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by GK Strategy 15th February, 2017

Are out of hours GP services the key to saving an A&E in crisis?

The worst-ever recorded A&E waiting times are a sobering reminder that while Britain’s growing population may be enjoying a decrease in mortality rates, our morbidity rates continue to rise. Put plainly, people are living longer, but doing so with diseases, like diabetes, which demand more complex (and therefore expensive) care – and sometimes, with more than one such condition.

Unlike previous generations, 30% of the population now account for 70% of NHS spending. Our very hospital-centred model of care is not suitable to tackle this in the most efficient way. While NHS England’s Sustainability and Transformation Plans seek to break away from this rigid structure by tailoring care to their local patches and streamlining delivery where possible, innovations and efficiencies can only make a finite number of gains. The current social care funding crisis means hospitals cannot discharge patients quickly enough into more appropriate community settings and any reforms will take time to implement. In the meantime, we must examine where we can improve existing configurations.

Numerous solutions have already been suggested, such as improving education for patients about when to go A&E, increased prescribing powers for pharmacists and investigating and remedying the causes of delayed transfers of care. While these are important and welcome changes, increased use of NHS 111 and out-of-hours GP services could alleviate the pressure on acute services without the need for expensive and lengthy policy change.

Out-of-hours GPs, who work outside of 9-5 weekday hours, are not the same as 7 day NHS services, which came under scrutiny at the end of last year with the renegotiation of the junior doctors’ contract. These ‘OOH’ GPs work alongside nurses and other clinicians in urgent care centres, NHS walk-in centres or minor injuries units, which may all be part of the same clinical hub. They are sometimes co-located in A&E departments or with ambulance services. As they assess and treat non-critical injuries such as sunburn, cuts and bruises, they serve an excellent complement to in-hours GP care, but their support for emergency care should be further enhanced.

Often patients are directed to out-of-hours services by NHS 111 advisors. Some patients may express discomfort at the idea of being triaged by a clinical advisor on the phone, and especially following the recent tragic cases of sepsis being mishandled or misdiagnosed by call handlers. However, as with all technological implementation, often it is not the idea that is flawed but rather the execution. NHS 111 plays a critical role in keeping patients in the community rather than potentially clogging up A&E for more seriously ill patients.

NHS England is finally waking up to the potential of out-of-hours care. The new GP contract, published last week, provides extra money for those practices which are open for longer hours and providing evening and weekend cover. The extra funding will not be available for those that do not open for longer hours.

Other barriers hinder progress. Out-of-hours doctors continue to face rising indemnity charges as they renew insurance for their practices against medical negligence claims. While NHS England has pledged money to assist for this financial year, unless indemnity insurers and medical defence organisations are more tightly brought to heel – for example by brokering a Crown indemnity deal as for hospital doctors, or bringing costs into line with in-hours working – out-of-hours practitioners will continue to face exorbitant costs to cover claims.

The triple threat of increased longevity, higher morbidity, and population growth is a ticking time bomb which will only continue to exert unprecedented pressures on the NHS. Investing in, and promoting, out-of-hours services could hold one of the keys to solving the A&E crisis, and be at the forefront of a new vision for the NHS.

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