Posts Tagged ‘Out of hours’


Since last time there are 4 new posts, all published on (here):

What is co-commissioning?  – which looks at how in a short space of time co-commissioning of primary care seemed to evolve from delegated budgets to partnership working between CCGs and NHS England.

Out of hours healthcare provision in need of urgent treatment – which suggests that with development of 111, extended primary care hours, and GP streams in A&E departments, the role of out of hours needs to be urgently reviewed.

The Lost Art of Clinical Commissioning – which says that because of procurement processes CCGs are losing their focus on inspiring and empowering clinicians from all specialties to come together to make change happen

Is the Better Care Fund preventing integration rather than promoting it? – concerns about the shift of money from health to social care, evidence about the lack of impact of integrating health and social care commissioning functions, and an overly bureaucratic process mean the potential gains of integration could be lost.

As always, any feedback gratefully received!  You can follow me on twitter @ccginsider, leave a comment here, or leave a comment on

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Primary care is stuck in the midst of a vicious cycle of declining profits and increasing workload, which makes finding the headroom to change nearly impossible. CCGs are stuck needing primary care to take on more work so that they can reduce the expenditure on hospital care.

We need to break this cycle, to enable both CCGs and primary care to be successful.  The key may lie in out of hours care.

CCGs are responsible for commissioning out of hours care.   PCTs in many places had run out of hours services into the ground.  Using fee for service models, costs had been reduced to the lowest possible point, often forcing local cooperatives who were providing a good service out of business, and bringing in outside companies who struggled to engage local GPs.  Now in many places we have a poor quality service, that struggles to fill its rotas, and that does not play any sort of active part in the local health economy.

Urgent care as we know is struggling across the country.  It is critical that out of hours primary care services plays a full part in managing demand and enabling the system to cope.  At present it is not, and it is clear that a new model is required.

The response of Jeremy Hunt appears to be to blame GPs for agreeing to a contract proposed to them by the government, and to try and pressure GPs into taking out of hours back on.  This, I would suggest, is not the level of thinking that is required.  Many GPs, having tasted life without out of hours, are firmly committed to never taking it back.

The opportunity lies in the fact that many practices understand the need to change as businesses but cannot understand how to.  Taking on new services appears to offer a very limited return and stretches further already over stretched GPs.  The bureaucracy of accreditation for new services creates barriers to entry that are not worth striving to overcome.  How then do practices secure new income streams for the future?

Out of hours is a service that GPs understand, that they have experience of operating at scale, and within which lies the potential for real innovation that will only come from frontline GPs.  Whilst not every GP would commit to out of hours working, if you take a big enough group of practices, rotas will be able to be filled.

The key is innovation.  Two things need to happen.  First, GPs need as a collective to form partnerships with others in the health economy.  If practices can learn to partner effectively as a group with ambulance services, accident and emergency departments, and even 111 (this may be pushing it too far!), out of hours admissions and A&E attendances could be dramatically reduced.

Second GP practices, both as clinical commissioners and as primary care providers, need to move away from fee for service models and embrace fee for outcomes models. CCGs are paying a huge amount for A&E attendances and emergency admissions out of hours.  If gain share arrangements can be developed where savings that are achieved are shared between commissioners and providers, everyone can win.

The existing model of out of hours provision is not fit for purpose.  We need a totally new model.  Primary care, either as commissioner or provider, cannot operate in isolation and be effective.  Out of hours presents a fantastic opportunity for CCGs to demonstrate the impact they can have as commissioners.  It presents a fantastic opportunity for GP practices to start to change the way they operate as businesses.  But time is short.  The urgent care system is in crisis.  CCGs won’t be around for long if they do not make an impact.  Change needs to happen now.