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Out-of-hours is key in new GP contract

01 Feb 2017

Dr Michael Kelleher

The funding and administration of GP out-of-hours services will be a key element of any new GMS contract, argues IMO GP Committee member Dr Michael Kelleher

It is widely accepted that a greatly enhanced primary care service is an essential foundation for our health service. In this regard, commencement of negotiations between the IMO, HSE and Department of Health (DoH) on a new GMS contract are welcome. The GP out-of-hours (OOH) service will be a very important issue for all stakeholders to a future contract.

General practice has a vital role to play in the delivery of effective patient care at all times of day, including outside normal working hours. For many of these patients general practice is best placed to provide the care they need.

In planning for a new contract, any out-of-hours component must recognise the requirements of the three major stakeholders to the service: the public, the State, and the GP service provider.

Currently there are eight regional co-op services operating throughout the country. Most GP OOH are now delivered by these co-op services with some alternate OOH services including a number of deputising services and a small number of locally based GP OOH rota based services.

The current beneficiaries and end users of GP OOH service include: public GMS and other eligible persons under current GMS contract; private patients; private for profit enterprises, such as nursing homes in private or corporate ownership; state institutions, e.g. state nursing homes, care facilities and other state institutions; and ambulance service, garda and social services.

From the list above we can see there are a large number of beneficiaries and end users of the current out-of-hours model. However, the current model incurs a net hourly loss for many GPs. It must be noted that while there is a marked regional variation in the cost of contribution by GPs, it is in the main uneconomic and unsustainable for GPs to maintain the current system at the current rates.

Contract obligation
The GMS contract states: “The medical practitioner shall also make suitable arrangements to enable contact to be made with him or his locum/deputy outside normal hours for urgent cases.” The co-op system arose out of this obligation.

It is clear, however, that the current system now goes far above the contractual obligation. Increasingly we are seeing routine care being dealt with in the out-of-hours system. This is not what the system was designed for.

Under-sixes and IMO warning
During the course of the negotiations on the under-sixes contract the IMO made clear to the DoH and HSE that introducing such a cohort would have a significant effect on the out-of-hours service. This has now come to pass and while it is true to state that each GMS/DVC/under-six patient seen in the OOH is on a fee per item basis (€41.63), the additional workload has stretched the capacity of out-of-hours services and in many cases the additional STC payments do not find their way to the individual GP.

While there is a lot of discussion with regard to a separate out-of-hours contract, we must be mindful of the lessons that can be learnt from GPs operating in the NHS. The 2004 GP Contract in the NHS passed the responsibility for organising out-of-hours services from individual doctors to the Primary Care Trusts (PCTs). Practices could opt out of the provision of out-of-hours services and lose the Stg£6,000, 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.

We can see that losing control of the out-of-hours system may not be a desirable outcome either for GPs or their patients. It creates a vacuum which is inevitably filled by corporate interests and can create increased rates of consultation during normal surgery hours as patients are referred back to their own GP for further consultation. So while separating the out-of-hours commitment from the GMS may have some merit, there are unquestionably drawbacks with this approach also. Careful consideration must be given to all contractual models.

Keeping GPs at the core of OOH service perhaps best serves all stakeholder interests given the substantial problems now faced by the UK operating a fragmented OOH care model.

GPs have many and varied opinions on the out-of-hours situation.mmm However, if there is one clear thread that unites us all it is that the cost of the red-eye shift should not have to be borne by GPs. It is unconscionable that GPs are suffering a loss in providing the additional cover needed to maintain 24/7 availability.

Co-op model
The current co-op model has inadequate state subvention combined with onerous individual GP co-op funding.

GP OOH is a premium service and requires a rate of remuneration commensurate with qualification, unique skill set and value to wider health service.

A new contract must define an OOH service as an “urgent out-of-hours GP service’, distinct and separate from an emergency ‘blue light service’, and particularly from the normal 9-5 GP service. There must be recognition of the three OOH stakeholders: patient, State/DoH and GP.

All three require an efficient, cost-effective, timely service within reasonable proximity to patients. Care must be treatment centre-based with a limited domiciliary service using a triage-based decision-making process to ensure the optimal allocation of limited OOH resource.

GP requirements

• A new contract must be viable and sustainable over the lifetime of the contract and capable of meeting changing healthcare delivery circumstances;
• It must ensure an equitable call commitment for all GP service providers;
• GP OOH is a premium service and requires remuneration commensurate with qualification, unique GP skill set and value to wider health service;
• No GP should be at a financial loss for providing the additional cover to ensure their patient can be seen at any hour of the day or night in an urgent medical situation;
• If we are to ensure that GPs remain at the heart of the out-of-hours service then the cost of the ‘red-eye’ shift cannot continue to be borne by the individual GP.

In conclusion, while the current system must be changed, it is evolution rather than revolution that is needed. We must be mindful of the experience of GPs operating in the NHS, but insist on out-of-hours care being correctly funded at co-op and GP level.

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