urgent primary care when GP surgeries are closed, typically from 6.30 pm to 8.00 am on weekdays and all day at weekends and bank holidays. In 2013-14, out-of-hours GP services in England handled around 5.8 million cases at an estimated cost of £400 million. Since 2004, GPs have been able to opt-out of providing out-of-hours care and most have done so. In these cases clinical commissioning groups are responsible for commissioning services. Around 10% of GPs have retained responsibility for out-of-hours care and NHS England commissions these services directly from the GP practices concerned. The Department of Health (the Department) is ultimately responsible for securing value for money for spending on health services and has set national quality requirements for all out-of-hours GP services. NHS England is accountable to the Department for the quality and value for money of out-of-hours GP services.

Conclusions and Recommendations

NHS England’s oversight of the value for money of out-of-hours GP services has been inadequate. Out-of-hours GP services are commissioned locally by clinical commissioning groups or NHS England’s local area teams. During 2013-14, 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. No up-to-date information is available to allow clinical commissioning groups to benchmark the cost of their services and how they perform against the national quality requirements. Available data is over 2 years old. NHS England said that scrutiny of out-of-hours GP services will increase in the future and that the Care Quality Commission would be inspecting the quality and safety of all services. However, assurances about future plans does not excuse the failure to provide proper oversight so far.

Recommendation: NHS England should adopt a proportionate oversight regime which provides it with assurance on the value for money of out-of-hours GP services and allows it to identify poorly performing services and make targeted interventions.

NHS England should do more to understand the reasons for the significant variations in cost and patient satisfaction. There is significant variation across the country in both the cost of out-of-hours GP services and patient satisfaction with these services. For example, the cost per case ranged from less than £29 to more than £134 in 2013-14. 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. NHS England demonstrated a general understanding of what may drive the variation in cost and patient satisfaction, but it appeared to have little specific information. In evidence to us, it relied almost entirely on the cost data collected by the National Audit Office and 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. A clear understanding of the reasons for variation and whether it can be justified is essential. This will help patients, NHS England, commissioners and providers to understand what good performance and an efficient service look like, and to drive improvements in value for money.

Recommendation: NHS England should take responsibility for developing an understanding of the significant variations across England in the cost of out-of-hours GP services and in the level of patient satisfaction with these services.

Clinical commissioning groups are not presently managing conflicts of interest when commissioning out-of-hours GP services. They should be able to demonstrate that they are. The design of the current system, where GPs can have interests in both the clinical commissioning groups that commission out-of-hours services and in the organisations that provide these services, brings an inherent risk of conflicts of interest. This issue should have been properly addressed before clinical commissioning groups were introduced. For example, in Barnet, Enfield and Haringey, a large number of GPs who work for the clinical commissioning groups also have shareholdings in the organisation that provides out-of-hours care. The National Audit Office found that clinical commissioning groups understood these risks and were acting to manage them, the potential for problems arising from conflicts of interest are considerable. However, where the number of GPs with conflicts is significant, this is not a practical solution. Some clinical commissioning groups have awarded out-of-hours contracts without a competitive procurement process which, when coupled with the potential for conflicts of interest, increases the risk to propriety and value for money. NHS England confirmed that it had issued guidance to clinical commissioning groups on how to handle conflicts of interest and that its local area teams would be seeking more assurance on this issue this year.

Recommendation: NHS England should test whether its guidance on conflicts of interest is being followed and assess whether it offers enough safeguards. Where contracts for out-of-hours GP services have been awarded since 1 April 2013, it should seek documentary evidence that no one with an interest in the successful provider organisation was involved in the procurement process.

The urgent and emergency care system is complex and fragmented and the present financial incentives run the risk of undermining effective integration of the different elements. The urgent and emergency care system includes out-of-hours GP services, walk-in centres, urgent care centres and A&E departments. The Government also has an ongoing £50 million initiative to encourage GPs to extend their opening hours. These elements have largely operated independently of each other and the system is fragmented as a result. NHS England accepts that a great deal needs to be done to redesign out-of-hours and emergency services. NHS England’s review of urgent and emergency care has identified that the financial incentives are an important barrier to encouraging integration and ensuring patients are treated in the best place. 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. This is because A&E departments tend to be paid on the basis of activity, while out-of-hours services tend to have block contracts where payments are not based on the number of cases handled. NHS England and Monitor are consulting on reforms to the payment frameworks for urgent and emergency care.

Recommendation: Given the pressures on the NHS budget it is important that NHS England should expedite the redesign of urgent and emergency care services. NHS England, working with Monitor, should urgently identify solutions for paying for urgent and emergency care that address the current mis-aligned incentives and promote the treatment of patients in the most appropriate setting and the most effective use of NHS resources.

Too many people are unaware of the different urgent care options and of how to contact them, meaning they may not receive care in the most appropriate setting. There are many ways to access urgent care which can leave people confused about what is the most appropriate service for them. As a result, too many go to A&E when they do not need to. NHS 111 is intended to provide a single entry point to urgent care, but about a third of adults in England have either not heard of NHS 111 or have heard of it but do not know what it is for. In addition, a quarter of adults have not heard of out-of-hours GP services. Awareness was lower still among certain groups including younger people and people from black and minority ethnic communities. While increasing awareness does not necessarily lead people to change their behaviour, NHS England acknowledged that it had a responsibility to improve public awareness of urgent care services so that NHS resources are used more efficiently.

Recommendation: NHS England should set targets to increase public awareness of out-of-hours GP services and NHS 111, and collect data to monitor progress. As well as general public awareness, it should focus particularly on those groups with the lowest levels of awareness.

NHS England cannot at present assess how many GPs will be needed over the coming years. Having enough GPs is crucial to providing a safe and responsive out-of-hours service and minimising expenditure on more expensive hospital services. The National Audit Office found that, although only 6% of GP shifts were filled by agency GPs, out-of-hours providers are finding it harder to attract enough GPs. The Department has commissioned Health Education England to increase the number of GP training places by 10,000. However, it is uncertain what the overall impact on GP numbers will be, as existing GPs will be retiring at the same time. 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.

Recommendation: The Department and NHS England should develop a model for the GP workforce now, and use the results to inform discussions about the budget the NHS needs and decisions about the number of GP training places required.

Further information

• National Audit Office report: Out-of-hours GP services in England
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