New Partnerships in Out-of-Hours Care
An Independent Review of
GP Out-of-Hours Services in England
Commissioned by the Department of Health October 2000
1 Current Provision 6
2 Basic Principles 10
3 A Model of Out-of-Hours Care 12
4 Information Flows 19
5 Quality Standards 21
6 A Framework of Local Accountability 27
7 An Approach Integrated with Other Local Providers 31
8 Funding the Model 36
9 Recruitment and Retention of Staff 41
10 The Supply of Medicines 43
11 Timescale for Implementation 45
Annex One Terms of Reference for the Review 47
Annex Two Review of the Research Literature 50
Annex Three Members of the External Reference Group 67
Annex Four A Model Service Level Agreement 68
Annex Five A List of Sources Consulted by the Review Team
The Review Team is pleased to submit its Report, Raising Standards
for Patients. New Partnerships in
The Report proposes a flexible, national model of integrated
out-of-hours provision, which will
deliver consistent standards of high quality care to patients
across the country. Those Quality
Standards will be secured in an accountability framework which
is both robust and transparent,
and the new model of service will be underpinned by appropriate
funding and organisational
Two basic principles are at the heart of this new approach:
??Patient access to out-of-hours care should be as simple
and straightforward as possible –
one telephone call, providing effective and timely advice
and, where necessary, a face-toface
consultation at a time and place agreed with the patient.
No multiple phone calls, no
double triage; just prompt, professional and appropriate responses
to the myriad different
needs of patients out-of-hours.
??All those professionals involved in the delivery of care
out-of-hours, regardless of the
sector of the service in which they work, should work together
co-operatively and collaboratively
to deliver the best possible service to patients and to make
the most effective
use of resources.
The model of integrated out-of-hours provision that is set
out in this Report will require significant
changes in attitude and expectation, quite as much as changes
in organisation and administration.
But lest this seems a recipe for revolutionary change, it
is important to emphasise that
all our proposals are grounded firmly in current best practice.
New organisational partnerships
already exist in a number of different parts of the country;
new forms of inter-professional cooperation
and collaboration have developed as those working in the same
built trust and confidence in each other's skills and competences;
more and more of the organisations
that provide out-of-hours services record and report on their
work in the manner that is
described in the Quality Standards. In short, by taking full
account of what has already been
achieved, the Review Team was able to formulate its proposals,
secure in the knowledge that its
recommendations are both realistic and achievable.
Finally, and not least for that reason, I wish to record my
warm thanks to all those who have
supported the work of the Review: Dr Nicholas Reeves and Dr
Ian Trimble for their work and
support in the central team; Dr Val Lattimer for guiding us
through the evidence; the members
of the Reference Group; all those individuals and organisations
who made submissions to the
Review; and, perhaps most important of all, those working
in the delivery of out-of-hours
services up and down the country who were willing to share
their knowledge and their experience
so freely with members of the Review Team.
Dr David Carson
Leader of the Review Team
On 2 March 2000, the Minister of State for Health announced
a Review of all arrangements of
GP out-of-hours cover across England (the full terms of reference
of the Review are set out in
Annex One on page 47). The aim of the Review was to identify
ways of bringing the standards
of all out-of-hours services up to the standard of the very
best, and to make recommendations
to the Minister on any priority actions that need to be taken
to improve those services.
The Review was to:
??Consider all arrangements for out-of-hours provision including
commercial services and practice rotas.
??Examine the approach that each adopts to quality assurance,
training, the availability and
use of clinical and non-clinical personnel and the use of
different models of skill-mix,
organisation, protocols, record keeping and quality assurance.
??Ascertain their accessibility and responsiveness, consistence
of response and treatment,
geography, equity in resource distribution, efficiency and
value for money.
??Examine the role played by Health Authorities in monitoring
the quality of the Out-of-
Hours Development Fund.
??Identify the potential for developing integrated services
with NHS Direct (including
Walk-in Centres and Social Services) and recommend organisational
models and practice
including quality standards that might address current and
future patient needs.
??Examine whether we are getting best value for money from
the existing spend, and
whether it is best targeted.
Dr David Carson (Head of Primary Care Strategy and Performance
at East London and the
City Health Authority) led the Review, supported by Dr Ian
Trimble (Chair of Nottingham City
North and West PCG) and Dr Nicholas Reeves (historian and
part-time Lay Member of the
Acton and Central Ealing PCG Board). Academic support was
provided by Dr Valerie Lattimer
(MRC Fellow at the University of Southampton), and Ms Vicky
Wright (a Management Trainee
from the Surrey Thames PCG) was seconded from her current
post to provide additional support.
The Review began with a careful analysis of the research literature,
examining all recent studies
of out-of-hours provision in order better to understand the
major features of the current position
(see Annex Two on pages 50-66). But, wide-ranging and helpful
as that evidence was, a
number of important questions remained unanswered and, to
answer those questions, a questionnaire
was sent to all Health Authorities; the Review Team also carried
out an extensive programme
of visits to current providers of out-of-hours services. In
these three different ways,
therefore, the Team developed and refined its understanding
of the out-of-hours services, ena-
bling it in particular accurately to identify current best
practice. This served the important purpose
of enabling the Review to ensure that all its recommendations
were firmly grounded in an
accurate understanding of current realities – every
one of its proposed Quality Standards, for
example, is already being achieved by an existing provider.
The Review Team took advice from an External Reference Group,
which drew together representatives
from an appropriate range of professional and lay organisations
(the members of that
Group are set out in Annex Three on page 67), and took further
advice from a wide range of
1: Current Provision
General Practitioners in the UK are responsible for the care
of their patients twenty-four hours
a day. With most primary care taking place during the day,
‘out-of-hours’ care has traditionally
been defined as the evenings, nights and weekends, periods
when GPs continue to provide a
service for patients who identify an urgent need for medical
care. Increasing demands for outof-
hours care in the 1970s and 1980s placed the system of 24-hour
care under increasing strain
and, by 1992, many GPs in England aspired to opt out of the
responsibility for out-of-hours
Notwithstanding that earlier history, however, the years since
have seen considerable innovation
in the delivery of out-of-hours services, with new approaches
being developed that were better
able both to meet patients’ needs and to manage demand.
Indeed, in finding solutions to the
crisis of the mid 1990s, GPs demonstrated a remarkable willingness
to reconsider local arrangements
for providing cover, and that new imagination and flexibility
resulted in unparalleled
co-operation between practices in the provision of out-of-hours
cover, much of which found
expression in the formation of GP Co-operatives.
Thus, as a result of those new developments, GPs can now fulfil
the terms of their current
contract by choosing from a variety of different forms of
out-of-hours cover. The four options
open to each individual GP are:
??Providing the service themselves.
??Joining a practice rota.
??Joining a GP Co-operative.
??Employing a deputising service.
Traditionally, the majority of GPs who did not offer their
own out-of-hours service employed a
deputising service to provide that service on their behalf
but, with the growth of GP Cooperatives
over the last five years, the pattern of provision has changed
significantly. Thus, today,
only about a third of GPs employ a deputising service, while
the majority of the remaining
two-thirds belong to GP Co-operatives. Moreover, the movement
from one provider to another
has been paralleled by equally significant changes in the
manner in which out-of-hours services
have been provided, and many of the initiatives pioneered
in the new GP Co-operatives are now
being introduced by other providers as well.
New developments in out-of-hours care
The first of these changes was the introduction of Primary
Care Centres, resourced out-ofhours
to enable patients to be seen in a properly equipped centre.
The advantages of such an
approach are obvious for, not only are there significant economies
of scale (one GP working in
a Primary Care Centre can see many more patients than if s/he
visits each of them separately in
their own homes), the Centre is much better suited to effective
patient assessment and diagnosis,
within a safe working environment. And, while some patients
were initially surprised by the request
to travel to such a Centre out-of-hours, recent research into
patient satisfaction suggests
that consultations in such Centres achieve very positive ratings.
Secondly, while all providers of out-of-hours services employ
staff to handle patients' calls, a
growing minority also offer nurse or GP telephone triage and
consultation. The benefits of this
second development are just as important, both because they
allow the clinical urgency of patients'
calls to be properly assessed and also because it quickly
became clear that a very significant
proportion of patient requests for out-of-hours care could
in fact be met by a telephone
consultation, without the need for the patient to travel to
a Primary Care Centre, or for a GP to
visit the patient at home. Nurse telephone consultations within
a GP Co-operative have already
been shown to be at least as safe and effective as GP telephone
consultations, and it has become
increasingly clear that, for those providers who offer such
a service, up to half of all patient requests
for out-of-hours care can be appropriately met in this way.
Nurse telephone consultations
of this kind were pioneered in GP Co-operatives and, more
often than not, nurses developed
these skills in an environment in which they had quick and
easy access to GPs working alongside
them. Indeed, this kind of active and willing partnership
between professionals (whose working
relationships had traditionally been constrained by strict
lines of demarcation) has been a striking
feature of the new style of working that has been developed
Partnership of a different kind has been the hallmark of an
even more recent development.
NHS Direct was originally conceived as a national advice and
information line, but it immediately
became clear that some 70% of its calls were made out-of-hours,
and it did not take a great
deal of imagination to recognise the enormous potential benefits
that could be achieved (for
patients and providers alike) if NHS Direct could be effectively
integrated with existing out-ofhours
service provision. New partnerships between GP Co-operatives
and local NHS Direct
sites have already been developed in six different sites,
and a significant number of further projects
to deliver integrated out-of-hours provision are already in
an advanced state of planning. In
all these examples, NHS Direct handles the calls and triages
the patient's needs – the local GP
Co-operative or deputising service provides the telephone
or face-to-face medical services for
those callers whose clinical needs can only be met in this
Not only do these developments mirror the inter-professional
partnership working that had
been pioneered within the GP Co-operatives, their success
has been a direct product of a collaborative
and co-operative approach to building a partnership between
All the parties to such a partnership have their own distinctive
and important role to play, and
only by developing a structure in which all those different
roles are given proper recognition can
such an approach succeed. The fact that NHS Direct is a national
organisation might have made
it difficult for it to develop partnerships of a kind that
take proper account of the special needs
of a particular locality, but where such attempts to develop
an integrated provision have been
successful, they have (without exception) been the product
of just this kind of local negotiation,
through which all the parties develop a real sense of ownership
of the new partnership to which
they now belong.
One further innovation is also making a contribution to the
way in which patients access care
out-of-hours. The first Walk-in Centre was opened in January
2000 to provide a nurse-led service
to deal with minor illness and treatments, and to further
encourage patients to manage their
own health, and by the end of 2000 a total of 40 such centres
will have opened across the
country. Because the majority are open from 7.00 a.m. until
10.00 p.m., seven days a week, there
is ample opportunity for them to make their own distinctive
contribution to the delivery of care
out-of-hours and, recognising this opportunity, a number of
GP Co-operatives have been actively
involved (either on their own or in partnership with others),
in the development of particular
centres. At the very least, this will allow for the seamless
transfer of patients from the
centre to the out-of-hours medical services, where a particular
patient's needs merit this; in the
longer run, there is abundant opportunity to co-locate Walk-in
Centres and out-of-hours Primary
Care Centres. Once again, partnership and co-operation signposts
the way to an approach
that offers patients a faster, more convenient access to the
services they need, in a manner that
makes the best possible use of the scarce resource of the
clinicians who provide those services.
Thus, in all these ways, the old pattern of meeting the vast
majority of patients' requests for outof-
hours care by a home visit by a GP has disappeared. The needs
of very many patients are
now met safely and appropriately by a telephone consultation
with a nurse or a GP and, of the
remainder, the majority are seen face-to-face in a Primary
Care Centre; a significant minority are
still visited at home by a GP. The size of that minority varies
from locality to locality and from
provider to provider but, over the last five years, the number
of home visits relative to all other
out-of-hours contacts has fallen consistently. There will
always be those whose clinical needs
out-of-hours can only be met in their own homes, but only
a comparatively small minority of
patients' needs require to be met in this way.
The role of Accident and Emergency Departments
There remains one further element in the current provision
of out-of-hours services, for while
professionals recognise only too clearly the powerful distinctions
between 'primary' and 'secondary'
care, many members of the public draw no such clear distinctions.
Indeed, it has long been
the case that many patients in inner-city urban areas have
accessed primary care out-of-hours
through the gateway of the Accident and Emergency Department
in their local hospital and,
notwithstanding a variety of initiatives designed to change
this behaviour, there is no evidence
to suggest that patients understand any better than they ever
did that such Departments are illequipped
to meet their needs. Thus they wait for many hours to be treated
by staff whose
training and experience is wholly different from that of a
primary care physician. Yet even here,
new partnerships have broken through traditional professional
barriers, developing a better way
of meeting the needs of these patients. Accident and Emergency
consultants, working with GPs
and nurses in the locality served by the hospital, have developed
a service in which all patients
attending Accident and Emergency are triaged at the door;
those with 'primary care' needs are
directed to a service resourced by local GPs and nurses and
the remainder are referred to a Department
of Emergency Medicine.
Thus, just like the innovations that were pioneered in the
GP Co-operatives, a willingness to
think outside the boundaries of traditional custom and practice
and to work together with professionals
from other disciplines and traditions, has resulted in a new
kind of partnership which
provides a better service for everyone. Patients receive the
treatment they need from the clinician
best trained to deliver it, with the minimum of delay, and
the clinicians benefit by working
in an environment in which their existing skills and competencies
are augmented and enhanced
by working alongside others from a different professional
2: Basic Principles
In embarking on this review of out-of-hours services, the
Team identified at the outset four
fundamental principles on which its work would be based:
??In re-examining the way in which such services can be best
developed, the Review Team
has sought throughout to look at out-of-hours provision from
the point of view of the patient,
developing an approach in which the proposed model of service
meets the needs of the
patient, rather than (as so often in the past) the patient
being required to meet the needs
of the model of service.
??All patients should have access to the same high quality,
out-of-hours services, regardless
of the part of the country in which they live, or the particular
GP practice with which
they are registered.
??The purpose of out-of-hours' services in primary care will
remain what it has always
been, namely to meet those urgent patient needs that cannot
safely be deferred until the
patient's own GP practice is next open.
??The provision of family doctor services will continue to
be based on the patient list system,
with GPs retaining 24 hour responsibility for their list.
While the Review did, of necessity, engage with the needs
of the many millions of patients who
constitute the majority of the population, the Team was acutely
aware that there are a number of
minority groups whose needs could easily be overlooked –
any out-of-hours service that uses
the telephone as the first point of contact, for example,
presents formidable problems for patients
whose first language is not English. Thus, in developing recommendations
meet the needs of the many millions who use out-of-hours services,
the Review has also paid
careful attention to those minority groups whose special needs
may need to be addressed in
Working from those basic principles, the Review Team has formulated
a set of particular recommendations
which are discussed in the following sections:
??Section Three sets out the model of out-of-hours care, while
Section Four examines the
flows of information that this model will require.
??Section Five outlines the Quality Standards which all out-of-hours
providers will have to
??Sections Six, Seven and Eight, examine respectively the
framework for local accountability,
the integrated planning, and the funding that is associated
with the model. These are
presented as three separate sections, but they are of course
inter-dependent and should
be read as such.
??Section Nine discusses issues of recruitment and retention
of staff, Section Ten explores
the particular problems associated with the supply of medicines
out-of-hours, while Section
Eleven outlines a timescale within which the recommendations
of the Review might
Note: Throughout the remainder of the Report, the term PCT/G
is used as shorthand for the
existing primary care organisation. Where a Primary Care Trust
(PCT) is yet to emerge, the roles
and responsibilities ascribed to PCT/Gs will be assumed jointly
by Primary Care Groups
(PCGs) and Health Authorities.
3: A Model of Out-of-Hours Care
The patient makes a single call,
forwarded automatically with an
GPor Nurse Face-to-Face Consultation
_ In Primary Care Centre or Walk-in Centre
_ In A&E Primary Care Centre
_ At home
Patient or call
next day or routine
booking to GP system)
or Home Care
Throughout its work, the Review Team has attempted to look
at out-of-hours services from the
patient, and the integ
rated model that is proposed, puts the patient experience
its very heart. Diagrammatically, the model looks like this:
The patient perspective
Looked at from the perspective of the patient, the most important
features of the proposed
model of out-of-hours provision can be identified as:
??Fast, fair and convenient access for all: the patient's
initial request is satisfied within a single
call (the solid green lines in the diagram opposite). Thus,
the patient (or a person calling
on the patient's behalf) either calls NHS Direct or the GP
practice where, out-of-hours,
the call is automatically routed to NHS Direct.
??When the call is first answered, the patient's details are
recorded and, in a very small minority
of cases, where the patient's initial description of his or
her symptoms is such that
urgent medical attention is needed, an ambulance is called.
??For all other callers, there are then two possible outcomes
to the call:
??The nurse or GP concludes the patient episode on the telephone
– where both a nurse
and a GP participate in this telephone consultation, the software
makes the results of
the initial nurse triage available to the GP, obviating the
need for a second triage by
??The nurse or GP who completes the telephone consultation,
negotiates (where necessary)
with the patient a time at which to come in to a Primary Care
Walk-in Centre or to be visited at home.
??While the single call that is at the heart of this model
will save time and unnecessary
repetition of information for all patients, it will be of
particular benefit to those who
find access to telephone services difficult where the need
to make multiple phone calls
causes particular difficulties.
??Because NHS Direct is a national service, working to common
clinical standards across
the country, the needs of all patients who access out-of-hours
services will be triaged in a
consistent, and consistently safe manner. Some of the most
striking variations in current
practice are to be found in the response to the patient's
initial call, and in this model
those variations will disappear.
??There are a small number of patients (those receiving palliative
care, for example) whose
particular needs can be established in advance and, with appropriate
identification on the
NHS Direct database, their calls will not be triaged but will
be passed directly to those
services that can meet their needs.
Integration, multi-professional and multi-agency working
In formulating this approach, the Review took account of a
number of submissions that
strongly supported an integrated model of out-of-hours provision,
a view confirmed by many
of the providers visited by the Review Team. There is a very
considerable body of knowledge
and experience within existing GP out-of-hours providers,
much of which has already resulted
in new, more integrated approaches to the delivery of the
service and, not least for this reason, it
is vital that none of this is lost in the transition to the
new model. Nowhere is this more clear
than in those areas where NHS Direct and existing GP out-of-hours
providers have already
developed an effective partnership, for the patients served
by these new partnerships have seen
significant improvements in the quality of service to which
they have access, improvements that
are mirrored in better conditions of work and enhanced job
satisfaction for those who work in
the service. Key features of this new approach include an
ability more effectively to manage
demand at peak periods with a larger number of staff, and
a willingness to share freely the
knowledge and experience that already resided in the established
out-of-hours provider and the
developing NHS Direct site. Within such a partnership approach,
the Team was especially impressed
by the particular advantages that derive from locating GPs
and nurses in such a way that
they can easily and quickly communicate with each other, for
this enables a level of trust and
understanding to develop that can break through the often
arbitrary barriers that have so often
separated professionals in the past. Indeed, establishing
trust and understanding is the precondition
for making the most appropriate use of the skills and competencies
of all the members
of the out-of-hours team.
Where such multi-professional partnerships are well-established,
it is not uncommon for all to
agree that nurses can properly make decisions about home visits
or attendances at Primary Care
Centres, without further reference to a GP. Moreover, this
approach will soon be taken a step
further, with the recognition that the needs of some patients
may be met most appropriately by
a face-to-face consultation with a nurse (whether in a Primary
Care Centre or in the patient's
home) rather than a GP. Individual nurse members of the out-of-hours
team have particular
skills which are especially well-suited to meeting the needs
of particular patients; making best
use of the resources of the whole team means creating opportunities
for those nurses to use
those skills. Thus, where nurse telephone consultations are
already a well-established feature of
out-of-hours provision, the Review envisages that they will
soon become an important feature
of face-to-face consultations as well.
The integration envisaged in the model does not stop at making
the best possible use of existing
GP out-of-hours resources, however, for it proposes also the
building of new partnerships
across a much wider range of traditional divisions between
different parts of the health service,
and between health and other services. Better communication
between the ambulance service
and GP out-of-hours services, for example, may enable the
needs of patients making Category
C calls to be more appropriately met by GP out-of-hours services.
A patient could be referred to
the community nursing or mental health out-of-hours' team,
and the Review Team has been
impressed by the fact that where a well-organised, out-of-hours
community nursing service
(properly integrated with the GP out-of-hours service) is
available, the quality of response to
patient needs was both more appropriate and effective.
Exactly the same principle applies to building new partnerships
with those who provide social
care. It has long been recognised that, in the absence of
appropriate social care, a patient may be
admitted to hospital as the only short-term way of meeting
their needs, and access to that care is
just as important out-of-hours as it is at any other time.
Across the country, the provision of
out-of-hours social care, and indeed community nursing and
specialist mental health provision,
is not consistent and, while this Review cannot make recommendations
about the way in which
these other services are provided, the model proposed here
will only achieve its full potential
when those other services are in fact available in every locality.
In short, an integrated model of out-of-hours provision will
provide patients with fast, fair and
convenient access to care, enabling all the available services
to be used in the most appropriate
and effective manner to meet those needs.
A new model of integrated out-of-hours provision should be
accessed by patients via a
single telephone call, routed in the first place through NHS
Direct passed, where necessary,
to the appropriate provider of out-of-hours services in that
The telephone has been the medium through which patients have
traditionally accessed out-ofhours
services, and its ever more central position in contemporary
society makes such an approach
only more appropriate. On the other hand, the Review Team
was acutely aware that
there are some groups for whom telephone access may act more
as a barrier than a bridge to
out-of-hours services. Most obviously, those who speak little
or no English may not even consider
using the telephone for this purpose; those with hearing impairment
will only be able to
telephone NHS Direct with appropriate telephone technology
at both ends of that exchange;
more widely, cultural barriers to using the telephone as a
medium through which to share private
medical information with an unseen individual, may (in effect)
disbar some older people and
some ethnic minority groups from out-of-hours services.
In exploring how these and similar problems might be overcome,
the Review Team has been
impressed with the strenuous efforts that NHS Direct is already
making to develop innovative
and imaginative solutions to what are, in reality, difficult
and intractable problems. On language,
provided the caller is able to identify in English the name
of the language in which they wish to
conduct their call, the service can already very quickly identify
an interpreter for more than one
hundred different languages; it may be possible in future
to employ voice recognition and translation
software to obviate the necessity of the caller making the
initial request in English. For
those with hearing impairment, NHS Direct is currently taking
advice from the Royal National
Institute for Deaf People on how best to modify its existing
telephone technology to meet the
needs both of the comparatively small numbers of people who
are profoundly deaf and of the
much larger numbers of people with less severe forms of hearing
In addition to these technological solutions, each NHS Direct
site is currently investigating how
best to work with its own local community to break down the
cultural barriers that may prevent
particular communities from using its service. There are a
wide variety of different ways in
which these difficult cultural problems could be tackled,
and some solutions may involve the
imaginative use of print and other media to present information
about the service in a form that
is properly tailored to that local population. It is very
likely, however, that many sites will have to
identify staff to work directly with those communities, accessing
existing groups and networks,
slowly building the trust and understanding that will make
the service truly available to all.
Difficult as all these problems are, the pivotal position
of NHS Direct in the model proposed
here, enables solutions to be developed that would be quite
beyond the scope of any individual
provider. The existing provision of translation services is
a clear example of this; the expertise
on which NHS Direct has been able to draw in working with
the Telephone Helpline Association
and a wide variety of community and special interest groups
is an equally clear illustration
of the unique potential that its national role allows it to
exploit. In short, while the nature of
these problems is such that they will never be solved entirely,
the role that NHS Direct will play
in a fully integrated model offers the prospect of very much
more progress than could ever be
achieved by individual providers each attempting to solve
these problems locally.
NHS Direct should continue to pay particular attention to
meeting the special needs of
hard-to-reach groups, and GP out-of-hours providers should
take early advantage of
these initiatives so that these groups are not disadvantaged
while accessing the GP
component of out-of-hours care.
Meeting the peak demands
Any service that has to cope with fluctuating demand, always
encounters special difficulties at
periods of peak demand, and the Review Team recognises that
there will be substantial problems
for those very short times during the year (Christmas, New
Year, Easter and other Bank
Holidays) when patient demand escalates far beyond the normal
weekly variations. Indeed, there
have been marked improvements in recent years, and many GP
out-of-hours providers have
demonstrated that they can in fact respond effectively to
these short-term surges in demand.
That said, looking at provision as a whole, it is clear that
these exceptional peaks still present
formidable problems, but with the completion of the national
roll-out of NHS Direct in the
autumn of 2000 a more robust solution can be found. For, when
NHS Direct is a truly national
service, its various call centres will be networked in such
a way that the total call handling capacity
in the system will be significantly greater than the sum of
its individual parts. Thus, the existence
of such a virtual network will provide an incomparably more
effective response to those
short-term surges in demand, and detailed modelling demonstrates
that the new capacity will
indeed be sufficient. Add to this, the full integration of
GP out-of-hours capacity proposed
here, and the flexibility and responsiveness of the system
as a whole will be strengthened still
Answering the calls is only part of the problem, however,
for each call must then be handled
safely and appropriately, and here the results of the current
NHS Direct software procurement
process are critical. The decision support software that will
be available in every site by April
2001 will reduce dramatically the length of time that it will
take for each call to be completed,
without sacrificing any of the clinical rigour that characterises
the existing support. Indeed, the
next generation of NHS Direct software will be both clinically
safer and also capable of much
more rapid modification and development. Thus, where necessary,
a new clinical algorithm
could be developed and implemented within hours, allowing
the service to respond much more
quickly and effectively to a new situation.
Yet neither of these technological changes would, in themselves,
allow the integrated out-ofhours
service effectively to meet the most challenging escalations
in demand, and the third element
in the equation is, in a sense, the most important of all.
Some existing GP out-of-hours
providers have already demonstrated their ability to deliver
a safe and reliable service at these
times, and in some areas a limited number of GP practices
have opened at times of greatest
demand to limit the pressure on out-of-hours providers. Thus,
in developing the new model, it
is vital that none of that knowledge and experience is lost;
all the members of a particular local
partnership will need to draw freely on each other's experience.
For this is indeed the essence of
a fully integrated approach, planned with a careful recognition
of all the resources available in a
given locality. It creates entirely new opportunities to make
the very best use of all the human
resources that are available in that locality. New flexibilities
will be a direct product of the
growing trust and confidence between all the participants
in this integrated service, and it is this
that will allow the provision to be managed in such a way
that it can indeed respond effectively
at periods of peak demand.
Primary Care Centres
The other aspect of the model to which the Review wishes to
draw particular attention is the
all-important role of the Primary Care Centre. As we have
already made clear, current best
practice already provides patients with appropriate local
access to such Centres out-of-hours,
and the model proposed in this Review will only work if Primary
Care Centres are made available
across the country.
At first sight, this might suggest a major programme of new
provision but, in reality, there are
many ways in which much better use could be made of existing
resources. As we have already
indicated, new partnerships between Accident and Emergency
Departments and their local GPs
can be developed; a Primary Care unit within such a Department
creates opportunities to provide
a much improved service, while making much better use of the
existing clinical resources.
New partnerships between cottage hospitals and local GPs open
up comparable opportunities
in rural areas. Historical divisions between GP Co-operatives
and deputising services have
sometimes resulted in the provision of rival Primary Care
Centres in very close physical proximity,
while in other areas patients have had to travel many miles
to the Centre used by their GP
when a Centre resourced by another provider may be just around
the corner. And finally, the
emergence of Walk-in Centres provides yet another opportunity
for imaginative and cost effective
solutions to the problem.
Whatever form the local solution takes, however, one further
aspect of the role of the Primary
Care Centre needs particular emphasis. In the past, patients'
access to urgent medicines out-ofhours
has been confused, time-consuming and inconsistent but, as
more and more patients access
out-of-hours care at Primary Care Centres, a solution to that
longstanding problem can at
last be found: those medicines can be made available to patients
at the same time and in the
same place as their out-of-hours consultation. A more detailed
discussion of the form that this
solution will take can be found in Section Ten below.
Thus, a central responsibility of those who plan out-of-hours
services locally will be to ensure
that sufficient Centres are made available in the locality
for which they are responsible to meet
the Quality Standards set out in this Report. Further discussion
of the way in which local outof-
hours services will be planned can be found in Section Seven
Sufficient Primary Care Centres should be provided to enable
out-of-hours providers to
meet the Quality Standards set out in this Report.
4: Information Flows
The integrated model described above can only work if data
are shared safely and promptly
between all the appropriate individuals and organisations
and, while the Review Team recognises
that much work remains to be done before the Electronic Patient
Record becomes a reality, this
work is currently being addressed as part of the implementation
of Information for Health. Once
that work has been completed, it will be possible to move
data electronically between the various
clinical systems and, when this has been achieved, an optimal
model for the way in which data
relating to out-of-hours patient care will need to flow around
the system can be described. That
model can most easily be represented in the following diagram:
data extracted from the EHR data reported back to the EHR
Thus, when the patient makes initial contact, the call handler,
nurse or GP would have access (in
real time) to the patient's Electronic Health Record, or some
subset of that Record. Following
the initial triage, details of that triage, together with
the original Record, would be transferred
electronically to the out-of-hours provider. Once the individual
patient's needs have been met
(whether by the NHS Direct nurse, or by the out-of-hours provider)
a report of the outcome
would then be transferred electronically to the Electronic
The Review Team understands that concerns about security and
confidentiality have led many to
argue that only a subset of the Record should be made available
outside records held in GP
practices but, whatever method is used, patients will have
to give their consent to data being
accessible in this way. The data can be made available via
the GP System, a central server or a
'smart card' – whatever particular method is chosen,
data will have to be encrypted and be coded
according to a standard clinical coding system. Equally, if
central server or 'smart card' technol-
_ Primary Care Centre
_ Walk in Centre
_ Accident & Emergency
_ Visiting GP or Nurse
technology is adopted to facilitate rapid access to clinical
data, it will be important to ensure that
the Electronic Health Record subset is regularly updated.
In addition to meeting the day-to-day needs of primary care
providers, the existence of the
electronic records described above will allow for the extraction
of anonymised data, itself an
essential pre-requisite for the proper monitoring and evaluation
of out-of-hours activity. All the
Quality Standards set out in Section Five below have been
developed with data collection in
mind and many out-of-hours providers already collect this
information; all that is proposed here
is a common format for those data.
The preceding paragraphs describe the optimal model which
will be in place in the medium
term but, in the period before that model is in place, the
recording of clinically-coded data
within the IT systems of out-of-hours providers and other
sections of the NHS will start to
take place. As these developments will ultimately form the
building blocks from which the
Electronic Health Record will be built, it is essential that
these emerging systems develop in a
way that is mutually compatible, enabling that sharing of
clinical data that is at the heart of this
The Review Team is acutely aware, however, that for certain
particular groups of patients, it
would not be appropriate to wait until the new electronic
exchange of data is in place. Thus,
NHS Direct, out-of-hours providers and GP practices should
develop methods to ensure appropriate
three-way exchange of information for patients:
??With terminal illness.
??With complex acute clinical needs.
??With mental health problems.
??With any other special needs.
??Who access their care through arrangements made under HSC
2000/001: Tackling Violence
Towards GPs and Their Staff.
Finally, the minimum standards set out in Good Medical Practice
for General Practitioners can only be
achieved if out-of-hours providers supply to GPs, by 9.00
a.m. on the next normal working day,
full and comprehensive clinical data for all out-of-hours
consultations. While this requirement
will be much easier to achieve with complete electronic exchange
of data, its implementation
cannot wait until then, and all providers will need to use
existing technology to meet this requirement
in the short term. Thus, all immediate and future data transfer
systems will have to
conform to current regulations regarding Data Protection and
When the Electronic Health Record is in place, a three-way
exchange of data between
NHS Direct, out-of-hours providers and GP clinical systems
should be established. In
the interim, all providers should report all out-of-hours
consultations to GPs by 9.00 a.m.
the next normal working day. Systems for the three-way sharing
of clinical data for patients
with special needs should be established in advance of the
implementation of the
Electronic Patient Record.
5: Quality Standards
The review of the research literature set out in Annex Two
reveals just how limited our current
understanding of the present quality of out-of-hours provision
is and, without the routine recording
of data across a wide range of aspects of that provision,
it will remain all but impossible
to make any accurate judgements about the quality of that
care. Moreover, recent investigations
by the Health Service Ombudsman have demonstrated the existence
of particular examples
of wholly inadequate care and, while existing data provide
no sense of how typical or untypical
those cases may be, the requirement that all providers of
out-of-hours services will have
to meet a set of minimum standards of care will go a very
long way towards ensuring that such
cases do not recur in future.
In thinking about the form that the standards should take,
the Review Team has set out to ensure
that all out-of-hours services are delivered to the same,
national quality standards. And,
while the formulation of such explicit and wide-ranging standards
represents a new departure
for primary care, such an approach is entirely consistent
with the aims and objectives of the
'new NHS' and the principles of good clinical governance.
Many organisations already routinely
monitor the standards of service delivery and, in order to
achieve consistent quality, all those
who play their part in the delivery of out-of-hours services
should do the same. There may be
additional costs associated with the introduction of such
monitoring, both in terms of capital
investment and training, but such investment is entirely justified
in ensuring that all services are
provided to the standards of the best.
Through its detailed discussions with existing out-of-hours
providers, the Review Team is satisfied
that, within the framework of an integrated provision of out-of-hours
services, all of these
Standards are realistic and achievable. Indeed, some existing
organisations are already very close
to meeting the majority of the Standards proposed here. But
it is important to emphasise that
these Standards are not 'set in tablets of stone'. The nature
of the data that will be accumulated
as a result of providers reporting on their performance in
relation to these Standards will create
a much clearer and more detailed picture of the character
of out-of-hours provision and, in the
light of that new data, there will be every reason to explore
ways in which the Standards can be
further refined and developed.
The Quality Standards set out in this Report should be met
by all providers within a
timescale specified in Section Twelve.
In order to be able to meet these standards, providers of
out-of-hours services will need to be
able to record:
??The numbers of telephone calls that are abandoned by the
??The length of time taken to answer the call.
??All the communications that take place when the call is
??Accurate details of all clinical consultations, recorded
in an appropriate IT clinical system.
All providers of out-of-hours services should put in place
appropriate systems for call
abandonment, time taken to answer the call, call recording
and the recording of all
The ability to report on the standards for call handling and
clinical prioritisation will pose particular
problems for those GPs who continue to provide their own out-of-hours
entirely on their own, or through a practice rota. The Review
Team recognises this difficulty but,
if their out-of-hours calls were handled by NHS Direct (in
the manner proposed in the fully
integrated model), then those problems would be resolved.
NHS Direct should therefore pay
particular attention to establishing effective links with
those GPs who wish to continue to offer
their own out-of-hours services, thereby making it easier
for them to meet the Quality Standards
set out below.
In developing a set of Quality Standards to ensure that patients
across the country can access
the same minimum quality of care out-of-hours, the Team has
grouped the standards in three
??Service and Organisational Models (including links to NHS
??Access and Triage.
While many of the principles that underpin Clinical Governance
out-of-hours are the same as
in-hours, there is a particular need to ensure that those
delivering these services (many of whom
fulfil other roles in-hours) pay appropriate attention to
the special skills and competencies that
are required to deliver effective out-of-hours services.
In the first instance, the monitoring of professionals' clinical
activity that is required by these
standards will identify those professionals whose performance
is significantly at variance from
that of their peers. But, as routine monitoring develops over
time, a cumulative database of
patterns of performance will start to emerge, and this will
in turn allow for a more rigorous and
systematic analysis of those standards.
1. All professionals involved in out-of-hours care must be
eligible to be employed within the
relevant parts of the NHS including General Medical Services.
2. The annual appraisal of individual professionals involved
in out-of-hours care will include
the assessment of out-of-hours skills. For GPs, this will
take place within the proposed
appraisal system that will be part of the revalidation of
all GPs; for other staff, it will be
part of the routine systems developed by all out-of-hours
3. Personal Development Plans should include the development
of skills related to out-ofhours
activity. These may include telephone triage skills development.
Record keeping and auditing:
1. Out-of-hours records will be maintained with reference
to the standards set out in Good
Medical Practice. Nursing records will be maintained with
reference to UKCC guidelines on
2. A sample of call records will be audited routinely in order
to assess their adequacy and
completeness, to appraise the clinical quality of the call
management process and to
monitor the flow of information within and between provider
organisations. A procedure
for assessing a random sample of calls (for example 1% per
month) will be developed for
use by all providers and will be based on current examples
of good practice, including
methods for multidisciplinary peer review. Clinical records
will be continuously audited via a
sampling method measuring standard of record keeping in relation
to each professional.
1% of each clinician's records will be audited.
3. The audit process will enable providers to review aspects
of individual professional
performance (such as referral patterns and prescribing practices)
performance (including consistencies and inconsistencies in
call disposition: calls triaged by
a nurse / nurse and doctor, calls resulting in a home visit,
calls resulting in attendance at a
Primary Care Centre). These data will facilitate feedback
to individuals, and will inform the
preparation of summary reports to Health Authorities and PCT/Gs.
4. The reporting of performance will be open within the organisation,
and the collated
information of subscribing contractors will be reported to
the local Health Authority.
Complaints and Patients' Satisfaction Data
1. All out-of-hours providers will comply with the NHS complaints
2. All providers will monitor and audit complaints in relation
to individual staff.
3. All providers will always investigate and review all significant
events1 and all reports on such
events must include clear recommendations; all reports will
be submitted to the appropriate
1 A significant event is an occurrence that is significant
or pivotal in either a desirable or undesirable way and which,
if not discovered or corrected in time, did or could lead
to patient morbidity or mortality. This definition is based
on Barach P. and Small S.D., 'Reporting and preventing medical
mishaps: lessons from non-medical near miss reporting
systems', British Medical Journal 320:759-763.
4. All providers must demonstrate that they are continuously
monitoring patient satisfaction
and taking appropriate action on the results of that monitoring.
Individual GPs and GP rotas
1. Individual GPs and practices not taking part in a Co-operative
or deputising arrangements
will report their service to the same standards.
Service and Organisational Models (including links to NHS
The structure of out-of-hours services envisaged by the Review
will require the closest possible
co-operation between the many different organisations (or
individuals) that will be involved in
the delivery of the service. It is thus crucial both that
there are explicit Service Level Agreements
for each of these inter-relationships and that robust methods
of monitoring these Service
Level Agreements are developed.
1. All accredited organisations must have clear mechanisms
for accepting delegated responsibility
(including indemnity cover) for the patients for whom they
make provision out-ofhours,
and they must further demonstrate their ability to match their
capacity to meet the
(changing) demand for those services.
2. All accredited organisations must report quarterly to the
Health Authority with evidence
that they are continuing to meet the Quality Standards.
3. Service Level Agreements will include standards for both
parties to the agreement – e.g.
NHS Direct and the out-of-hours provider.
4. There must be rapid and effective transmission of out-of-hours
patient data from NHSD to
the service provider, and from the service provider to the
GP practice, as defined in Recommendation
5. All out-of-hours providers must be represented in, and
play an active role within, the local
emergency planning system.
6. All out-of-hours providers must be members of Local Winter
Planning Groups and Emergency
Care Liaison Groups – these groups must include:
6.1. The appropriate GP Co-operatives.
6.2. GP rotas.
6.3. Deputising services.
6.4. NHS Direct (the relevant regional hub).
6.5. Local PCT/Gs.
6.6. The Health Authority.
6.7. Local Ambulance Services.
6.8. The local Accident and Emergency Departments.
6.9. Walk-in Centres (if appropriate).
6.10. Social Services.
6.11. The Local Pharmaceutical Committee.
6.12. Lay representation.
7. All out-of-hours providers must examine all significant
events and report the outcomes of
those reviews to the local Health Authority.
8. Out-of-hours service providers must be able to supply full
clinical details of consultations to
the host GP by the start of the next working day.
9. All out-of-hours providers must have clinical and organisational
systems which are
continuously able to report these standards.
10. All out-of-hours organisations that employ staff and are
stewards of public funds must
comply with standard NHS corporate governance standards.
11. All organisations providing or employing clinical staff
must be able to support the
requirements of revalidation for medical staff.
12. All organisations must meet NHS human resources standards
for continuing personal
development and the accreditation of staff.
13. All employment practices must conform to NHS human resources
Access and Triage
In determining the detailed standards set out below, special
attention was paid to a number of
??Problems that require rapid intervention that must be identified
as such and passed to
the Ambulance Service.
??Response times must be determined by clinical need.
??Response times must be agreed after negotiation between
the clinician and the patient
during the initial telephone consultation.
??Intervention times must be agreed after negotiation between
the clinician and the patient.
??All encounters with the patient must be appropriately recorded,
so that every aspect of
the out-of-hours service can be properly audited.
1. Call engaged and abandonment standards (an abandoned call
is defined as one where the
caller discontinues the call after 30 seconds, allowing time
to listen to a message which may
be played before the call is answered):
1.1. No more than 0.1% of calls engaged.
1.2. No more than 5% calls abandoned.
2. Time taken for the initial call to be answered by a person:
2.1. 90% answered within 30 seconds.
2.2. All answered within 90 seconds.
3. Identification of immediate life threatening conditions:
3.1. 90% of immediate life threatening conditions identified
within 1 minute.
3.2. All life threatening conditions identified within 15
3.3. 90% of immediate life threatening conditions passed to
the Ambulance Service
within 1 minute.
3.4. All life threatening conditions passed to the Ambulance
Service within 15 minutes.
4. Definitive telephone triage and disposal (excluding those
patients who access a Primary
Care Centre, Accident and Emergency Department or Walk-in
Centre direct, without
preliminary telephone triage – see 7. below):
4.1. 90% complete within 20 minutes.
4.2. All complete within 30 minutes.
5. Time to episode complete (disposal):
5.1. Emergency: Within 1 hour.
5.2. Urgent: Within 2 hours.
5.3. Less urgent: Within 6 hours.
6. Patients to be informed of timescale during initial consultation,
including time to visit at
home or appointment time at Primary Care Centre or Walk-in
Centre, and always contacted
if an agreed home visit is delayed or if an appointment time
at a Primary Care Centre is
7. For those patients who have not been triaged on the telephone
and who access a Primary
Care Centre, Accident and Emergency Department or Walk-in
Time from arrival to initial contact:
7.1. 90% of initial triage completed within 5 minutes.
7.2. All initial triages completed within 10 minutes.
Time from initial contact to consultation:
7.3. 90% of patients offered consultation within 45 minutes
7.4. All patients offered consultation within 60 minutes of
8. Non English speaking users:
8.1. 90% provided with translation service within 10 minutes
of initial contact.
8.2. All provided with translation service within 15 minutes
of initial contact.
9. Patients with impaired hearing:
9.1. A dedicated telephone number will be provided for text
phone users to enable them
to access the service.
9.2. Appropriate technology will be installed in NHS Direct
call centres to enable callers
with less severe hearing impairment to access the service.
6: A Framework of Local
National Quality Standards are, in the end, only as good as
the framework of local accountability
that is developed to ensure that they are met by the organisations
and individuals involved in
their delivery and, at the heart of this proposed framework
are a series of Service Level Agreements
indicated by the dotted red lines in the diagram below. Moreover,
this structure will be
underpinned by the local PCT/G, whose function is not only
to ensure that the provision of
high quality, out-of-hours services in its locality is planned
in such a way that it deliver 'best
value' for the local health economy, but also that all parties
properly fulfil their obligations under
the Service Level Agreements (the dotted brown line below):
GPCo -Op Deputising GPRota s GP
Service Level Agreements
GPs GPs GPs
Service Level Agreements
Primary Care Trust
GMS Terms of Service/PMS Contract
The strengths of such an approach derive from the fact that
Service Level Agreements impose
duties and obligations on both parties to the agreement. Thus,
while NHS Direct is a national
organisation, accountable nationally to the NHS Executive,
the Service Level Agreements proposed
in the diagram above enable local providers to hold it accountable
locally for the services
that it delivers. In the same way, the Agreements enable NHS
Direct to ensure that each of the
very different providers of out-of-hours services in a given
locality meets its common (national)
standards. In exactly the same way, the Agreements impose
mutual duties and obligations on
individual GPs and the organisations with which they contract
to provide their out-of-hours
services. And at the heart of all these Agreements are the
Quality Standards set out in this Report,
Standards which will ensure that all patients (regardless
of the part of the country in
which they live, or the particular GP practice with which
they are registered) have access to the
same high quality provision of out-of-hours care.
Finally, the robust character of these Agreements is underpinned
by the requirement for both
parties to report their performance to the PCT/G on a quarterly
basis, enabling the PCT/G to
be satisfied that the terms of the Service Level Agreement
are indeed being met; the PCT/G
will then report these outcomes to the Health Authority annually.
An example of such a Service
Level Agreement is included in Annex Four.
Service Level Agreements incorporating all the Quality Standards
should be established,
between NHS Direct and all providers of out-of-hours services,
and between GPs and
all providers of out-of-hours services. Compliance with these
Agreements should be
monitored by the PCT/G with responsibility for planning out-of-hours
services in that
locality and should be reported to the Health Authority.
Powerful as such Agreements are, however, they only make sense
if the provider of out-ofhours
services is already in a position to offer a service that
is capable of meeting the Quality
Standards set out in Section Five above. In order to ensure
this, the Review proposes that the
Health Authority will take responsibility for accrediting
all the organisations (GP Co-Operatives,
Deputising Services and GP Rotas) that might provide out-of-hours
services in its area. The
Authority would have to be satisfied, therefore, that these
organisations had developed robust
systems to deliver effective clinical and corporate governance
and that they held appropriate
indemnity cover for the provision of those services.
The model described above makes no attempt to define the size
of any of the out-of-hours
providers, but in many of its visits the Review Team has been
impressed by the argument that
there is in reality an irreducible minimum below which it
would prove very difficult to provide a
service that met those Quality Standards; very small providers
would invariably find it impossible
to develop the infrastructure that is in reality a precondition
of achieving those Standards.
Thus, while individual Health Authorities will in the end
have the responsibility for deciding
whether or not to accredit a particular provider, they would
(of necessity) need to be absolutely
certain that a small GP Co-operative, deputising company or
GP Rota would in fact be in a position
to resource an out-of-hours service capable of meeting those
Once an organisation had been accredited, the Health Authority
would then be responsible for
ensuring that the performance of the organisation met the
Quality Standards. All Standards
have equal status and any assessment of whether or not they
are being met must take account of
the provider's performance across the full range. In the first
instance, audit data would be reported
quarterly to the PCT/G, with an annual report by the PCT/G
to the Health Authority,
but PCT/Gs will have a duty to report to the Health Authority
if, at any time, they have serious
concerns about the ability of an individual provider to meet
Once such a report has been made, if the Health Authority
is satisfied that the provider is indeed
failing to meet the Standards, a remedial notice will be issued,
requiring the provider to
meet the Standards within a maximum of six months. If, at
the end of six months, the Standards
are still not being met, accreditation will then be withdrawn
and the provider will no
longer be able to provide services for GMS contractors or
PMS sites. In such circumstances,
responsibility for the provision of those services will revert
to the GPs who had delegated their
out-of-hours responsibilities to that provider although, in
almost all circumstances, the Health
Authority and the PCT/G, working with those GPs, would have
made sure that appropriate alternative
arrangements for the proper provision of out-of-hours services
would have been put
Individual GPs who provide their own out-of-hours services
(either on their own or through a
practice rota), or who belong to a small, informal GP rota,
and who are working within GMS
rules, will be required to meet exactly the same Quality Standards,
for it is only in this way that
real equity of provision for patients will ever be achieved.
They will report their performance
directly to the Health Authority. The PMS contracts of those
GPs who also deliver their out-ofhours
services in this way will be amended so that they too include
the requirement to meet and
report on the Quality Standards. In either case, Health Authorities
will be charged with responsibility
for taking appropriate action wherever an individual GP fails
to meet the Standards.
While we do not wish to prescribe the mechanism that the Health
Authority would use to discharge
this role, it must include effective lay representation in
addition to the usual health professionals,
for it is only in this way that it will be able to discharge
a proper level of accountability
to the wider community that it serves. An obvious source of
such lay representation could be
the Lay Members of Primary Care Group Boards or the Non-Executive
Directors of Primary
Care Trust Boards, lay people with a real understanding of
primary care in the locality. Regional
Offices of the NHS Executive would be responsible for managing
the performance of Health
Authorities, but the most important characteristic of the
proposed framework is the new opportunity
that it creates for effective local ownership of the provision
of out-of-hours services, an
appropriate recognition of the local partnerships that will
characterise the new model of the
integrated provision of out-of-hours services.
Fundamental as such lay participation will be to delivering
an effective form of accreditation, it
is equally important that (wherever appropriate) the new mechanisms
for lay scrutiny of the
work of the NHS envisaged in The NHS Plan pay proper attention
to services provided out-ofhours.
In particular, the role envisaged for the new Patients' Forums,
which will be established in
every Primary Care Trust, provides an important opportunity
to give local people the opportunity
to scrutinise and comment on the quality of the services in
their own area and, in setting
the agenda for these new organisations, PCT/Gs must ensure
that proper attention is focused
on the delivery of care out-of-hours.
In discharging the accreditation function, an individual Health
Authority may find that it is asked
to accredit a large organisation that wishes to provide out-of-hours
services in a number of different
localities, spread across more than one Health Authority.
In such a situation, there would
be little sense in each of these Health Authorities attempting
to accredit the same organisation
separately, for not only would this generate unnecessary costs
in time and resources, it might
even result in the same organisation being accredited by one
Health Authority, while failing to
achieve accreditation with another. Wherever such a situation
occurs, therefore, all the Health
Authorities involved should identify a single lead Health
Authority to accredit the organisation
on their behalf.
Finally, the Review Team is aware of the considerable variations
that have sometimes arisen
when Health Authorities have been charged with responsibility
for administering what were intended
to be national standards. Given the critical importance of
achieving equity of provision
across the country, the Review recommends that detailed guidance
for Health Authorities be
developed, to enable them to implement their new powers of
accreditation in a manner that is
indeed truly consistent.
Health Authorities should be responsible for the accreditation
of all organised out-ofhours
providers and should monitor the quality of out-of-hours services
those GPs who do not use such providers. Detailed guidance
should be developed for
the manner in which accreditation is to be implemented.
In summary, the accountability framework proposed here has
three central features:
??All organisations offering an out-of-hours service will
have to be accredited by their local
??Service Level Agreements between NHS Direct and all providers
of out-of-hours services,
and between those providers and GPs, will allow all the 'players'
in a locality to hold
each other accountable for the services each delivers.
??PCT/Gs will monitor compliance with these Service Level
Agreements, with data reported
to the PCT/G quarterly; the PCT/G will in turn report these
data to the Health
In addition, the PCT/G will have overall responsibility for
the planning of out-of-hours services
in its locality, and the nature of that role is set out in
Section Seven below.
7: An Approach Integrated with
Other Local Providers
The majority of patient demands for primary care out-of-hours
have been handled by GP practices
and the different organisations that work on their behalf
but, in many urban areas, a significant
number of patients use their local Accident and Emergency
Department as their source
of primary care out-of-hours – some studies show that
as many as 40% of those who present
out-of-hours are in fact in need of primary care. Moreover,
where patients have access to a
Walk-in Centre, they may well start to use it in the same
While the traditional approach has sought to characterise
such patient behaviour as 'inappropriate'
(and has attempted to challenge the attitudes that lay behind
that behaviour), the fact remains
that significant numbers of people in urban areas continue
to attempt to access 'primary
care' out-of-hours through their local Accident and Emergency
Department – indeed, some data
suggests that the number of people who act in this way is
rising. Thus, true to the principle of
making the provision fit the needs of patients, the Review
Team is convinced that it makes
sense to look again at the way in which the NHS responds to
those particular needs, and two
aspects of current provision provide the foundations on which
to do just that. First, many current
providers resource local Primary Care Centres out-of-hours
and, whereas traditionally all
patients who needed a face-to-face consultation were visited
in their home, patients are increasingly
encouraged to attend at such a Centre. And secondly, in an
approach to which we have
already made reference (see page 5 above), some Accident and
Emergency Departments have
been reconfigured to make separate and appropriate provision
for those who need primary care
on the one hand, and those truly in need of emergency medicine
on the other.
On the other hand, such an approach is still extremely unusual;
almost always, the barriers that
traditionally separated Accident and Emergency Departments
from those who provide out-ofhours
primary care services are still firmly in place. With only
a little imagination, however, it
would be possible to develop a model in which all out-of-hours
services (whether presently located
in the primary or secondary sector) could be reconfigured
in such a way that, between
them, they would be very much better placed to meet the needs
of patients. Thus, wherever appropriate,
Primary Care Centres would be located alongside a local Accident
Department, with all patients triaged at the door, and referred
either to the Primary Care Centre
or the Department of Emergency Medicine.
Indeed, a common, consistent response to all patient demands
for out-of-hours care could be
provided, with nurses in Walk-in Centres, Accident and Emergency
Departments, Primary Care
Centres and NHS Direct using exactly the same software-based
protocols to formulate appropriate
responses to those demands. Such an integrated, consistent
approach may represent
something of a radical departure for an organisation which
has, on occasion, shown itself un-
willing to cross traditional, long-established boundaries
but, in our judgement, the substantial
improvements in both the quality of patient care and the efficiency
of provision that this would
deliver provide abundant justification for such a change.
In order to achieve such a level of integration, all out-of-hours
services in a given locality should
be planned as a single, integrated service and, given the
reconfiguration of primary care that will
continue to take place over the next couple of years, the
responsibility for such integrated commissioning
will rest with the local Primary Care Trust. Such an approach
can be represented diagrammatically:
In fact, the basis for such an approach can already be found
in the work that Health Authorities
have already done in their Winter Planning Groups, where all
the key 'players' already come together
(including for example: GP Co-operatives, GP rotas, deputising
services, NHS Direct,
local PCT/Gs, the Health Authority, local Accident and Emergency
Centres, the Local Pharmaceutical Committee and Social Services);
indeed, in some Health
Authorities, Winter Planning Groups (which, of necessity,
have a short-term focus) have given
rise to Emergency Care Liaison Groups. PCT/Gs might well work
through such a Group to
plan an integrated out-of-hours provision in its locality,
which will properly meet the needs of
the local population. In determining how to deliver this responsibility,
PCT/Gs will need to
consult with their Local Medical Committees about the role
that they might most appropriately
play in this developing situation.
Such an integrated approach will bring to an end some of the
anomalies of the current position
where, for example, an Accident and Emergency Department and
a Primary Care Centre can be
located in close physical proximity, and yet offer quite separate,
autonomous services to their
patients. Moreover, better communication and co-operation
between existing providers of outof-
hours services, will create new opportunities for the more
effective use of scarce resources. It
has become clear from a number of the Review Team's visits
that out-of-hours providers are
finding it increasingly difficult to recruit appropriate medical
staff, and the changing expectations
of new entrants into General Practice may well exacerbate
this trend (see also Section Ten
below). Thus an approach that plans out-of-hours provision
by taking account of all the resources
that are available locally, will be able more effectively
to resolve this problem.
GPRota s PCT/G plans
Pharmacy Walk-in Centre
Accident & Emergency
Mental Health Team GPs
In parallel to these new partnerships across the PCT/G, however,
it is equally important that
comparable partnerships are built at the level of the relationship
between NHS Direct and its
local out-of-hours providers, to ensure that the Clinical
Governance agenda is effectively delivered.
Thus each NHS Direct site will need to develop a Clinical
Steering Group that brings together
medical and nursing staff from both NHS Direct and GP out-of-hours
work with that site. The Group would monitor and evaluate
the clinical outcomes of its services
and the way in which those services are delivered, paying
particular attention to the rigorous
analysis of any significant events. It would develop a joint
Complaints Procedure for all those
involved in the delivery of out-of-hours services, and also
develop appropriate methods for assessing
patient satisfaction and taking action on the results of that
In formulating their approach to the provision of out-of-hours
services in the area for which
they are responsible, PCT/Gs will also need to take into account
two additional aspects of the
situation. Like every other NHS organisation, the PCT/G is
charged with responsibility for ensuring
'best value' in both financial and service terms for the resources
that it deploys in the local
health economy, and the provision of services will always
have to be achieved within the parameters
of a defined budget. In that context, an undue proliferation
of small providers may
well undermine the ability to provide high quality services
at a reasonable price and, thus, even if
a particular provider has been accredited by the Health Authority
as being fit for purpose, the
PCT/G will have to exercise careful judgement about which
providers best meet the needs of
the local health economy as a whole. Moreover, when considering
any proposed changes in existing
provision, the PCT/G will once again have to take account
of the impact such changes
may have on the wider health economy. The Review Team has
been made aware of just how
destabilising even quite small changes in provision can be,
and it will be an important part of
the new role of the PCT/G to avoid this happening. On the
other hand, there is nothing in the
Review's recommendations that will inhibit a new provider
from presenting proposals as to how
it could improve on the quality of services that are currently
provided, and there is every reason
why the PCT/G would want to look very carefully at just such
Secondly, PCT/Gs must take an appropriate strategic view of
the provision of services in the
wider health economy outside its own immediate boundaries.
As yet it is far from clear what
patient population the typical PCT/G will serve, and an individual
PCT/G may well find that it
is working with a major out-of-hours provider whose services
are made available to patients
across more than one PCT/G. In such circumstances, it will
be very important for neighbouring
PCT/Gs to consult with each other in the provision of services
– they may indeed decide that
they want to develop a more formal relationship for this part
of their work, with one PCT/G
taking the lead on their behalf.
A fully integrated out-of-hours service should be planned
by the PCT/G in each locality,
bringing together all appropriate service providers.
A Clinical Steering Group should be established by each NHS
Direct provider Trust to
deliver the Clinical Governance agenda.
Contracts and arrangements between practices and out-ofhours
The majority of practices now use some form of organised out-of-hours
care, devolving their
responsibility to a GP Co-operative, a deputising service
or taking part in a local extended rota.
These contracts are typically negotiated practice by practice
but, in the absence of clear, measurable
standards, the inevitable result is considerable inconsistency
of provision. They may also
represent a significant potential threat to the stability
of out-of-hours provision in a given locality,
where even the larger providers may be vulnerable to the consequences
of a small number of
GPs changing their out-of-hours provider at will. Not least
because it is aware of this danger,
the Review Team has been especially impressed by approaches
in which GPs have come together
to contract jointly with their local deputising service. For,
by working collaboratively in
this way, these GPs have secured very many of the same benefits
that derive from the model of
medium-sized GP Co-operatives, both in terms of economies
of scale but also, and even more
important, in terms of the rigour of the quality standards
that they have been able to put in
Although the Review Team cannot recommend that this model
must provide the basis for the
relationship between practices and out-of-hours providers,
it is evident that such arrangements
have clear advantages for both practices and patients. Thus,
individually negotiated arrangements
must, at the very least, be as consistent with the local plan
for integrated out-of-hours
care and with the Quality Standards, as those arrangements
negotiated collectively. Equally, individually
negotiated arrangements involving the devolution of out-of-hours
responsibilities to a
third party can only be entered into with accredited providers,
and must be approved by the
Every arrangement involving a GP devolving out-of-hours responsibilities
to an out-ofhours
provider, whether negotiated individually or collectively,
should only be entered
into with an accredited provider and should be approved by
The approach set out in the integrated model also takes proper
account of an important change
that has invariably been associated with the development of
GP Co-operatives. At present, GPs
assume 24-hour responsibility for the care of their patients,
but in practice many GPs have devolved
the out-of-hours portion of that responsibility to another
organisation, in which they
may or may not play a part in staffing its services. The Review
recommends that the individual
GP 'contract' is amended to allow a GP to devolve responsibility
for the out-of-hours element
of the contract to an accredited organisation (in addition
to existing arrangements for transferring
responsibility to another GP on the medical list). By definition,
such organisations will only be
accredited by the Health Authority if they can demonstrate
that they are meeting appropriate
standards of service delivery and care and that they have
put in place robust and acceptable arrangements
for indemnity cover. Moreover, should it be demonstrated that
any such organisation
is failing to meet these standards, then the Health Authority
(which holds each GP's contract)
will, in the last resort, return the 24 hour responsibility
to the individual GP. In almost all
circumstances, however, the Health Authority (working closely
with the PCT/G and the GPs),
would have made sure that alternative arrangements for the
proper provision of out-of-hours
services would have been put in place.
The GP 'contract' should be modified to allow a GP to devolve
responsibility for the outof-
hours element to an accredited organisation with appropriate
indemnity cover, but
where that organisation fails to meet appropriate standards
of service delivery and care,
the Health Authority should, in the last resort, return the
24 hour responsibility to the
8: Funding the Model
The terms of reference of this Review are such that it would
not be appropriate for it to make
detailed recommendations about the level at which its new
model of integrated out-of-hours
services will be funded. The Department of Health will wish
to respond to the recommendations
set out in this Report, exploring in particular their financial
and regulatory implications.
On the other hand, the broad principles on which its integrated
model of out-of-hours service
provision should be funded are clearly matters on which the
Review is entitled to comment, and
the Review Team has identified a number of general principles
that all organisations and individuals
who provide those services must follow:
??All services must conform with the principles of 'best value'.
??Funds must be allocated in such a way that all patients
have access to the same high
quality out-of-hours services, regardless of where they live.
??There must be transparent and open information about the
way in which all out-ofhours
services are funded.
In addition to these basic principles, the Review has looked
carefully at the way in which the
funding of the integrated model might most appropriately be
administered, and the proposed
new pattern of allocating these resources can be set out most
easily in the following diagram –
the solid red lines represent the funding flows; the dotted
green lines represent a fully integrated
package of funding (a level of integration to which some PCTs
Primary Care Trust
'Unified Budget' NHS Direct
GPRota s GP
Deputising Community Nursing
Mental Health Team
Pharmacy A & E
The implementation of this model of integrated provision will
result in approximately half of
all calls concluding with NHS Direct. Thus, as out-of-hours
providers will no longer carry this
workload, they will be able to redirect existing out-of-hours
resources to support the new activity
required to meet the Quality Standards. In addition, the Review
Team is persuaded that existing
providers will be able to achieve further economies of scale
in relation to call handling
and basic audit activity, provided that there is a rationalisation
of the remaining call management,
information technology and audit functions. This may require
the merger of some smaller
organisations and the bringing together of some other functions
to meet the Quality Standards.
In reviewing existing provision, the Team has looked especially
closely at the way in which
Health Authorities have administered the Out-of-Hours Development
Fund and it is clear, both
from the data that we have collected from Health Authorities,
and from the discussions that we
have had with local providers, that current arrangements have
not always resulted in the development
of a quality service or in the infrastructure required to
develop such a service. Equally, it
is clear that very many out-of-hours providers have found
the annual cycle of decisions about
the allocation of the Fund enormously problematic –
planning that is constrained within a
twelve month timescale might be seen by some as a contradiction
in terms. Thus the Review
recommends that out-of-hours providers will in future enjoy
the security of a three-year rolling
funding allocation, subject always to the constraints that
derive from the effective monitoring of
their performance against the Quality Standards – an
approach that is directly analogous to the
Long Term Service Agreements being developed between PCTs
and other providers.
Given the central role that PCTs will play in the planning
of out-of-hours services in their locality,
it makes sense to recognise this in the arrangements that
are made to administer the funding
of those services. The Review therefore proposes that PCTs
should administer and allocate the
funds that support out-of-hours provision, a proposal that
satisfies the principle of transparency
and openness, as all PCTs are obliged to publish detailed
Finally, while existing financial support for out-of-hours
services will be retained, it needs to be
targeted much more explicitly to achieve the significant improvements
in quality which are at the
heart of this Report, and we therefore recommend that the
Out-of-Hours Development Fund
be renamed the 'Out-of-Hours Quality Fund' and any expenditure
which serves to support and
improve the quality of out-of-hours service provision will
be a legitimate call on that fund.
The Out-of-Hours Development Fund should be renamed the Out-of-Hours
Fund, allocated and administered by PCTs as part of their
overall planning of out-ofhours
provision, within a three year rolling funding allocation.
Any expenditure which
serves to support, improve and maintain the quality of out-of-hours
should be a legitimate call on that fund.
Individual GPs offering their own out-of-hours services
GPs who provide their own out-of-hours services and who both
meet and report on the Quality
Standards will be able to access the Out-of-Hours Quality
GPs who do not delegate responsibility for their out-of-hours
services should be able to
access the Out-of-Hours Quality Fund, provided that they are
able to report compliance
with the Quality Standards.
'Items of Service' payments
In the light of the radical changes in the character of out-of-hours
services that have taken place
in recent years (described above in Section One), one aspect
of the way in which these services
are presently funded no longer makes sense. The 'Item of Service'
payments that are associated
with face-to-face consultations were created at a time when
the vast majority of out-of-hours
care took this form; today, more than half of all requests
for out-of-hours care are safely and
appropriately met on the telephone, and yet such consultations
attract no payment at all.
Moreover, while such payments do represent a crude measure
of the level of out-of-hours demand
that falls on a particular GP or practice, the changing character
of service delivery makes
them less and less appropriate and it is at least theoretically
possible that there might come a
time when such payments would act as a perverse incentive,
encouraging some GPs to consult
face-to-face when a telephone consultation would in fact represent
a much better use of this
For all these reasons, the Review has concluded that it makes
no sense to retain a separate 'Item
of Service' payment.
'Items of Service' payments should cease, and these monies
should be redistributed,
taking proper account of the differential demands on practices
for out-of-hours services.
Given the particular, short-term needs that will have to be
met to enable some providers of outof-
hours services to invest in the IT and organisational systems
that are a precondition of a
quality service, a proportion of out-of-hours funding should
be used to create an Out-of-Hours
A proportion of out-of-hours funding should be used to create
an Out-of-Hours Implementation
It has long been argued that the provision of out-of-hours
services in rural areas necessarily
incurs higher costs (especially in terms of additional infrastructure
costs associated with problems
of geography and transport) and, in recognition of these claims,
an additional £2 million
was identified in the Out-of-Hours Development Fund in the
financial year 1999/2000 to offset
those additional costs. Not least for this reason, the Review
Team has looked especially carefully
at the issue, trying to identify whether there are indeed
additional rural costs and, if so, precisely
what they are.
A careful analysis of the existing data serves only to emphasise
the limits of our existing understanding
of the costs of this particular aspect of health service provision.
For while it is possible
to make comparisons between the costs of the out-of-hours
services provided by different
GP Co-operatives, comparisons which reveal as much as an eightfold
variation, the current data
do not allow rurality to be identified as an independent determinant
of demand. Thus in sharp
contrast to both age and social deprivation, which have both
been clearly shown to be important
variables, significantly affecting the levels of demand and
thus the costs of provision, the existing
data simply do not allow the costs associated with rurality
to be isolated in the same way.
That said, it is certainly possible that out-of-hours providers
meeting the needs of elderly, deprived
populations in rural areas may face the highest level of demand
of all, yet even here the
data does not presently exist even to confirm such a proposition,
let alone identify those out-ofhours
providers who are in fact having to meet those demands.
Part of the problem with current data derives from the fact
that no less than three-quarters of
all GP Co-operatives serve rural or mixed rural/urban populations
and it is thus difficult to isolate
the rural dimension from the other elements in the service
provided that determines their
costs. More important, the character and extent of the out-of-hours
service that individual Cooperatives
provide differs widely, and with such disparities in character
of provision it is impossible
to make any sensible comparisons. Indeed, looked at simply
in terms of activity (contact
rates per 1000 patients per annum), there are as striking
differences between different rural providers
as there are between rural and urban providers.
That said, if the Quality Standards recommended in this Report
are adopted, the data that will
accumulate as out-of-hours providers report on those Standards
will provide, for the first time,
an appropriate common denominator against which to start to
make realistic comparisons between
different providers. And once meaningful comparisons can be
made, then it will at last be
possible to start to disentangle the true nature of the costs
that are associated with the provision
of out-of-hours services to different populations in different
parts of the country. The Review
recommends therefore, that at the earliest possible opportunity,
a careful and rigorous analysis
of the data about out-of-hours activity is carried out, with
a view to identify what the different
factors are that determine levels of demand. Armed with that
data, it will then be possible to
allocate the monies that are available to fund out-of-hours
services in a manner that accurately
reflects real differences in demand for those services.
As soon as practicable, the data that derives from out-of-hours
providers reporting on
the Quality Standards should be analysed to identify the actual
determinants of demand,
with a view to allocating out-of-hours funds in a manner that
takes proper account
of real differences in costs of provision and levels of activity.
9: Recruitment and Retention of
Recruiting and retaining high quality staff is at the heart
of any successful delivery of service,
and meeting this particular challenge in the provision of
out-of-hours services will probably
prove more difficult than meeting the financial challenges
contained in the recommendations of
this Report. That said, the Team has been particularly impressed
by the imaginative approaches
to workforce planning and development that are already taking
place across the service, and it is
already clear that innovative solutions to these problems
can both meet the needs of the service
and the needs of the staff themselves.
A particularly good example of such an approach has been the
use of General Practice nurses
in carrying out the triage function in GP Co-operatives for,
not only has this broadened the experience
of those nurses, adding an important extra dimension to their
portfolio of skills and
competencies, it has also created a larger pool of skilled
staff on which the service can draw at
times of greatest demand. Building on examples like this,
it would not be difficult to envisage a
situation in which nurses could rotate between a wide variety
of different services, including for
example, General Practice nursing, NHS Direct, Accident and
Emergency nursing and community
nursing. Rotations like this would result in a new, multi-skilled
nurse, who would combine
telephone and face-to-face triage skills, with more conventional,
'hands on' clinical skills. And
the end result of that would be a core of nurses, well-placed
to offer effective triage in daytime
General Practice and Accident and Emergency services.
On the other hand, the Review Team is also aware of growing
problems of recruiting and retaining
doctors to work in out-of-hours services, not least as new
entrants into the profession
aspire to a more limited definition of their role. Equally,
the demands of care for patients in
General Practice become increasingly complex, and those GPs
who still provide their own outof-
hours care are finding it increasingly difficult to balance
the demands of night and day
working. Indeed, it is for all these reasons that the Review
Team's determination to achieve the
more effective use of scarce resources, should be implemented
as quickly as possible – the further
growth of GP Co-operatives and the more appropriate use of
deputising services represents
two especially important ways in which more effective use
of these scarce resources can be
Important as such developments will be, however, the central
human resource problem will
never be solved if the traditionally rigid lines of demarcation
between different clinicians are
maintained. The Review therefore recommends strongly that
all involved in the delivery of outof-
hours care look again at the roles that are currently played
by their staff, exploring whether
the many skills and competencies of their staff (especially
their nurses) are in fact being used to
the full. We understand that there is marked reluctance in
some areas of the country to embrace
these changes, but we are convinced that, if change does not
occur, then those areas will find it
increasingly difficult to attract staff.
All out-of-hours providers should re-examine the way in which
they use their staff, exploring
in particular whether their current procedures allow nurses
to make full use of
their many skills and competencies, with a view to developing
a new way of working in
which the resources of all the staff who work in the out-of-hours
team are used to their
10: The Supply of Medicines
Access to appropriate medicines out-of-hours has always been
problematic and, after consulting
widely, the Review Team is clear that the current situation
is far from satisfactory. In essence the
problem derives from the fact that patients with acute illness
may need to start their medicine
without delay and an initial supply needs to be provided either
at the time of the consultation,
or very soon thereafter.
Traditionally, GPs solved this problem by providing a small
supply of that medicine from their
own resources, leaving the patient with a prescription for
the remaining course of treatment.
But because there has been no agreed method for identifying
and supplying these medicines,
there have been marked variations in the range that each individual
GP has carried. Indeed, in
some cases GPs have had recourse to 'free' starter packs provided
by pharmaceutical companies,
creating a situation in which new or more expensive drugs
may have been prescribed where, in
normal circumstances, the GP would have prescribed a cheaper
or more well-established product.
A number of organised providers have attempted to solve this
problem by identifying a
standard formulary for out-of-hours drugs, but overall the
pattern of supply remains patchy and
inconsistent. Moreover, whatever the particular local arrangements,
there are also occasions
when the patient needs a drug that the GP does not carry,
and complex and time-consuming
procedures (often involving the police as well as a pharmacist)
have to be followed to supply
In sum, the present position is confused, complex and inconsistent
and, in line with the Review's
determination to ensure that patients across the country have
access to the same high
quality of provision, a new approach to out-of-hours medicine
supply is long overdue. The
starting point lies in the recognition that the majority of
patients who need medicines urgently
are already being seen in a Primary Care Centre and thus,
from the patient's point of view, it
would be incomparably better if the full course of their medicine
could be dispensed in the
Centre, thereby obviating the need for a further trip to a
community pharmacist the next day.
Indeed, some out-of-hours providers, working in partnership
with a local community pharmacist,
have attempted to develop just such a service, only to be
told that the current regulations
While changing those regulations is one of the steps that
will have to be taken to implement a
'one stop' approach, it will be just as important to develop
an appropriate formulary for out-ofhours
medicines, ensuring that the new providers carry a sufficiently
wide range of drugs to
meet the vast majority of out-of-hours needs (including the
particular needs of terminally ill
patients). For if that work is done successfully, then the
number of occasions when it will be
necessary to access additional medicines from a community
pharmacy out-of-hours can be
substantially reduced. That said, such occasions will, of
necessity, occasionally arise, and the
PCT/G and the Health Authority will need to develop a proper
strategy to ensure that all outof-
hours providers have quick and easy access to the on-call
Other than in exceptional circumstances, patients should be
able to receive the medication
they need at the same time and in the same place as the out-of-hours
The existing remuneration and contractual arrangements for
out-of-hours providers and
pharmaceutical services should be reviewed and, where appropriate,
modified to allow
for the provision of all appropriate medicines in the manner
set out in Recommendation
11: Timescale for Implementation
All the work that has been done thus far suggests that the
new model of integrated out-ofhours
provision set out in this paper can be achieved within a reasonable
timescale, and none of
the visits that the Review Team has made to existing providers
has revealed any unforeseen obstacles
that might stand in the way of achieving that objective. That
said, there are marked differences
between different providers' ability quickly to meet all the
Quality Standards set out in
Section Five of this Report: some providers could meet all
those standards tomorrow, while
very many more will need to complete a properly planned programme
of development before
they would be in a position to do this.
Recruiting appropriate high quality staff is one aspect of
implementation that could pose problems,
and we have already drawn attention to the fact that some
providers are already experiencing
difficulties in recruiting appropriate medical staff for their
services. Real as such difficulties
are, the experience of those providers who have solved this
problem suggests that a more
imaginative approach to the balance of professionals engaged
in the provision of out-of-hours
services can in fact provide the answer. An out-of-hours service
that was wholly dependent on
doctors to provide its clinical services (whether on the telephone
or face-to-face) will almost
certainly find it more and more difficult to solve this problem;
a service that employs an appropriate
mix of nurses and doctors will, in almost all circumstances,
be able to recruit sufficient
appropriate staff to provide the high quality proposed in
Taking all this into account, the Review concludes that out-of-hours
providers can start to report
on the Quality Standards from April 2001. Different providers
will face different challenges
in meeting those Standards and, while it is important that
all the necessary changes should be
implemented as quickly as possible, particular priority must
be given to implementing those
Standards which ensure the clinical safety of the service.
Out-of-hours providers should start to report on the Quality
Standards set out in this
Report from April 2001.
It will clearly take longer to achieve the full model of integrated
service provision set out in this
Report. Out-of-hours providers will need to be accredited,
PCT/Gs will need to plan the provision
of services in their area, and those providers with no experience
of an integrated service
will need time to learn from the experience of those who have
already pioneered such services.
That said, the Review is confident that the fully integrated
model can be in place by 2004.
The fully integrated model of out-of-hours provision set out
in this Report should be
achieved by all GPs and out-of-hours providers by 2004.
Annex One: Terms of Reference
for the Review
1. The Minister for Health, Mr John Denham, has requested
a review of all arrangements of
GP out of hours cover across England. The aim of the review
is to identify ways of
bringing standards of all out of hours (OOH) services up to
the standard of the best, and
make recommendations to him on any priority actions to improve
2. The Review will:
??consider all arrangements for out of hours provision including
(co-ops), commercial services and practice rotas;
??examine the approach that each adopts to quality assurance,
training, the availability
and use of clinical and non-clinical personnel and the use
of different models of
skill-mix, organisation, protocols, record keeping and quality
??examine the role played by HAs in monitoring the quality
of the OOH Development
??ascertain their accessibility and responsiveness, consistency
of response and treatment,
geography, equity in resource distribution, efficiency and
value for money;
??identify the potential for developing integrated services
with NHS Direct (including
Walk-in Centres and Social Services) and recommend organisational
and practice including quality standards and their enforcement,
that might address
current and future patient needs;
??examine whether we are getting best value for money from
the existing spend on
the OOH Development Fund, and whether it is best targeted.
METHOD/APPROACH TO REVIEW
3. It will be conducted by a small review team led by Dr David
Carson. An external
reference group comprising of key stakeholders will meet at
4. The key areas of work will be -
a. Identification of best practice in existing service (co-ops,
small rural practices).
b. Review of evidence relating to out of hours care to ensure
have an evidence base.
c. Exploration of existing NHS Direct relationships with Primary
identify best reproducible practice.
d. Medicine supply arrangements.
e. Identify existing cost base and resource utilisation within
co-ops, deputising and
f. Develop explicit standards in relation to:
ii. Service & Organisational Models (including links to
iii. Clinical Governance (including critical event analysis,
iv. Continuous Professional Development & Accreditation
g. Develop an outline accountability framework for the standards.
h. Develop recommendations in relation to financial framework
incentives are aligned.
5. Each member of the team will lead and work on specific
areas with support from DOH
staff and academic network. Testing of identified recommendations
will occur with the
reference group throughout the review. Data to be gathered
and later testing of
recommendations via structured telephone interviews (with
academic advice on
structure/process). An early request for views and models
will be made to a limited list of
organisations. A key principle will be the involvement of
non-professional people and
organisations at all stages of the process.
6. A report, with recommendations, will be presented to MS(H)
by 31st August 2000.
7. Key issues will be -
a. A flexible national model which can be implemented locally
b. An accountability framework which is robust and transparent.
c. Professional acceptance of an integrated approach including
d. Identifying possible recommendations for NHS Direct Model
foster local working partnerships.
e. Professional acceptance of explicit governance process.
8. The following areas will fall outside the scope of the
a. Services provided within “normal working hours”.
b. Out of Hours Dentistry.
LIST OF INTERVIEWEES
9. Interviewees will include the following:
??NHS Direct (all types of existing models)
??Providers identified by early research who have good models
and also those with
models that seem to be having difficulties.
??Existing OOH Pharmacy supplier
Annex Two: Review of the
Primary care research is considered to be an emerging discipline
within the health sciences1 and
a relatively substantial UK literature concerning issues in
out-of-hours general practice care has
developed since the 1970s. Much of the literature has addressed
patterns of demand and activity,
and service organisation. Early studies tended to be descriptive,
small scale (commonly focused
on a single site) and drew on data collected over short time
periods, but these studies were important
in describing a picture of out-of-hours primary care, and
in identifying questions for
further research. Fewer studies have used comparative methods,
or have addressed patient expectations,
experience or satisfaction with out-of-hours care, and fewer
still have measured
health outcomes associated with different patterns of service
delivery. A seminal review of the
out-of-hours literature was published in 19942 and we have
considered this together with publications
over the last ten years in order to better understand the
features of the current provision.
A literature search of published material since January 1990
was undertaken in May 2000 using
the on-line services Medline, Embase, EconLit, CINHAL, British
Nursing Index and HMIC.
The review aimed to address the question ‘what evidence
is there of the effectiveness, safety and
acceptability of different models of out-of-hours primary
care?’ There are few randomised controlled
trials in this area, and given the available timescale the
review was not designed as a ‘systematic
review’.3 Thesaurus and free text search terms used
included: family practice, out-of-hours
care, out-of-hours primary care, 24-hour primary care, after
surgery hours, demand for out-of-hours care, GP cooperatives,
deputising services, night visits, home visits, call handling,
telephone triage, out-of-hours triage, telephone
advice, telephone consultation, inappropriate calls and rural
general practice. On-line searching was
supplemented by manual searching of recent journals and grey
literature. All texts identified by
on-line search were obtained except where it was clear from
the title or abstract that they were
unsuitable. Texts were selected for review if they were published
between January 1990 and May
2000 in a peer reviewed journal; were written in English;
and reported primary research, or primary
analysis of routinely available data. An overview of the themes
in the literature is summarised
below, followed by a synopsis of key papers.
Need and demand for out-of-hours care
The collection of routine activity data by GPs about their
out-of-hours work has enabled a
number of studies to describe patterns of demand.4-11 Current
estimates suggest that on average,
a registered population of 1,000 patients will generate approximately
160 out-of-hours calls
per annum7 though it should be noted these estimates are normally
based on the number of
calls received by service providers and do not take account
of abandoned calls. In any year, outof-
hours contacts are likely to be made by approximately 10%
of the registered population12
and, although the majority of callers will make only one contact,
some patients need to use the
service more frequently.13 Patterns of demand can be predicted
with reference to the literature,
with peaks occurring during early evenings, and high demand
on Saturdays and Sundays during
the day and the evening. Demand on Sunday mornings typically
exceeds that at any other time in
the week. High levels of demand are also observed on public
holidays, though these time periods
are often excluded in analyses of demand as they are atypical.
There is some evidence that
during the peak millennium period, extended opening of general
practice surgeries on public
holidays contributed to the overall approach to managing demand.14
The proportions of patients
receiving telephone advice, attending a Primary Care Centre
or receiving a home visit vary
between providers15-20 though rates of home visiting have
shown the most marked variation.
The proportions of calls concerning children under four years
and people over 75 years of age
are generally greater than their numbers in the population
would suggest.7,12 Women tend to
make more contact with out-of-hours services than men,28 with
approximately a third of all callers
calling about themselves, with the remaining two-thirds calling
on behalf of another adult or
about the care of a child. Determinants of demand are not
entirely understood, but it appears
that variation in the need for out-of-hours care is largely
explained by deprivation (typically associated
with strong demand) and age-related vulnerability.7,9,21-23
Patient expectations about the
role of out-of-hours services may also exert some influence
on demand and, where the public
do not have good access to information about how out-of-hours
care is organised, attendance at
an Accident and Emergency Department, for example, becomes
a reasonable option. Assessment
of urgency by General Practitioners varies24,49 and estimates
suggest that between 20%
and 40% of out-of-hours attendances at Accident and Emergency
Departments are for primary
care health problems.25-28 Broad consensus around the most
common health concerns
prompting out-of-hours calls has emerged24,48 but in a qualitative
study of patients’ accounts of
calling the doctor out-of-hours, the presence of symptoms
was not the only factor to determine
a call; other factors, including past experiences of using
health services, were important.29
The organisation of out-of-hours care
General Practitioners appeared to experience increasing strain
as the demand for out-of-hours
care rose dramatically in the 1980s and 1990s.2, 30-32 Views
on the organisation of out-of-hours
care at this time revealed an eagerness to consider new approaches
to organising services, even
though there was little evidence of the comparative effectiveness
of different models.30 Such
comparisons remain few in number today, but what data there
are highlight differences in response
times, prescribing rates and patient satisfaction between
providers.8,18,19 A survey of the
standards set by Family Health Service Authorities for deputising
services in 199433 and a survey
to assess the organisation of out-of-hours primary care services17
revealed wide variation in demand
and types of provision. Accurate, contemporary data on the
number and characteristics of
organised providers of out-of-hours care in England are not
Nurse telephone triage and consultation have been introduced
by a small number of providers
of out-of-hours primary care. The literature on the safety
and effectiveness of telephone triage
and consultation is limited, though when supported by clinical
decision support software, nurse
triage (tested in a randomised controlled trial in the environment
of a GP Co-operative) has
been shown to be at least as safe and effective as usual care.12,34
Nurses typically manage 50% of
out-of-hours calls without referral to a GP, and enable patients
with urgent needs to be prioritised.
In contrast, there is no published evidence of the safety
or effectiveness of receptionist or
call handler triage. Incomplete assessment and early closure
of a call before an informed decision
can be made have been identified as factors contributing to
‘poor’ telephone consultation
amongst a range of health professionals.35 The extent to which
levels of experience and relevant
training influence competence on the telephone is not clear,
though one study found that nurses
with at least ten years clinical experience made more consistent
decisions than did nurses with
Expectations, experience and satisfaction
with out-of-hours care
The validity of the notion ‘satisfaction’, as
a single concept, and the merits and limitations of
alternative approaches to measuring it have been discussed
in the wider literature.37-40 Reports of
patient and caller satisfaction with out-of-hours care have
shown the high levels of satisfaction
typical of many studies of health care interventions, but
few have identified specific sources of
satisfaction or dissatisfaction.16, 41, 42 One validated out-of-hours
satisfaction questionnaire42 has
been used in a range of settings, but there is a tendency
for evaluators to design their own instruments,
or modify existing ones without proper tests of validity and
reliability. Recent evidence
suggests that patients may be less satisfied with the way
in which their care was managed
out-of-hours (at a Centre, or over the telephone for example)
where this was at odds with their
prior expectations.16 Further work is needed to determine
patient preferences for different models
of out-of-hours care and to assess the responsiveness of out-of-hours
services to patients
with special needs. People whose first language is not English
may be unaware of the existence
of out-of-hours services, may experience difficulties communicating
with health professionals
and may experience delays in gaining access to health care,43
and the reporting of community
oriented approaches to service development is welcome in this
Health outcomes, costs and subsequent
use of health services
Little is known about the relationship between the organisation
and delivery of out-of-hours
care and health outcomes for individual patients. It remains
important to understand how patterns
of service provision affect the quality and outcomes of care,
but study design in this area
is difficult, not least because service providers do not use
a common method of coding and recording
data concerning presenting complaint, provisional diagnosis
and call outcome. Out-ofhours
providers can be expected to have data concerning the call
disposition, but arguably, the
episode of care extends beyond this. Measurement of health
outcomes involves follow up of
patients and the co-operation of other agencies. For example,
health outcome was measured
using the SF36 questionnaire in a comparison of care provided
by different out-of-hours providers,
19 and a study of nurse telephone consultation found no increase
in the number of patients
seeking daytime surgery appointments within three days.45
Typically, 5% of patients re-
ceiving out-of-hours care are admitted to hospital as an emergency,
7.9.12 but little is known about
the timeliness and appropriateness of care leading to out-of-hours
admission. A cost analysis
from an NHS perspective of nurse telephone consultation based
on data from a randomised
controlled trial in one General Practice (GP) Co-operative,
showed that reduced emergency admissions
to hospital determined a reduction in costs for the NHS.46
Several economic analyses and economic evaluations of out-of-hours
primary care are currently
in progress in the UK. The published literature is currently
limited, and evidence relates mainly
to GP Co-operatives. The extent of financial support received
and predicted to be needed for
GP Co-operatives was assessed in a questionnaire survey.47
Detailed case studies of seven cooperatives
as part of the National Health Technology Assessment Programme
reported up to an
eightfold variation in overall operating costs of Co-operatives16
and the incremental costs of
providing a county-wide GP Co-operative service have been
reported.48 Without evidence of
effectiveness however, comparisons on the basis of cost alone
Recent work on the demand for and supply of out-of-hours care
in populations covered by GP
Co-operatives has provided a useful baseline against which
the impact of further development
and previous activity can be assessed.7 Indeed, if out-of-hours
call rates for the period 1987-
19892 (130 to 176 per 1,000 patients per annum) are compared
with recent estimates7 (159 per
1,000 patients per annum) it is difficult to argue for a continued
rise in demand for out-of-hours
primary care. However, though much research has centred on
out-of-hours care organised in
Co-operatives, and occasionally in deputising services, it
may be misleading to assume that the
picture is similar across the country. Levels of demand may
be similar (accepting the important
impact of deprivation on demand), but processes and outcomes
of care for the patients of General
Practitioners operating practice rotas or providing their
own out-of-hours care are not well
reflected in the literature.
A previous review of the literature2 noted a lack of data
on costs and a paucity of evaluative
studies comparing different models of care. It appears that
some progress has been made, and
two major trials of out-of-hours primary care have been reported
since 1994. Economic evaluation
remains underdeveloped, however, and more detailed cost analyses
are needed to account
for the early evidence of wide variation in the overall costs
of out-of-hours care provision.
Evaluations of different service models and the care pathways
they create are required in order
to build an evidence base which can inform clinical practice
in the out-of-hours setting. In particular,
there is an urgent need for studies that venture beyond the
measurement of routine variables,
and relatively crude outcome measures such as hospital admission
and death. This will
only be possible as more appropriate outcome measures for
primary care, including intermediate
outcome measures, are validated.
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18. Cragg DK, McKinley RK, Roland MO, Campbell SM, Van F,
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20. O’Donnell CA, McConnachie A, Moffat K, Drummond
N, Wilson P (1999) Cross sectional study of
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30. Lattimer V, Smith H, Hungin P, Glasper G, George S. (1996)
Future provision of out of hours primary
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31. Hayter P, Peckham S, Robinson R. (1996) Morale in General
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R. (1997) Reliability and validity of a
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43. Free C, White P, Shipman C, Dale J. (1999) Access to and
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44. Dale J, Shipman C, Laycock L, Davies M. (1996) Creating
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45. Thompson F, George S, Lattimer V, Smith H, Moore M, Turnbull
J, Mullee M, Thomas E, Bond H,
Glasper A. (1999) Overnight calls in primary care: randomised
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nurse telephone consultation. British Medical Journal 319:1408.
46. Lattimer V, Sassi F, George S, Moore M, Turnbull J, Mullee
M, Smith S. (2000) Cost analysis of
nurse telephone consultation in out of hours primary care:
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hours: a survey of general practice co-operatives. British
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48. Brogan B, Pickard D, Gray A, Fairman S, Hill A. (1998)
The use of out of hours health services: a
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49. Court BV, Bradley CP, Cheng KK, Lancashire RJ. (1996)
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Synopsis of key studies
[ref. no.] Method Process / outcome measures and results
Salisbury et al
Observational study of demand
for and supply of outof-
hours care from GPs in
England and Scotland using a
representative sample of 20
co-operatives, their routine
data and interviews with managers.
Numbers and distribution of calls adjusted for population,
patient age & sex; proportions of patients consulting
at home, at primary care centre; response times; hospital
admission rates. Call rate excluding Bank Holidays was 159
1,000 patients per year with little seasonal or within week
Calls concerning children < 5 years outnumbered those
concerning adults by 4:1. Patients living in deprived areas
70% more calls than patients living in non deprived areas.
calls were managed by telephone advice, 24% by home visit,
and 30% by attendance at a centre. 60% calls were responded
to within 30 minutes, 83% within 1 hour. 5.5% patients were
admitted to hospital.
Lattimer et al
Cost analysis from an NHS
perspective of nurse telephone
consultation based on data
from randomised controlled
Costs and savings to the NHS during the trial year. Additional
cost of providing nurse telephone consultation for a population
of 97,000 was £81,237 per annum. This determined a £94
reduction of other costs for the NHS arising from reduced
emergency admissions to hospital. In comparison with usual
care, patients managed by nurse telephone consultation were
less likely to be admitted to hospital, and less likely to
short (1-3) day stays. Additional savings for general practice
arose from reduced travel to home visits and fewer surgery
appointments within three days of a call.
Free et al,
Qualitative study of the experiences
and perceptions of
members of Vietnamese
community groups in seeking
out-of-hours health care.
In six focus groups conducted in Cantonese and Vietnamese,
participants revealed that they did not know about GP out-ofhours
arrangements. Key problems were in communicating
with health professionals, their answering or interpreting
Some had needed to use the 999 service. Commonly, participants
had experienced delays in gaining access to health care
and confusion concerning advice and medication.
Four year follow up study
(1990-1994) of frequent attenders
to an out of general
practice in Aarhus, Denmark
using data from the Public
Health Insurance database.
Adults having four or more out-of-hours contacts in a calendar
year (10% all attenders) were defined as frequent attenders.
Attendance was measured over a four year period. Age above
50 years significantly predicted future frequent attendance.
group generated 42% of contacts in 1990 and 33% in 1991.
25% contacted at least once in the following years.
Audit of all out-of-hours contacts
to 25 practices during 4
months in 1995-6. GP assessment
of the urgency of each
Assessment of urgency and type of service received. 1027 of
1862 contacts (67%) were rated as having a physical, psychological
or social need for urgent help. 55% visits were retrospectively
rated medically necessary, of these most were for
physical problems. 60.7% home visits, 36.9% telephone consultation,
2.4% surgery attendance.
al, 1999 
Cross sectional study of patient
contacts with GEMS
over one week in 1996 to
investigate social variation in
use of an out-of-hours patient
Time of first contact; patient age; socio demographic category
derived from postcode; numbers attending centre and using
free transport, receiving home visits or telephone advice.
3193 contacts, 54% attended centres, 23% received home visits
14% received telephone advice and an ambulance was sent to
2%. Contact rate equivalent to 158 contacts per 1,000 per
Significant interactions were observed between socioeconomic
category and age group (60% higher contact rates for
children and adults from deprived areas). Elderly people in
affluent areas had 38% higher use than those in deprived areas.
Adults and elderly people from deprived areas most likely
receive a home visit. Lack of association between socio demographic
category and centre attendance attributed to provision
[ref. no.] Method Process / outcome measures and results
al, 1999 
Randomised controlled trial of
the management of overnight
calls using nurse telephone
consultation. (Parallel trial
with Lattimer et al, 1998).
As for main trial plus number of patients attending daytime
surgery within three days of a call. 59% calls were managed
the nurse alone Reductions observed in the proportions of
managed by GP telephone advice, and ending in a home visit.
Nurse managed as high a proportion of calls at night as during
evenings and weekends, without more patients attending daytime
al, 1998 
Randomised controlled trial
(blocked design) of nurse
telephone consultation in a
GP Co-operative compared
with usual care, in a population
of 97,000. Study powered
to determine equivalence in
the incidence of potential
Death within 7 days of contact with the service, emergency
hospital admission within 24 hours and within 3 days; attendance
at A&E within 3 days; number and management of calls.
Nurses managed 49.8% of calls during intervention periods,
without referral to a GP. Fewer deaths and emergency admissions
in the intervention arm were within limits defined for
equivalence. Equivalence also observed in the number of A&E
Brogan et al,
Prospective cross sectional
survey and cost description of
patient contacts with out main
of hours services over 2
months to determine use and
incremental costs of out-ofhours
services in Buckinghamshire.
Contacts with patients and cost of out-of-hours services (general
practices, accident and emergency departments, ambulance
services and community nursing services). In general practice,
call rate per annum was equivalent to 197 per 1,000 patients.
35% calls were managed by home visit, 37% by surgery attendance
and 28% by telephone advice. 51% contacts occurred
between 7-10 pm. GPs rated 5% contacts as urgent, 55% as
necessary, 26% as could have waited until the next day and
as unnecessary. Upper respiratory tract infection, diarrhoea
vomiting, ear infections, chest infections, abdominal pain
amongst the most common patient problems. Estimated costs
of providing GP Co-operative care across the county were
equivalent to £5190 / 1,000 population per annum.
Carlisle et al,
Six month study of the out-ofhours
activity of 6 general
practices and the A&E department
in Nottingham to
determine relationship of
activity to deprivation and
distance from A&E
Contact rates for GP and accident and emergency services calculated
by electoral ward; Jarman and Townsend deprivation
scores and distance of electoral wards from A&E department.
Wide variations between electoral wards in both general practice
and accident and emergency events were observed. Deprivation
scores explained more than half of the variation, out-ofhours
activity was highest in deprived inner city areas. Highly
deprived areas close to A&E generated high levels of activity
for general practice and A&E services, with no evidence
substitution between services. The Jarman score explained
of the variation in the GP contact rates and 43% of the variation
in A&E contact rates.
Before and after comparison 5
years after of the 1992 reform
of out-of-hours general practice
in Denmark in which GP
telephone triage was introduced.
Number of out-of-hours services; GP workload, service costs;
patient satisfaction. Proportion of calls managed by telephone
consultation almost doubled, to 48%. Surgery consultations
were largely unchanged, but home visits were greatly reduced
(18%). Fewer doctors (50% versus 70%) were working more
than 5 hours per week. Overall patient satisfaction in 1995
Cragg et al
Randomised controlled trial.
Comparison of care provided
by practice doctors and doctors
from deputising services.
Care provided to 2152 patients.
Survey response rate
Health status (assessed using Anglicised SF36 questionnaire
plus interviewer version), patient satisfaction, subsequent
service use. No differences were observed in change in health,
overall health status or subsequent use of health services.
seen by deputising services were less satisfied with the
care they received. Process measures: response to call, time
visit, prescribing, hospital admissions. Practice doctors
likely to give telephone advice and to visit more quickly
deputising doctors. Less likely to prescribe, were more likely
prescribe generic drugs, and less likely to prescribe antibiotics.
Organisation of doctors in large groupings may reduce patient
[ref. no.] Method Process / outcome measures and results
Observational study of two
out-of-hours services in London,
a GP Co-operative and a
deputising service. Care provided
to 5812 patients (3920
calls to the co-operative and
1892 calls to the deputising
service), all those calling during
an eight week period.
Rates of home visiting, telephone advice and attendance at
primary centre; hospital admission rates, prescribing rates
response times. Deputising doctors visited 76% patients and
gave telephone advice to 19%. In contrast co-operative doctors
visited 32% patients and gave telephone advice to 58%. Higher
admission rates for GP Co-operative patients are attributed
the observation co-op GPs were more likely to admit patients
who were visited. Response times, median time to visit 65-75
Postal questionnaire survey of
patients receiving care from a
GP Co-operative and from a
deputising service (n=2312).
Overall and specific satisfaction with out-of-hours care.
satisfaction was similar. Patients having contact with deputising
services were less satisfied with the explanation and advice
received and with waiting times for visits. Patients over
were more satisfied and differences in satisfaction between
and ethnic groups were observed.
Shipman et al,
Audit of out-of-hours services
in 21 London practices and 2
local A&E departments, interviews
with 82 patients who
Differential use of services, time of contact, age profile
and nature of presenting complaints. A&E and general
medical services were used differently. Musculo-skeletal problems
constituted largest group of complaints for A&E attenders.
More families with children under 10 years contacted a
GP, with respiratory, digestive and viral or non-specific
being prevalent. Women more likely to contact a GP and
men to attend A&E. Perceived access, quality and availability
service important when choosing a provider.
al, 1997 
Development and testing of a
questionnaire to measure patient
satisfaction with out-ofhours
Validity (content) and reliability (internal test-retest)
of a 32
item questionnaire. Levels of reliability were satisfactory
7 scales (Likert 5 point): satisfaction with communication
management, doctors’ attitude, continuity of care, delay
visit, access to out-of-hours care, initial contact person,
Lattimer et al,
Pilot study of nurse telephone
triage in out-of-hours primary
care to test feasibility.
Triage outcome and pattern of referral, caller satisfaction.
calls were managed by the nurse alone. 39% calls concerned
children. 87% callers were satisfied or highly satisfied with
Jessop et al,
Postal questionnaire survey of
all 98 GP Co-operatives registered
with the National
Association. Response rate
Number of GPs in co-operative, extent of support received
predicted to be needed from out-of-hours development fund;
provision of home visiting, telephone advice and consultation
at base; employment of non-medical staff; mechanisms for
monitoring and reporting quality; contact with Community
Health Councils (CHCs); patient participation in co-op development.
Respondents were 5476 GPs covering 11.4 million
patients. Most co-operatives had been established since 1995,
median value for members was 82. 91% organisations had received
support from the out-of-hours development fund, average
receipt £108,000 and would need further funding on average
of £152,000 in the following year. Most employed nonmedical
managers and 28% employed nurses. Half had contact
with CHCs, none had involved patients in service development.
Hopton et al,
Qualitative study of patients’
accounts (46) of calling the
doctor out-of-hours, using
Respondents described the problem in terms of symptoms
Presence of symptoms was the main reason for calling, but
other factors were important: feelings and concerns about
illnesses; responsibility for others; previous attempts to
manage the problem; past experiences of using health services,
including ‘past frights’ in which illnesses had
turned out to be
more serious than expected, lack of confidence in or good
of health professionals.
[ref. no.] Method Process / outcome measures and results
Court et al,
Questionnaire survey of 720
general practitioners to identify
factors influencing decision
to visit out-of-hours.
Appraisal of the likelihood of 13 factors identified by focus
group influencing decision to visit. Five most important factors
were the patient, or someone on their behalf saying that the
situation was urgent, not wanting to miss an urgent condition,
demand for a visit, patient said to be unfit to travel, wanting
Dale et al,
Needs assessment using rapid
appraisal methods of out-ofhours
care in a multiethnic
socially deprived inner city
district of London.
Strengths and weaknesses of out-of-hours services and suggestions
for improvement. Wide range of health, social and nonstatutory
services already available but dissatisfaction was widespread.
Problems concerned access, availability, demand for
services and inter-agency communication. Concurrence around
areas for development included the need for an out-of-hours
co-operative, primary care emergency centres and telephone
triage and advice.
Lattimer et al,
Questionnaire survey of general
practitioners in two primary
care research networks
about their views on the future
provision of out-of-hours
Intention to reduce or opt out of on call; plans for changing
out-of-hours arrangements; most important changes needed to
out-of-hours care; willingness to try and perceived strengths
and limitations of primary care emergency centres, telephone
triage services and co-operatives. 83% respondents willing
try al least one option, primary care emergency centres most
popular. New alternatives would need to reduce time on call
and workload and maintain continuity of care. 61% hoped to
reduce time spent on call, 25% wished to opt out completely.
GPs keen to try alternative arrangements despite lack of evidence
Cross sectional study of calls
to 8 general practices in Midlothian
over 10 weeks, prior to
the opening of a primary care
Numbers of calls, call disposition, numbers referred to A&E
for hospital admission. Estimated call rate was 265 per 1,000
patients per annum. 63% patients received a home visit (of
these 18% attracted night visit fee), 8% were seen in surgery,
29% received telephone advice alone. 15% patients were referred
to hospital. Doctors rated 61% calls as necessary, 29% as
unnecessary and were unsure about the need for 9% calls.
Majeed et al,
Ecological study of night visiting
rates in general practice.
Variation in night visiting rates based on night visit fees
over 1 year in a London Family Health Services Authority.
Annual night visiting rates varied from 3 per 1,000 to 75
1,000 patients. One third of the variation between practices
could be explained by differences in % practice population
under 5 yrs, % reporting chronic illness variables associated
with social deprivation. No association found between visiting
rates and % population aged 35-54 years, distance between
surgery and nearest A&E.
Cragg et al,
Cross sectional survey of all
callers to a deputising service
switchboard operating primary
care centres in 5 areas of
England. 1000 patients agreeing
to attend and 1,000 patients
not agreeing to attend
were studied. Questionnaire
for self completion administered
to all attenders at the
Demography, clinical details and social circumstances of all
patients; satisfaction of those agreeing to attend a centre.
attendance rate was 22.4%, most patients invited to
attend were not able or not willing to do so. Factors affecting
attendance included access to a car, perceived severity of
affecting ability to attend, location of facility and distance
travel. Largest group of attenders were young children brought
by parents. Satisfaction amongst attenders was high, most
would attend again in similar circumstances. Short waiting
were highly valued.
[ref. no.] Method Process / outcome measures and results
Telephone survey investigation
of the standards set by 81
FHSAs for deputising services.
Procedures for notification to use deputising services, procedures
for monitoring use and compliance with 1984 guidelines
on the use of deputising services. Most authorities required
GPs to notify them of intention to use a deputising service
only 21 collected data on timing and extent of use. Arrangements
for liaison between authorities and between authorities
and deputising services varied greatly, as did the level of
monitoring. Response time was most frequently monitored
quality standard, setting and monitoring of more comprehensive
standards is recommended.
Telephone survey of 97
FHSA’s to assess the use and
organisation of out-of-hours
services in primary care.
Rate of use of out-of-hours care, methods of provision, role
authorities. Mean number of night visits per unrestricted
was 35.3 per 1,000. Higher rates observed in authorities
covering large towns or cities. 81 authorities had at least
commercial deputising service. In almost half the authorities,
75% GPs had consent to use deputising, not all did.
Baker et al,
Study of routine FHSA data to
compare trends in night visiting
before and after the 1990
contract for general practitioners.
Mean number of night visits; % GPs with consent to use deputising
services; % night visits by deputies from 1987-1990 and
for % change between years. FHSA’s were clustered according
to deprivation and population age profile. Effect of the new
contract had been to increase visiting in FHSA’s with
elderly populations and in the most affluent authorities.
reliance on deputising services was observed.
Carlisle et al,
Study of the impact of Jarman
and Townsend deprivation
scores and unemployment
rates on night visiting in different
electoral wards within
one general practice
Night visit rate correlated with measures of deprivation.
night visit rate was 33 per 1,000 patients, but a 2.8 fold
in visit rates was observed between electoral wards (19.6
per 1,000). Children under the age of 5yrs and adults over
yrs were more likely to receive a visit than their numbers
population might suggest. Townsend score and unemployment
rate were significantly associated with the night visiting
Analysis of night visit claim
forms for one FHSA in 1991-
1992 to describe the time
distribution of visits and to
evaluate trends for the period
Times of visits, proportion performed by deputies, trend in
number of visits (adjusted for extended claimable hours in
contract). Extended hours accounted for one third of the increase
in visiting. Rates of visiting had doubled in over 10 years,
with 31.5 night visits per 1,000 in 1992. Use of deputies
fallen by half since 1989. Results suggest long term rising
Comparative study of telephone
advice in out-of-hours
consultations in 13 general
practices in north London
during one month.
Numbers of calls, call management and disposition; relationship
between cal management and use of deputising services. Variation
observed in the frequency of calls being managed by telephone
advice (5-57%) and by home visit (20-65%). Practices
with high use of telephone advice were less likely to use
Analysis of out-of-hours
workload in one general practice
(list size 13,309) over a
year based on a written log of
Contact rate and night visit rate per 1,000. Percentage of
managed by telephone advice or by home visit. Jarman scores
indicated main residential areas were not deprived, yet contact
rates were 273/1,000. Authors suggest that high visit rate
associated with demand for a 24 hour service than with social
46% calls were managed by telephone advice, mean rate of
admission to hospital was 4.9%. Doctors visiting rate varied
from 41% to 78% calls received.
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Annex Three: Members of the
Dr Maureen Baker, Royal College of General Practitioners
Mr Nick Clark, National Institute of Clinical Excellence
Ms Donna Covey, Association of Community Health Councils of
England and Wales
Dr Andrew Dun, Healthcall
Dr Bruce Herriott, GP & part-time Medical Director of
Herefordshire Health Authority
Dr Adrian Jacobs, South and West Devon Health Authority
Mrs Lynne Murgatroyd, Clinical Lead Nurse at Wakefield Walk-in
Dr Mark Reynolds, Chairman National Association of GP Co-operatives
Dr Peter Sanderson, GPC
Dr Stephen Shortt, NHS Direct
Ms Sally Williams, Consumers' Association
Annex Four: A model Service
An example of a draft Service Level Agreement between one
NHS Direct site and its local outof-
hours provider, in which the different roles and responsibilities
of both parties to the agreement
are clearly set out, is reproduced below. This is an example
of a current Service Level
Agreement which would have to be modified to meet the Quality
Standards set out in this Report.
This service level agreement recognises the co-operation and
goodwill between NEMS and East Midlands NHS
Direct; and recognises the best intentions of both parties
to facilitate quality and responsive healthcare services for
the population of the East Midlands. Both parties further
agree to work together to develop ongoing improvements
in the provision of care, to ensure that the population of
East Midlands receive seamless, joined up health care, from
the appropriately skilled person, at the appropriate time,
in the appropriate place. The parties to this agreement
recognise that responsibilities are to be met according to
Health Service Circular 1999 / 235 Annex A, and
summarised in Annex D (copy of which attached); dated 3rd
November 1999.The service agreement addresses the
1. Parties to the agreement
5. Call reception
6. NHS Direct responsiveness
7. NEMS responsiveness
9. Quality of advice
11. Contacting primary care services
12. Complaints / audit
13. Peak load management
16. Amendments to agreement
1. Parties to the agreement
This agreement is made between NHS Direct (East Midlands)
– Nottingham Community Health Trust (hereinafter
referred to as "NHS Direct") and Nottingham Emergency
Medical Service (hereinafter referred to as "NEMS").
2.1 In this agreement, the following expressions shall have
the following meanings: -
2.2 "NHS Direct" shall mean NHS Direct (East Midlands)
– hosted by Nottingham Community Health Trust
2.3 The "Health Information Service" linked with
NHS Direct and providing service to NEMS patients will be
included within all the references to "NHS Direct".
2.4 "Agreement Manager" shall mean NHS Direct's
nominated Manager for this Agreement.
2.5 "NEMS" shall mean Nottingham Emergency Medical
2.6 "Authorised Officer" shall mean the Officer
empowered by NEMS to act as Control Officer for this
2.7 "Agreement Standard" shall mean such a standard
as complies in each and every aspect with all relevant
provisions of this Agreement.
2.8 "The Services" shall mean providing call handling
and nurse triage support for all "Out of Hours"
received from patients of NEMS practices.
2.9 Reference to time shall be construed during the period
of summer -time to be British Summer Time and
otherwise Greenwich Mean Time.
2.10 Patient summary file shall mean the data set as agreed
between NEMS and NHS Direct.
3.1 NHS Direct shall provide the services from its Call Centre
at Victoria Health Centre and Inham Nook,
Nottingham or any other location agreed between the parties.
3.2 The Call Centre will be appropriately equipped to enable
3.3 NHS Direct shall permit access into the NHS Direct premises
for any person authorised by NEMS for the
purpose of inspection without prior notice at any reasonable
time. Access is to be sought via the on call
NHS Direct manager.
3.4 All decisions relating to any aspect of NHS Direct operations
which may effect NEMS must be discussed
with the NEMS Management or Board at the time or prior to
any alteration to the service, staffing
organisation or procedures, except where that alteration is
in line with previously agreed contingency or
3.5 All decisions relating to any aspect of NEMS operations
which may affect NHS Direct must be discussed
with the NHS Direct Management or Board at the time or prior
to any alteration to the service, staffing
organisation or procedures, except where that alteration is
in line with previously agreed contingency or
3.6 Minutes of joint meetings and decisions made will be recorded
and circulated to the NHS Direct and
NHS Direct staff shall regard all information, including patient
information, relating to NEMS patients,
staff, systems and operations as confidential. Information
should only be released to third parties with the
express approval of an NEMS approved officer under established
procedures e.g. complaints procedure.
5. Call Reception
To ensure that out of hours calls can be identified NEMS will
ensure that patient calling the out of hours
service will have their calls transferred by an automatic
call divert facility to a dedicated telephone number
agreed with NHS Direct.
6. NHS Direct Responsiveness
6.1 Time in which the phone will be answered
6.1.1 NHS Direct will ensure that telephone calls from patients
"Out of Hours" will be answered in line with the
quality standards identified in the monitoring reports required
of NHS Direct management.
6.1.2 NHS Direct will ensure that 90% of all telephone calls
from patients "Out of Hours" will be answered
within 30 seconds.
6.1.3 NHS Direct will ensure that all telephone calls from
patients "Out of Hours" will be answered within
6.2 Time to speak to a nurse (if required)
6.2.1 NHS Direct will ensure that 90% of calls requiring "Nurse
Triage" will be commenced within 5 minutes of
the call being received.
6.2.2 NHS Direct will ensure that all calls requiring "Nurse
Triage" will be commenced within 15 minutes of the
call being received.
6.2.3 NHS Direct will ensure that nurse triage of "all
urgent calls" will be commenced within 5 minutes.
6.3 Time to speak to an interpreter (if required)
6.3.1 NHS Direct will ensure that 90% of calls requiring an
interpreter will be commenced within 15 minutes of
the call being received.
6.3.2 NHS Direct will ensure that all calls requiring an interpreter
will be undertaken within 30 minutes of the
call being received.
6.4 Abandoned calls
6.4.1 In the operation of the integrated NHS Direct-NEMS service
an abandoned call will be defined as a call
that is abandoned after 30 seconds.
6.4.2 The level of abandoned calls shall be no more than 3-5%
of all calls received.
6.4.3 The method of recording will be based on hourly volumes
of calls received with a procedure in place to
establish and report the percentage of calls abandoned.
7. NEMS Responsiveness
7.1 NEMS is required by East Midlands NHS Direct to have satisfactory
quality standards in place that govern
the speed of response of its GP services.
7.2 Doctor Advice
90 % of doctor-patients telephone consultations will commence
within 30 minutes of the time of receipt of
the indication of a doctor advice outcome at the NEMS operations
100 % of doctor-patients telephone consultations will commence
within 45 minutes of the time of receipt
of the indication of a doctor advice outcome at the NEMS operations
Where there is likelihood that the standards above will not
be achieved the patient will be informed, the
reason explained and the likely delay estimated.
7.3 PCC Attendance
90 % of patients’ consultations will commence within
30 minutes of the time of arrival at the PCC.
100% of patients’ consultations will commence within
45 minutes of the time of arrival at the PCC.
Where there is likelihood that the standards above will not
be achieved the patient will be informed, the
reason explained and the likely delay estimated.
7.4 Home Visits
75 % of home visits will commence within 1 hour minutes of
the time of receipt of the indication of a
home visit outcome at the NEMS operations centre.
100 % of home visits will commence within 3 hours minutes
of the time of receipt of the indication of a
home visit outcome at the NEMS operations centre.
Where there is likelihood that the standards above will not
be achieved the patient will be telephoned, the
reason explained and the likely delay estimated.
8.1 standing arrangements for service resilience
8.1.1 East Midlands NHS Direct will provide a continuous information,
advice and onward referral service to
members of the public 24 hours a day, every day of the year.
8.1.2 The integrated nurse triage service will be available
7 days a week according to the schedule below, or at
any other times agreed between NEMS and the Director of East
Midlands NHS Direct:
Monday to Friday 1830 hours to 0830 hours the following day
Thursday 1200 hours to 0830 hours the following day
Saturday 1200 hours to 0830 hours the following day
Sunday 0830 hours to 0830 hours the following day
Bank Holidays 0830 hours to 0830 hours the following day
8.1.3 ‘Immediate Care’ Outcome
Where a call is assessed by a call handler (according to protocol)
or a nurse advisor to require an immediate
care response, the call handler or nurse advisor will make
arrangements for a 999-ambulance response and
the caller informed.
8.1.4 ‘Speak to Provider’ Outcome
A) A call will be assessed by the Nurse Advisor and electronically
passed to NEMS if speak to
provider outcome is reached.
B) The TAS assessment will be closed when the patient summary
file is retrieved by the Adastra
C) In the event of electronic delivery failure, the patient
summary report will be faxed to NEMS on
the appropriate fax number or delivered via an appropriate
manual system if fax inoperative.
8.1.5 ‘Urgent GP Care’ Outcome
A) Call will be assessed by the Nurse Advisor.
B) The Nurse Advisor will negotiate where the individual caller
needs to be seen according to
address, location and NEMS visiting criteria (Appendix 1)
i.e. Home visit or patient to visit
Primary Care Centre (with or without patient transport, according
to agreed criteria, Appendix 2)
or telephone advice from a doctor.
C) The TAS assessment will be closed when the patient summary
file is retrieved by the Adastra
D) In the event of electronic delivery failure, the patient
summary report will be faxed to NEMS on
the appropriate fax number or delivered via an appropriate
manual system if fax inoperative.
8.1.6 NEMS duty doctors will not ordinarily change the call
outcome disposition and will not do so without
informing the nurse advisor who has consulted the reference
patient, or the team leader if the nurse advisor
is not available.
8.1.7 Any calls received from patients who disagree with the
outcome or recommendations or who insist on
speaking to a Doctor or who cannot locate their nearest Primary
Care Centre, will be passed to NEMS for
onward transmission to the appropriate Primary Care Centre
for GP resolution.
8.2 service arrangements with telecoms and IT suppliers.
8.2.1 NHS Direct will utilise the appropriate systems in the
provision of the service. Details of the equipment
specification and associated maintenance agreements are to
be available to NEMS. The Clinical Decision
Support Systems operated will be the TAS system unless or
until another system is defined by the National
Procurement Process specification for decision support systems.
8.2.2 East Midlands NHS Direct will maintain rapid response
contracts with all its suppliers of operation-critical
software and hardware.
8.2.3 East Midlands NHS Direct will operate extremely resilient
and constantly tested IT systems. These will
include diverse telecom routing with two independent service
providers; both analogue and digital services;
generator back up with uninterruptible power supply (UPS);
dedicated UPS for individual file servers and
PCs; two duplicated and geographically separate communications
rooms; two duplicated and mirrored file
8.2.4 All IT systems will be subject to a rigorous back up
8.2.5 All IT systems will be subject to rigorous security
protocols, according to NHS and industry best practice.
8.2.6 NHS Direct shall not transfer or assign any part thereof
and shall not subcontract any part of the provision
of the services without prior consultation.
8.3 for urgent attention in the event of service failure
8.3.1 In the event of total failure of the information technology
and or clinical decision support system, calls
would be dealt with as described in the Nurse Training Module
for emergency procedures (Appendix 3 ).
8.3.2 Subject to appropriate IT and training development,
calls may be directed to NHS Direct in TAS or other
linked site. This would occur following an agreed procedure
between NHS Direct and NEMS.
8.4 arrangements for transferring calls to another NHS Direct
8.4.1 Notwithstanding the above, in the event of a total or
partial failure of systems on site, East Midlands NHS
Direct will transfer all or part of its workload on to all
or some of its partner NHS Direct sites elsewhere in
the country. This transfer will be actioned within 5 minutes
of a failure. This transfer will be regularly
tested. Undifferentiated patient contacts from the integrated
NEMS-NHS Direct service will be the last
group of calls to be transferred, and then only after discussion
with the NEMS on call manager.
8.4.2 Key to such a procedure would be assurances that partner
NHS Direct sites or any other provider could
adhere to 7.1, 7.2, 7.3 and a similar signed Service Level
8.4.3 All partner NHS Direct sites will be copied with this
SLA together with the contact details that will allow
for the continual transfer of referrals through to NEMS. These
referrals in instances of total site failure may
be routed via an East Midlands NHS Direct remote site to maintain
the specificity of local arrangements.
9. Quality of advice
9.1 details of staff qualifications
9.1.1 East Midlands NHS Direct will employ fully qualified
and trained staff to provide its services. Its nurses all
have 4 years of post-registration experience.
9.1.2 NHS Direct shall employ sufficient staff to ensure that
the services are provided at the agreed times and in
all respects of the Service Level Agreement standard.
9.1.3 NHS Direct Staff will be required to adhere to the agreed
standards of NHS Direct.
9.1.4 NHS Direct shall ensure that every person employed in
and about the provision of the services is at all
times properly and sufficiently trained and instructed with
??The task or tasks that person has to perform
??The time scales and urgency to which they have to perform
??Adherence to all relevant provisions of the Service Level
??All relevant procedures and governance standards as may
be agreed by NEMS
??The need for those working in the National Health Service
to observe the highest standards of
courtesy and consideration.
9.1.5 A Continuous Quality Improvement Programme will be implemented
by NHS Direct.
9.2 details of decision support systems used
9.2.1 The East Midlands NHS Direct centre will use only an
approved clinical support system as described in the
9.2.2 East Midlands NHS Direct will use the TAS decision support
software supplied by Plain Software unless or
until another system is defined by the National Procurement
Process specification for decision support
systems. This is subject to both local and national quality
assurance and audit, with sitting panels of
eminent professionals monitoring the assessments and protocols
used, and developing them in line with
9.3 details of training
9.3.1 NHS Direct will have an accredited training system in
place which will ensure a high quality of service delivery.
9.3.2 Training is given to all nurses and health information
advisors, and assistant health information advisors on
communications skills, the use of the technology employed
in the call centre, use of the information databases,
and a familiarisation course covering the other NHS providers
of East Midlands and other social and
voluntary organisations. More detailed training is given to
nurses on the skills of clinical triage processes
and the TAS decision support software.
9.4 details of audit and performance management
9.4.1 Accountability for performance is met through NHS management
structures and to local services and the
local population through the stakeholder group and the Clinical
Steering Group (Appendix 5) respectively
and in line with the common Clinical Governance Framework
9.4.2 All calls will be data recorded, 1% of which will be
reviewed by medical and nurse specialists of the clinical
governance team which will have NEMS representation.
9.4.3 A retrospective audit carried out to ensure that the
appropriate protocols have been followed. All
symptom-based calls must be undertaken using the approved
clinical decision support system.
9.4.4 All instances where clinical staff have overridden protocols
will be reviewed by medical and nurse
9.4.5 The individual patient encounter record will provide
a full audit trail for all assessments.
9.4.6 A fully approved audit trail will have two defined elements:
9.4.7 Clinical is defined as all aspects relating to Clinical
Governance from the time the call is received until the
call is concluded with an end point decision.
9.4.8 Operational is defined as the recording of all times
relating to each separate element of the operation of
NHS Direct-NEMS within the service provided.
??Time call received
??Time basic patient data concluded
??Time Nurse triage commenced
??Time Nurse triage concluded with end point decision
??Time full data package transferred to NEMS
9.4.9 Monthly live supervision of all staff will be undertaken
using a documented monitoring system.
9.4.10 Voice Recorded Data: 1 % of all recorded calls to be
reviewed by medical and nurse specialists and a
retrospective audit carried out on a weekly basis to ensure
the correct training procedures have been
9.4.11 NHS Direct will provide NEMS with weekly and monthly
reports showing all calls received "Out of
Hours" from the NEMS patient base classified by outcomes.
9.4.12 NHS Direct shall insure against its full liability.
NHS Direct shall, upon request, produce to NEMS
documentary evidence that the insurance cover is being properly
9.4.13 Upon application to the Director, NHS Direct will allow
NEMS internal and other nominated Auditors
access to papers relating to this Service Agreement for the
purpose of audit.
10.1 format and timescales for data transfer
12.1.1 NHS Direct will transfer immediately on the end point
being reached the result of the triage to NEMS by
way of electronic transfer. These calls will be monitored
to ensure transfer has been concluded
10.1.2 All calls to be time monitored from receipt of call
to transmission to NEMS.
10.2 content including minimum data set
Every contact will carry a unique reference number to allow
for audit and the communication of
information on a confidential basis.
Patient data to the extent provided by the caller - full name,
full address and post-code (current and home),
date of birth, gender, (current and home) phone number, GP
(own and temporary if not local).
Clinical data - patients own symptoms, protocol outcome, nurse
assessment, details of any follow up that
East Midlands NHS Direct deem should be considered by the
patient’s own general practitioner .
Operational data - time call received, time basic patient
data concluded, time Nurse triage commenced, time
Nurse triage concluded with end point decision, time of any
subsequent contact by a nurse, time full data
package transferred to NEMS.
10.3 confidentiality issues
All calls received "Out of Hours" from the NEMS
patient base by automatic call divert via the dedicated
NEMS line, are classified as calls being transferred to NHS
Direct by GP's under their "Terms and
conditions of service".
10.4 consultations which resulted in a primary care referral
and those which did not
10.4.1 All primary care referrals must have full details transmitted
to NEMS for onward transmission.
10.4.2 Data recorded of details of Self Care referrals dealt
with during "Out of Hours" may be transmitted, if
requested to NEMS by the following morning (before 0800 hours)
for onward transmission to GP
practices by NEMS.
10.4.3 Data details of triage outcome referrals which refer
patients to contact their own GP outside the "Out of
Hours" time-scale must be transmitted to NEMS by the
following morning (before 0800 hours) for onward
transmission to GP practices by NEMS.
10.5 urgent and routine referrals
10.5.1 Data recorded of details of Urgent referrals to 999
or A&E Departments must be transmitted to NEMS by
the following morning (before 0800 hours) for onward transmission
to GP practices by NEMS.
10.5.2 Data recorded of details of routine referrals which
are not included in any of the above categories must be
transmitted to NEMS by the following morning (before 0800
hours) for onward transmission to GP
practices by NEMS.
10.6 special needs patients
A database of patients in the community who have special needs
will be maintained by NHS Direct and
NEMS. These patients will be identified by their registered
GPs, who will notify NEMS in the first instance.
NEMS will communicate the patient details and the terms of
the dedicated response required for
the nominated patient to NHS Direct electronically using a
dedicated proforma (Appendix 7). Receipt with
be confirmed by telephone with the duty team leader.
11. Contacting primary care services
11.1 Nurse Triage End Points
11.1.1 After NHS Direct have received an "Out of Hours"
call from a patient and a Nurse Triage has taken place
the following end points will be reached:
??GP - Face to Face Home Visit
??GP - Face to Face Centre Visit
??GP - Face to Face Centre Visit with Patient Transport
??GP - Telephone Advice
??GP - Triage or Re-triage - Refused/Reassessment
??Nurse - Self Help
11.1.2 The above end points together with full patient data
including protocol decision will be immediately and
electronically transmitted to NEMS for onward transmission
to the patient’s registered GP.
11.1.3 NHS Direct and NEMS will develop a structure that allows
for feedback so that the appropriateness of the
complete patient pathway through NHS Direct and NEMS can be
assessed, including timings and clinical
12.1 A joint complaints procedure
12.1.1 A joint complaints procedure will be required to be
maintained between NEMS and East Midlands NHS
Direct (Appendix 8). This will follow standard NHS complaint
procedures. NHS Direct and NEMS will
handle complaints via the respective complaints officers and
procedures of the two organisations. Each will
liaise closely with the other over the complaint process and
complaints received will be reported for
comment to the respective boards at monthly intervals.
12.1.2 NHS Direct will notify NEMS of any complaint involving
the NEMS service immediately upon receipt of
12.1.3 NEMS will notify NHS Direct of any complaint involving
the NHS Direct service immediately upon
receipt of the complaint.
12.1.4 A joint follow through procedure will be established
to ensure all complaints are concluded within a
satisfactory timeframe. All endeavours are required of both
parties to ensure responses to complaints are
made in full within 20 working days of receipt of any complaint.
In the event of a critical incident or
potential critical incident, both NEMS and East Midlands NHS
Direct need to be able to accept the role of
an independent NHS review of the incident, that may be required
by NHS Direct Local, National or
12.1.5 East Midlands NHS Direct will establish systems for
the early notification of both positive and
12.1.6 East Midlands NHS Direct will establish a rapid response
procedure for the notification of any potential
12.2 arrangements for audit including a system for notifying
12.2.1 A formal set of criteria to be agreed jointly for the
analysis of data.
12.2.2 Mechanism for analysis of data should include both
NHS Direct and NEMS call outcome monitoring.
12.3 feedback on clinical outcomes.
12.3.1 NEMS GP's comments on all referrals should be checked
against protocol end points, if found to be at
variance on an inappropriate number, then a mechanism of reporting
and training modification needs to be
in place to improve performance.
12.3.2 Evaluation of the nurse triage service procedures and
outcomes should be reported to NEMS at quarterly
12.3.3 Any recommendations from NEMS Medical Managers regarding
the evaluation of nurse triage outcomes
would be referred to the Clinical Steering Group for NHS Direct.
A time-scale for response and review of outcomes
needs to be established.
12.3.4 East Midlands NHS Direct will provide detailed information
on the outcomes it refers into NEMS, and
requires of NEMS to provide detailed final outcomes on these
12.4 costs relating to audit
Agreed costs relating to NHS Direct audit undertaken by NEMS
Management or Board members will be
met from NHS Direct budgets.
13. Peak load management
13.1 steps to be taken to match capacity to demand
13.1.1 NHS Direct in consultation with NEMS will project future
demands using historic data so that staffing in
the call centre for non-exceptional circumstances is adequate
to meet demand.
13.1.2 Data produced will be used to predict future peaks
and NHS Direct will ensure sufficient staff are available
to cover such times.
13.1.3 In exceptional circumstances East Midlands NHS Direct
will employ flexible pool staff (trained exactly to
the same standard as permanent staff), to allow it to staff
up to meet exceptional demand at short notice.
13.1.4 Potential emergency call procedures are maintained
whatever the overall call volumes being experienced.
13.1.5 Should call volumes reach emergency levels, there will
be call transferring arrangements in place that are
regularly tested, that allow for a proportion of East Midlands
NHS Direct calls to be taken a partner NHS
Direct site or sites, so that the quality of service to callers
13.1.6 When call volumes reach emergency levels, there will
be call transferring arrangements in place that are
regularly tested, that allow for all or a proportion of NEMS-East
Midlands NHS Direct calls to be taken by
NEMS, so that the quality of service to callers is maintained.
13.2 steps to ensure the prioritisation of clinically urgent
The criteria format to be agreed between NHS Direct medical
team and NEMS medical managers in line
with national guidelines.
When necessary calls will be prioritised from call handlers
to nurses using strict protocols that are agreed
and tested across NHS Direct sites nationally. Voice and data
systems will allow potential emergency calls
to be prioritised through to nurses immediately.
Calls will be prioritised by nurses into NEMS according to
the protocols of the TAS decision support system.
These too are subject to national verification regimes.
13.3 steps to inform callers on occasions when normal responsiveness
standards cannot be met
13.3.1 In an emergency voice messages will be rapidly installed
to alert callers of the response situation.
13.3.2 If the agreed time-scale for nurse call-backs cannot
be achieved, NHS Direct should call to inform the
caller that there is a delay, while at the same time ascertain
whether the symptoms have deteriorated.
13.3.3 Prioritisation of calls should only be necessary in
13.3.4 If the overall call volumes are placing pressures on
the responsiveness of the East Midlands NHS Direct
services, the call handlers have a live database of outstanding
calls and will inform callers of the current response
Publicity materials during the "Pilot" will be produced
by NHS Direct with the agreement of the NEMS
Board on the final wording to be used before circulation to
14.1 practice leaflets
14.1.1 All practices will receive sufficient leaflets to enable
them to both send one to each patient household and
have sufficient for distribution at their surgeries.
14.2 posters in the surgery
14.2.1 All practices will receive sufficient posters to enable
them to keep these on their surgery walls in good
condition for a minimum period of two years.
14.2.2 Practices may wish to have posters in suitable alternative
premises within their catchment area to ensure
continued recognition of the service by patients. e.g. chemists,
libraries, community centres etc.
15.1 NHS Direct will provide to NEMS weekly, and monthly reports
showing the total number of calls handled
and categorised by call outcome.
15.2 NHS Direct and NEMS will hold regular weekly and monthly
meetings to monitor the performance of this
Service Level Agreement.
15.3 NHS Direct will provide written reports to NEMS on a
quarterly basis to enable ongoing reviews of service
16. Amendments to agreement
Any variation to the provision of the service must be agreed,
in, writing, by both parties to this Service
Annex Five: A List of Sources
consulted by the
The following list identifies all the sources that were consulted
by the Review Team in the
course of its work. Relevant published sources are identified
in a bibliography at the end of Annex
Two (pages 50 to 54 above); all other sources, including all
those out-of-hours providers
visited by the Review Team, are listed here.
Organisations visited by the Review Team:
1. Out-of-Hours Providers:
1.1. Association of Medway Doctors on Call (MEDDOC)
1.2. Association of Cornwall Doctors on Call (KERNOWDOC)
1.3. Devon Doctors on Call
1.4. East Kent Co-op
1.5. Go To Doc, Oldham
1.6. HARMONI, West London
1.7. Healthcall Bristol
1.8. Healthcall Hull
1.9. Healthcall Leighton
1.10. Healthcall Mytchett
1.11. Healthcall Newcastle
1.12. Healthcall Sheffield
1.13. Healthcall Southend
1.14. Newcastle Emergency Doctors Service (NEDS)
1.15. Nottingham Emergency Medical Services (NEMS)
1.16. North Bradford Doctors Co-operative Ltd.
1.17. Reading Doctors on Call (REDDOC)
1.18. Sevenoaks and District (SEVDOC)
1.19. Solihull Doctors Out of Hours Service (SOLIDOC)
1.20. South Cheshire Primary Care Services
1.21. Yorkshire Pennine Doctors (PENDOC)
2. Health Authorities
2.1. Berkshire Health Authority
2.2. Herefordshire Health Authority
2.3. Lincolnshire Health Authority
2.4. North and East Devon Health Authority
3.1. Aarhus County Out-of-Hours Services, Denmark
3.2. Bradford Home Treatment Service
3.3. Bromyard Surgery, Hereford
3.4. Dr Erling Kjaerulff's Practice, Aarhus, Denmark
3.5. Ledbury Market Surgery, Hereford
3.6. Lambeth, Southwark and Lewisham Immediate Access Project
3.7. NHS Direct Central Team
3.8. NHS Direct Devon and Cornwall
3.9. NHS Direct Northumberland
3.10. NHS Direct West London
3.11. NHS Direct West Yorkshire
3.12. Southampton East PCT/G
3.13. Surrey Oaklands NHS Trust
3.14. Surrey Thames Primary Care Group
3.15. The Research Unit for General Practice, Department of
University of Aarhus, Denmark
3.16. The Surgery, Meads
3.17. Wakefield Walk-in Centre
Submissions to the Review
1. Consumer's Association, 12 June 2000.
2. Essex County Council Social Services, 17 June 2000.
3. General Practitioners' Committee, 30 August 2000.
4. Healthcall submissions dated 4 May 2000, 12 June 2000,
13 July 2000, 14 July 2000 and 4
5. Lambeth, Southwark and Lewisham Immediate Access Project,
Department of General
Practice and Primary Care, Guy's King's and St Thomas' School
of Medicine, undated.
6. National Association of GP Co-operatives – submissions
dated 21 February 2000, 10 April
2000, 14 May 2000, 26 May 2000, 6 July 2000 and 29 August
7. Nestor Medical Duty Services, 20 June 2000.
8. Peter Sanderson, GPC, 28 May 2000.
9. Royal College of General Practitioners, 31 May 2000 and
8 August 2000.
10. Southampton and South West Hampshire Health Authority,
14 June 2000.
11. South and West Devon Health Authority, 30 May 2000.
12. The Royal National Institute for Deaf People, 25 May 2000.
13. United Kingdom Central Council for Nursing, Midwifery
and Health Visiting, 15 June 2000.
Other Sources consulted by the Review Team
1. Bradford Home Treatment Service
1.1. Brief Description of the Service
1.2. The Team Philosophy
1.3. Bruce M.Z. Cohen, 'An Evaluation of the Bradford Home
University of Bradford, February 1999
1.4. Details of the Beacon Award achieved by the service.
1.5. A number of short articles discussing the work of the
2. CAPITA Conference: The Future of Out-of-Hours Care: An
Agenda for Dependable
High Quality Services, Monday 17th April 2000 .
2.1. Papers presented to the conference.
3. Consumers Association
3.1. In an emergency (February 1999) Health Which?
3.2. In the balance (October 1998) Health Which?
3.3. NHS Direct Investigated (August 200) Health Which?
3.4. Out of Hours Care (April 1998) Which?
3.5. The Good GP Guide (September 1996) Which?
3.6. Visiting an out-of-hours clinic (April 1998) Which?
4. Department of Health
4.1. National Health Service General Medical Services Statement
of Fees and Allowances
Payable to General Medical Practitioners in England and Wales,
4.2. National Health Service (General Medical Services) Regulations
1992 (as amended).
4.3. Finance Directorate Letter (95) 65 Out of Hours Development
Fund – 1995/96
Spend dated 20th December 1995.
4.4. Finance Directorate Letter (95) 55 Cash allocation for
Out of Hours Development
Fund 1995/1996 dated 15th November 1995.
4.5. Family Health Service Letter (68) 95 General Practitioner
Out of Hours Services
dated 14th November 1995.
4.6. Finance Directorate Letter (96) 12 Out of Hours Development
Fund use of
1995/1996 Allocation dated 27th February 1996.
4.7. National Health Service (Primary Care) Act 1997
4.8. Press Release dated Friday 4th June 1999 “Extra
Money for GP Out of Hours Services
Targeted to Rural Areas”.
4.9. Winter Planning – National Content for LWPG Planning.
5. Devon Doctors on Call
5.1. Hospital admissions.
5.3. Medical Directors Role Duty Doctor Recruitment.
5.4. Priority of Calls
5.5. Visit Protocols.
6. Gloucestershire Community Health Council
6.1. Chelt-Doc GP Out of Hours Emergency Service: Patient
Opinion Survey, 1999.
7. Go To Doc, Oldham
7.1. List of Service Charges.
8. Health Authorities
8.1. Barking & Havering Health Authority
8.1.1. Out of Hours Development Fund, 1998/9.
8.2. Berkshire Health Authority
8.2.1. Berkshire Out of Hours Working Group: Quality Standards
in GP Out of Hours
8.3. Birmingham Health Authority
8.3.1. Birmingham Local Medical Committee: Monitoring Arrangements
for Out of Hours
8.4. Cornwall and Isles of Scilly Health Authority
8.4.1. Criteria for Quality Care Provided by the General Practice
Co-operative in Cornwall
outside surgery times.
8.5. East London & City Health Authority
8.5.1. Out of Hours Development Fund, 2000-2001. Assessment
of the current state of GP
Out of Hours Provision in ELCHA.
8.5.2. Out of Hours Development Fund, 2000-2001 Quality Criteria.
8.6. East Kent Health Authority
8.6.1. Seadoc Quality Document.
8.7. East Riding & Hull Health Authority
8.7.1. Out of Hours Development Scheme: Policy on the Use
of Development Funds.
8.8. Gloucestershire Health Authority
8.8.1. Message Link – Quality Standards for GP Out of
8.9. Lambeth Southwark & Lewisham Health Authority
8.9.1. 2000/2001 Business Planning Guidance for Out-of-Hours
8.9.2. Out of Hours Monitoring Sub-Committee Quarterly Monitoring
8.9.3. Lambeth Southwark & Lewisham LMC Out of Hours Monitoring
Sub-Committee: Terms of Reference, Monitoring and Development
Criteria, Out of
Hours Service Provision Criteria and Out of Hours Development
8.10. Leicestershire Health Authority
8.10.1. Operational / Clinical Procedures: Implementation
by March 2000.
8.11. Lincolnshire Health Authority
8.11.1. GP Guidelines for Out of Hours Visiting.
8.12. Merton, Sutton & Wandsworth Health Authority
8.12.1. Guidelines for Prioritisation of Calls
8.12.2. Joint Health Authority / LMC Deputising Services Sub-Committee
Terms of Reference.
8.13. North Essex Health Authority
8.13.1. Start Up Costs for New GP Coops.
8.14. Northamptonshire Health Authority
8.14.1. Northamptonshire Local Medical Committee: GP out of
hours – Quality Framework.
8.15. Northumberland Health Authority
8.15.1. Standards of Out of Hours Care: An Accreditation Tool
8.16. Oxfordshire Health Authority
8.16.1. Draft Framework for Quality Standards for Discussion.
8.17. Shropshire Health Authority
8.17.1. Shropshire Health Authority / Shropshire LMC: Agreed
Standards for Organisations
Providing Out of Hours Emergency Care.
8.18. Somerset Health Authority and Somerset LMC
8.18.1. Joint Policy for Out of Hours Services 1999/2000.
8.19. Tees Health Authority
8.19.1. Primary Care Out of Hours Premises Based Care
8.19.2. York Health Economics Consortium (1998) Research to
Establish Patient Satisfaction
with GP Out of Hours Services on Teesside: Appendices.
9. Healthcall Group Ltd Medical Division
9.1. Branch Monthly Quality Report
9.2. Clinical Advice Telephone Questionnaire
9.3. Clinical Prioritisation Guidelines
9.4. Quality Manual.
9.5. Healthcall Controlled Drugs List
9.6. Healthcall Formulary
9.7. Healthcall Leighton Draft Service Level Agreement.
9.8. Healthcall 'In House' Complaints Procedure dated April
9.9. Local Clinical Governance Boards
9.10. National Clinical Governance Committee – Healthcall
10. Immediate Access Project
10.1. Payne, F. Shipman C, Dale J. Patients’ Experiences
of Receiving Telephone Advice
from a GP Co-operative (accepted for publication in Family
Practice, July 2000).
10.2. Shipman C, Payne F, Dale J, Jessop L. Out of Hours Primary
Care Centres: What do
patients think about attending them? (accepted for publication
in Family Practice, July
10.3. Managing medicines-related calls to NHS Direct Southeast
11. King’s and Lewisham A&E Primary Care Services
11.1. Business Report (1999) Departments of A&E Medicine,
King’s Healthcare NHS
Trust and University Hospital Lewisham and Department of General
Primary Care Guys, King’s and St Thomas’ School
of Medicine, London.
11.2. Mascarenhas C. (1998) Accident and Emergency Primary
Care Services: Operational
Management Systems. Departments of A&E Medicine and General
Primary Care, King’s College School of Medicine and
12. KPMG Consulting
12.1. KPMG Consulting, Department of Health: Evaluating and
developing NHS Direct,
Report, Autumn 1999.
12.2. KPMG Peat Marwick, National Health Service Management
Options for the GMS Out of Hours Service, June 1994.
13. Leicestershire Community Health Council
13.1. Patient Satisfaction Survey of General Practice Out
of Hours Provision: Leicester
West Medical Co-operative, 1999.
14. London Health Authorities Chief Executives' Group
14.1. Complaints Procedure, Out of Area Treatments and Primary
Groups, 12 March
15. MAIDDOC – Maidstone Doctors on Call
15.1. Annual Report 1999
15.2. Call Statistics
15.3. Report on Admissions by Tracey Seaman, April 2000
16. Manchester Emergency Doctor Service (MEDS)
16.1. Clinical governance.
16.2. Quality Criteria.
16.4. Urgent Calls Criteria.
16.6. Guidance for the Duty Doctor.
17. Maldon Doctors on Call (MALDOC)
17.1. Re: Out of Hours Rural Fund dated 26th May 2000.
18. MEDS – A Division of Nestor Medical Duty Services
18.1. Out of Hours Review, Nestor Medical Duty Services, June
18.2. Triage and Telephone Advice Guidelines, December 1999
19. Merton Sutton and Wandsworth GP Nightline
19.1. 1999 Subscribers Questionnaire Results
19.2. Millennium Report dated 16th March 2000.
19.3. Nightline Tips. Follow these 7 tips for smooth, complaint
free Telephone Consultations.
19.4. Nightline Annual Subscribers Report 1999
19.5. Summary of data presented to Annual Subscribers Meeting
20. National Association of GP Co-operatives.
20.1. 'Call splitting’ ideas', by Dr Mark Reynolds,
20.2. Conference Reports: Newcastle (2000), Warwick (1998),
20.3. Co-operatives – Where Next? Draft for discussion
from Dr Mark Reynolds MBE,
20.4. Definition of Out of Hours Services. Draft for Discussion
– Dr Mark Reynolds
MBE NAGPC, May 2000.
20.5. Draft paper on the Use of Drugs in Coops, by L.P. Kelman
Manager of NAGPC,
20.6. 'GP Co-operatives and NHS Direct – Where Now?',
a paper by Dr Mark Reynolds
MBE and Logie Kelman, April 2000
20.7. Role of Nursing in GP Co-operatives, October 1998.
20.8. Report on the NHS Direct Study Day, November 1998.
20.9. Scottish Conference, 18th and 19th May 2000: Papers
presented to the Conference.
21. NHS Direct Central Team
21.1. Consultancy Brief: NHS Direct Audit with Respect to
People with Disabilities.
21.2. Membership of the NHS Direct access issues evaluation
21.3. NHS Direct Project plan for playing its proper part
in delivering the standards outlined
in the Mental Health Service National Service Framework.
21.4. The Voice – Newsletter for NHS Direct, December
21.5. Working with Black and Ethnic Communities (Draft 5)
22. North Bradford Doctors Co-op
22.1. Annual Report 1999-2000.
22.2. An outline of the service.
23. Northern Doctors Urgent Care Ltd
23.1. Service Agreement between NHS Direct Northeast and North
Service NHD Trust and Northern Doctors Urgent Care Ltd
24. North Manchester Community Health Council
24.1. Survey of people who used the “E-Merge”
GP out of hours service, 1999.
25. Dr David Paynton
25.1. Out of Hours - Key Issues, 14th June 2000.
26. Reading Doctors On Call (REDDOC)
26.1. A Guide for Members.
26.2. Analysis of patient satisfaction questionnaires.
26.3. Dr Jeremy Lade, 'Making the best case for Co-operative
Winter Pressures Funding'.
26.4. Operations Room Staff Induction File.
26.5. Operations Room Staff Training File.
27. Rochdale Community Health Council
27.1. Access to Out of Hours and Emergency Services in Bury
and Rochdale. A report of
a project from Rochdale Community Health Council, 1999.
28. Royal College of General Practitioners
28.1. NHS Alliance and RCGP Discussion Paper on The Implications
for General Practice
of NHS Direct and Walk-in-Centres, December 1999.
Quality in Out of Hours Care, February 2000.
28.2. RCGP Outline Paper for Out of Hours, February 2000.
28.3. RCGP Quality Criteria for Out of Hours (draft).
28.4. Response to 'Supporting Doctors, Protecting Patients',
28.5. Summary Paper – GP Out of Hours Services Working
Group Report, January 1999.
29. Scottish Executive
29.1. A comparison of models of delivery of Out of Hours Care
in Scotland – Scottish
Out of Hours Study Group.
29.2. National Framework of Standards for Organisations Providing
Out of Hours Primary
Care, June 2000.
29.3. The Scottish Office Department of Health – GP
Out of Hours Services Working
Group Report, October 1998.
30. Sheffield GP Cooperative
30.1. Annual report 1998-1999.
31. SOLIDOC, Solihull
31.1. Nurse Triage Protocols
31.2. Administration Protocols.
31.3. Service Information.
31.4. A Guide to Responsibilities and Procedures.
31.5. Annual Report 1999.
31.6. Examples of completed Patient Satisfaction Forms.
31.7. Examples of statistical data derived from the service
32. South Thames Regional Drug Information Service
32.1. Notes on enquiries.
33. University of Aarhus, Denmark: Research Unit for General
33.1. Christensen M B, Oleson F O. (2000) Out of hours service
in Denmark – Evaluation of
the Reform. The Research Unit for General Practice, Department
of General Practice,
University of Aarhus, Denmark. Slide presentation.
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