Most out-of-hours GPs deliver excellent care, but improvements are still needed

Inspections of 30 NHS GP out-of-hours services by the Care Quality Commission (CQC) have found many examples of excellent practice but also identified variation in the quality of safety and care.

A report, ‘Findings from the first comprehensive inspections’, by Professor Steve Field, Chief Inspector of General Practice, published today (Friday 3 October) brings together the findings from those inspections, which were carried out by teams that included an expert inspector, a GP, practice manager or practice nurse, and people who have experience of using out-of-hours services.

The inspections also gave CQC the opportunity to look at progress against recommendations made in a review commissioned in 2010 by the Minister for Health, which was led by Professor Steve Field (when he was Chairman of the Royal College of General Practitioners) and Professor David Colin-Thomé, (when he was National Director for Primary Care) following high profile failures in out-of-hours services. CQC’s report concludes that there has been progress since the 2010 review, but that there is still some room for improvement.

The 30 services inspected are run by 24 organisations and provide out-of-hours care for approximately 36 per cent of the population in England; some 19 million people. Of the services we inspected, the populations covered by the providers ranged from 88,000 to 1.5 million, both within inner city and rural areas.

Professor Field said: "Out-of-hours services are often considered to be higher risk than those provided during the day by GP surgeries and we know that some have seriously failed people in the past. At the start of our inspections, I did not have high hopes about the quality of out-of-hours care. However, I am delighted that these inspections have shown that in most cases the care people receive out of hours is safe, effective, caring, responsive and well-led.

"We saw lots of good practice and it’s important that these services learn from each other to improve their services. There are also some important lessons in here for all GP services to learn from, including those that only provide care during the day. This will help tackle the variation we saw and ensure that everyone receives a high quality service whatever time of day they need to access primary care."

This is the first step in our approach to assessing the quality of urgent care, more broadly. In the autumn we will be expanding our inspections to cover a wider range of urgent care providers including NHS 111. In future, we will want to ensure patients have access to high quality urgent care across primary, secondary and social care, when they need it.

Good practice found during these inspections included:

• Most of the out-of-hours providers CQC inspected regularly monitored the quality of care they provided. They shared lessons learned and the subsequent actions with all staff.
• There were fewer locum GPs covering shifts than expected in the inspected services. Most of the GPs were sessional GPs from the local community. This meant people were receiving care from GPs who were familiar with the needs of the local population and with local care services.
• There were some good examples of services reaching out to the local community to raise awareness of services and to make contact with people who may have poor access to primary care.
• Some providers had developed innovative and responsive care as a result of feedback from local people, such as providing transport to enable patients to visit following feedback that a lack of transport was stopping some patients from attending appointments. Several services had systems in place to predict and manage high levels of activity.

However, CQC found some variation in the quality and safety of care people receive across the services and concluded that improvements are still needed. For example, some providers did not:

• have safe mechanisms for storing and checking the stocks of medicines held, and recording controlled drugs
• have appropriate recruitment processes in place
• have adequate systems for checking and monitoring equipment, including oxygen and emergency medicines
• inform patients how they could make complaints about the service

Where CQC found problems, it was clear about the improvements providers needed to make, but no concerns were serious enough to require a warning action or other enforcement action.

Professor David Colin-Thomé, who was the independent chair of CQC’s review of out-of-hours GP services, said: "We have been impressed by the good quality of most of the GP out-of-hours providers visited. GP OOH services are frequently subject to unwarranted criticism. This report taken together with the recent NAO report provide evidence to repudiate much of that criticism. As in all healthcare services of course, high quality is not uniform, and we have identified good and sometimes not so good performance."

The ministerial review was carried out in the following the death of David Gray, who died after an excessive dose of diamorphine was given to him by a locum GP, working out-of-hours for Take Care Now, in 2008.

Heath Minister Lord Howe said: "It is really positive to see that the vast majority of patients are receiving high quality, safe care from their GP out of hours service.

"But it is important that we eliminate variation so that all patients get the best possible care around the clock."

Dr Mike Bewick, Deputy Medical Director at NHS England, said: "Patients need a consistent, high quality service in and out of hours and the feedback from this report is encouraging. Where variations and inconsistencies have been identified, I am pleased that action has been taken to put improvements in place.

"It is important that Clinical Commissioning Groups and GP services look at the many good examples of excellent practice across the country alongside ongoing feedback from their patients, to drive improvements."

Today’s report has the full details of the progress against the 2010 recommendations. This includes:

• Commissioning and performance management of GP out-of-hours providers. The 2010 ministerial review highlighted concerns about how these services are commissioned and quality checked. Evidence from a recent National Audit Office report found that while many clinical commissioning groups (CCGs) actively manage their contracts, there was room for improvement – for example there was a wide variation in the level of information that CCGs receive and they could do more to encourage providers to perform well.
• Selection, induction, training and use of out-of-hours clinicians. The ministerial review highlighted the importance of having staff that are selected, inducted and trained using rigorous and effective procedures. Checking on these issues is a key part of CQC’s new inspection approach. Most of the services we inspected had processes in place for recruitment and induction, but a few did not.
• Management and operation of performers lists. At the time of the ministerial review all GPs had to be included in local lists held by the primary care trusts (PCTs) before they could practice as a GP. However, there were no systems in place to enable concerns to be shared between PCTs. NHS England now hold a central performers’ list, which is populated from local lists. NHS England is currently undertaking further work to refine this.
• Changes to the English language test. The ministerial review expressed concern about the competency in the English language of doctors from outside the UK. At the time of the review, doctors from the European Union were able to practise irrespective of their language abilities. From June 2014, the General Medical Council (GMC) has been able to test language abilities of these doctors if they have concerns about a doctor’s English skills.