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September 2018
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Raising standards in out-of-hours healthcare

The public perception is that out-of-hours healthcare is provided to the same standard as daytime GP services. Out-of-hours care is often delivered by private companies that do not have to adhere to the same standards of training, competence, scrutiny and risk management as NHS organisations. Arif Ahmed, co-founder and Director of ikonami, examines why private providers have become so prevalent and reveals potential strategies to improve standards of care and to bridge the patient care gap.

At the turn of the millennium the Government commissioned three reports on improving out-of-hours healthcare. The Carson report suggested a fully integrated model, involving GPs, A&E departments, ambulance services, Primary Care Trusts (PCTs) and other partner organisations. Then in 2004 the New GP Contract was agreed, enabling General Practitioners to opt out of offering out-of-hours care in return for a 6% pay-cut. Dr Carson and the other experts could never have anticipated this scenario, nor that 9 out of 10 GP practices would have opted out by 2007 . In many parts of the UK, a fundamental component of Carson’s integrated model – the local GP – no longer provided out-of-hours care, so PCTs had to turn to the private sector to bridge the gap.

The involvement of private healthcare providers has sometimes been controversial. Reports that locum doctors were being flown into the UK from other countries, without adequate checks on the practitioner’s fluency in English, generated a public outcry. In addition, many of these doctors are not familiar with the workings of the NHS. Both issues can negatively impact patient care. Yet out-of-hours healthcare now relies upon the contribution of private providers, so how can we ensure standards of care?

Identifying the main issues

Three major issues need to be overcome: commissioning and contracts, communications and culture. When PCTs first brought private providers on board, many worked through the commissioning process without the necessary background information. Relevant data on levels of demand, the medical conditions encountered, morbidity and costs were held by GP’s rather than PCTs (if recorded at all). This made it impossible to scope out contracts from an informed position. In addition, while the money released by GP’s opting out went into PCT funds, PCTs and providers had yet to realise that this did not cover the true costs of staffing and running out-of-hours care. As a result, some private providers were left to meet a level of demand that had not been anticipated at a price that made it difficult to deliver a high-quality, effective service.

Since 2004, other changes in the NHS mean there is more measurement and reporting on activities and outcomes so PCTs are now better informed. In addition, private providers will have generated their own internal data on levels of demand and the real cost of service provision. This management information can be shared to enable the development of more equitable and accurate contracts that meet patient needs and reduce risk.
Communication and shared values are key

Many PCTs also found it hard to establish and maintain good, clear and regular communications with their private providers. This could be problematic if private providers are not forewarned about localised outbreaks of certain viruses or demographic changes in the local community (like a growing elderly population or local baby boom) that require staff to have particular skills. PCTs gather this type of information and work closely with regional and national healthcare bodies to plan ahead. If they keep private providers informed and are clear about their expectations in terms of levels and quality of service, the private provider is more likely to maintain a better standard of care.

Finally, the culture of the NHS now emphasises risk management, compliance and staff competence, partly because NHS organisations are subject to scrutiny under schemes like the Clinical Negligence Scheme for Trusts and the Care Quality Commission (CQC). This has forced skills and training up the organisational agenda, but that culture is not necessarily shared by private sector care providers, on whom the cost considerations of training provision will weigh more heavily. Yet PCTs should insist their service providers adopt NHS best practice regarding employment, training and development, risk management and reporting. A tool like the Knowledge and Skills Framework (KSF), which details the skills, learning and competences necessary for every job role in NHS organisations, can be used to create a common understanding of what is expected on an individual and organisational basis. Moreover, the CQC regulates all care services in England across public and private sectors, so private companies will have to comply with its standards of care provision and reporting, which will also help to raise standards. The CQC recently warned that it wants to see improved scrutiny of private care providers by PCTs, when it reviewed the case of an elderly patient who was given an overdose by a locum doctor employed by a private out-of-hours care provider.

Working together

GP’s are unlikely to opt back in to providing out-of-hours care, so private companies will remain an important part of healthcare provision. But as noted by the CQC, the onus is on PCTs to ensure that private providers comply with public-sector standards of care. PCTs cannot achieve this through infrequent communication and monitoring the care provider from a distance. Rather, PCTs must learn to view them as colleagues and partners who are an integral part of the PCT’s operations. Where possible, the PCT should enable the private care provider to have secure, remote access to relevant management information systems, so they can provide up-to-date information on activity and outcomes. This data then becomes part of the PCT’s normal risk management analysis and service delivery planning activities.
The PCT should also share with the care provider the training agenda that it feels is necessary to meet patient needs and ensure competence – and ensure that any staff who interact with patients have been trained appropriately. To facilitate this, the PCT may wish to offer the care provider places on its own internal training courses, or have its learning and development team act as consultants to advise on mandatory training and the use of technology, such as learning management systems, the e-KSF, e-learning and social learning tools like wikis and blogs, to improve levels of competence and knowledge.

Working together will involve cultural and organisational change on both sides and it is not a challenge to be taken lightly, but it can be achieved through robust contracts, good communication and sharing the best of the systems and culture of the NHS. If managed properly, this new version of Carson’s integrated model may even deliver higher levels of patient care while reducing costs to healthcare system as a whole, which might become increasingly important as the NHS faces funding cutbacks over the coming years.
Arif Ahmed is the co-founder & Director of ikonami. He has seven years experience in providing bespoke learning solutions for the private and private sector. ikonami is a provider of bespoke learning software systems for government, independent healthcare and other organisations seeking learning and development efficiency. The company was founded in 1999 and originally provided project management consultancy to help organisations exploit the benefits of technology. In response to client demand, ikonami evolved into a full-service technology company that combines its specialised software offerings with a variety of service capabilities, including full Learning Process Outsourcing (LPO).

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