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Focus on out-of-hours

• Annex 1 - Innovative out-of-hours schemes
• Definition of out-of-hours
• Informing patients of the transfer of responsibility for out-of-hours
• Out-of-hours funding
• Practices and LMCs
• Procedure for handing over responsibility for out-of-hours
• Those that cannot hand over responsibility
• Transfer of responsibility
• Transferring responsibility for out-of-hours

• Between 1 April 2004 and 1 January 2005, with the agreement of the Primary Care Organisation (PCO), practices can transfer responsibility for out-of-hours provisions.
• From 1 January 2005, where practices have handed over responsibility, PCOs will take full responsibility for making sure there is effective out-of-hours provision:

• Once a date has been agreed between the PCO and practice (OOH day), and has passed the PCO will not be able to transfer out-of-hours back to GPs who handed over responsibility, if the PCO has any problems providing or commissioning the services.
• Between 1 April 2004 and 1 January 2005, after out-of-hours (OOH) day (the date on which the out-of-hours transfer of responsibility is to commence) has arrived, and in the absence of a service of notice by the PCO under schedule 3 para 5(10(a) of the NHS (GMS) regulations 2004 or an application to the Strategic Health Authority under para 5(1)(b) having been made before OOH day, then the PCO will not be able to transfer out-of-hours responsibility back to the practice.
• Contractors will have a right to transfer responsibility for out-of-hours from 1 January 2005, except where the strategic health authority has agreed (or the Assessment Panel in Scotland) with the PCO that there are exceptional circumstances.

• Practices that do not want to retain responsibility for out-of-hours, can hand over responsibility for providing the service from 1 January 2005 (or before 1 January 2005 if the PCO has arrangements in place to allow this). The PCO will not have a veto on this. If you want to transfer responsibility from 1 January 2005, you can do this without the approval of the PCO unless at least one month before 1 January 2005, the PCO serves notice that it has made an application to postpone or refuse the transfer. This should only occur with regard to those practices in very remote or isolated areas and where the Strategic Health Authority (SHA) (or in Scotland, the Assessment Panel) has agreed with the PCO that there are exceptional circumstances (see below).
• Practices can continue to provide out-of-hours services if they choose to do so.
• Transferring responsibility is not possible on an individual doctor basis. Under the practice-based contract, the transfer of responsibility is on a practice basis only. How a practice makes that decision will be subject to the arrangements in their partnership agreement.
• PCOs can consider a range of alternative providers for out of hours:

• From 1 January 2005, a contractor who provides out-of-hours services must, in the provision of such services, meet the quality standards set out in the document entitled ‘National quality requirements in the delivery of out-of-hours services'. These quality standards are available on the Department of Health's website . In Scotland, the standards for out-of-hours services are currently being developed by Quality Improvement Scotland
• Any practice that hands over responsibility for out of hours will not automatically be entitled to provide the service if they wish to move back at a later date. Practices that transfer responsibility or new practices that want to provide out-of-hours services “will be considered alongside other potential providers” [paragraph 2.19 contract document]. All potential providers will have to show that they meet the relevant accreditation standards.
• GMS and PMS practices do not have preferred-provider status for out-of-hours services that other contractors have chosen not to provide.
• A practice may not withdraw an out-of-hours transfer of responsibility notice once it has been approved by the PCO without the PCO’s agreement.
• Transfer of responsibility is all or nothing. The practice cannot, for example, hand over only at weekends.
• The new arrangements for out of hours will not prevent practices being able to offer surgeries or consultations during the out-of-hours period, for example, Saturday morning surgeries. In addition, PCOs can commission services during the out-of-hours period to deliver longer hours of operation:
• PCOs may contract to deliver this as an enhanced service at the request of the practice
• where the PCO asks the practice to open at any time during the out-of-hours period, the PCO must contract for this as an enhanced service
• where the PCO does not agree to contract for this as an enhanced service, the practice will be under no obligation to provide this but, if it chooses to do so, it will have to fund this out of the practice’s global sum.

• Practices which decide to hand over responsibility must give notice to the PCO, in writing, and specify the date from which it would like the transfer to take effect. This must be either three or six months after the date of service of the out-of-hours transfer of responsibility notice. The practice does not have to give reasons for handing over responsibility.
• PCOs should approve the transfer of responsibility notice as soon as is reasonably practicable or within 28 days of receiving the notice and specify the date on which the out-of-hours transfer is to commence.
• Where a practice relinquishes responsibility for out of hours it must comply with any reasonable request for information relating to the provision of that service. All GMS contracts include a term requiring contractors to co-operate with other people who provide out-of-hours services to their patients. [Paragraph 43.2 of the GMS contract]
• When responding to the notice (within no more than 28 days), the PCO cannot refuse the transfer of responsibility request. For notices given before 1 October 2004, it can however set a different target date for the transfer to take effect. This can be any day from the date specified by the contractor up to 1 January 2005. For notices given after 1 October 2004, the PCO must specify the date given by the contractor in its transfer notice (that is, 3 or 6 months from the date of the notice)
• The PCO must do its best to put in place the necessary arrangements for the contractor to transfer responsibility by that target date. Where this is not possible the PCO can, if necessary, extend the period to 9 months. The nine month rule means that, for example, a contractor that gives notice on 1st May 2004 may not be able to hand over responsibility until 1st February 2005, if the PCO is unable to secure alternative provision before then
• The PCO can only refuse or further delay transfer of responsibility in exceptional circumstances, for example if the contractor’s location is so remote or isolated that there is no realistic alternative to the contractor continuing to provide its own out-of-hours services. In England, exceptional circumstances are expected to be extremely rare and the PCO would require the SHA’s permission. SHAs will also be performance managing PCO progress towards effective re-provision, to ensure that there is no slippage. In Scotland it is anticipated that only a very few of the most isolated practices will be unable to hand over responsibility. PCOs must obtain the agreement of the Assessment Panel before the Practice’s application to transfer responsibility is refused or postponed.
• Nothing in the transfer procedures prevents PCOs and contractors at any time agreeing a different date for the transfer to take effect.

• the retention of the out-of-hours abatement
• payment of the weighted capitation share of the OOHDF and any increased investment by the NHS Boards for providing out-of-hours services
• an additional payment to cover any differential between the total of these and the locally determined premium payable to salaried GMS practitioners for providing out-of-hours services.

• LMCs may wish to consider developing model letters for use by practices informing patients of the change in out-of-hours services.
• Fewer practices will be providing out-of-hours services in the new contract world. This is an opportunity for PCOs and for co-ops to review and consider the services they are providing and to plan new ways of providing these services. Examples of innovative out-of-hours schemes are attached at annex 1. These can also be found in the contract supporting documentation
• LMCs could consider working with the PCO to ensure that any service commissioned by the PCO will be of equal or improved standard to current out-of-hours services, and comprehensive enough to prevent increasing amounts of work cascading back to practices in hours. All the services PCOs commission will need to meet the national quality standards.

• Large co-op (500 GPs) incorporating visiting service, five primary care centres
• Integration between NHS Direct and co-op. All A&E calls intercepted and routed as appropriate
• In A&E department nurses triage patients in waiting area where there are also phone boxes for patients to speak to NHS Direct.

• Aim is to provide patients with the same experience whether accessing emergency care in person or by telephone
• Partnership between co-op, NHS Direct, PCT, A&E, acute trust, out-of-hours co-op, community pharmacists, mental health and social services
• A&E streamline patients into minor illness, minor injury and majors
• Minor injury seen by senior house officers
• Minor illness seen by nurse practitioners or GPs
• Skill mix being implemented (injury/illness)
• GPs contracted so their indemnity remains with MDOs
• Running since April 2002, and currently under evaluation

• Home visits by GPs would cease between 7pm and 8am
• An experienced doctor would be present in two centres within the PCT area
• These doctors would have admission rights to the hospitals, on-call diagnostic imaging and emergency pathology facilities
• These doctors would assume responsibility for the inpatients of the hospital

• Three paramedics in three ambulance vehicles on the road in radio contact with medical centres and ambulance control for:
• Urgent home assessments
• Transportation to medical centres if necessary
• Initiation of front line treatment e.g. pain control, catheterisation etc.

• Nursing and social care staff (numbers required are not yet clear) on the road in radio contact with medical centre, paramedical service and ambulance control for:
• pallative care
• general nursing interventions to sustain people at home
• social care interventions to sustain people at home
• to remain if required in people’s homes and throughout the night for crisis management.

• Integration of local co-operative and the nurse led walk-in centre onto one site by April 2003
• Service development consistent with the Carson vision, phased implementation due to some current issues connecting to NHS Direct
• Will provide base for evening and night community nursing and paramedic support team
• In the interim GPs are being resourced to cover the ‘red eye’ shift – there are proposals for nurses working initially in parallel with the out-of-hours doctors to determine if a nurse led service is viable
• Additional nursing required has been identified in the Access & Capacity return.

• Trust provides call answering & referral, organisation of GP out-of-hours bases and provision of vehicles, drivers and communications to local co-ops
• A variety of commercial deputising, self-funding and ‘paying’ GP co-operatives currently exist in the area
• All are under pressure with fewer GPs willing to participate in out-of-hours work
• In 2000, a community paramedic was based in a GP surgery in a very rural area – resulting in improved ambulance response times. GPs have integrated the paramedic into their work
• The paramedic now does emergency house calls, takes bloods and performs ECGs, assists practice nurses and responds to 999 calls
• In 2001, 29 additional paramedics were based in GP practices in community roles. They refer suitable 999 cases back to practice team, resulting in increased ambulance performance. They are being used to ease some aspects of GP and primary care workload
• The Trust is working with the Workforce Confederation to extend higher education programmes for paramedics to develop primary care emergency practitioners and thus be able to undertake more of the role of the out-of-hours GP.

• The emerging vision is to develop a high quality, integrated, multi-agency, multi-disciplinary, urgent out-of-hours service with single call access. Key features of this service are perceived to be:
• An integrated urgent care service operating from a single set of premises, incorporating out-of-hours nursing services, GP out-of-hours services and accident and emergency care
• A multi-disciplinary approach to triage, assessment and treatment which is nurse led, with streaming to appropriate health and social care professionals
• Joint development of the role of nurse practitioners across A&E and primary care
• A satellite nurse led out-of-hours service, with appropriate links to the core out-of-hours centre in terms of transport and back up from medical staff
• Strong links with intermediate care services and social care services, and the ability to access these as and when required
• Primary care practitioners to have access to investigations out of hours
• Integrated information systems to facilitate communication and transfer of data between agencies
• A seamless care pathway for people accessing services
• Single telephone access to out-of-hours health and social care services