CHALLENGES FOR THE FUTURE OF OUT-OF-HOURS SERVICES
Doctors, Nurses and other Allied Health Professionals
General Practitioners
One of the design concepts for NHS 24 was that it would co-ordinate out-of-hours demand with the GP out-of-hours co-operatives that had spread across much of Scotland (though much less so in remote and rural Scotland) since the mid 1990s. But by spring of 2003 it was becoming clear that a new General Medical Services contract, being negotiated at a UK level, would allow most GPs to opt out of their responsibility for providing patient care in out-of-hours periods (generally 6.30 pm to 8.00 am Monday to Friday and for the whole of Saturday and Sunday and public holidays). So, even before NHS 24 had effectively linked up with every Health Board area in Scotland its essential role had evolved to being the first point of contact for all patients wishing to contact GP OOH centres.
As suggested in our interim report, many Health Boards seemed to conclude that once they had been technologically "wired up" to NHS 24 then most, if not all, of their OOH responsibilities would effectively be taken over by NHS 24. Health Boards had been required to prepare plans to meet their responsibilities once the new doctors' contract took effect, but a few of those plans were perhaps more aspirational than operational. The majority of Health Board-run GP OOH services became integrated in the last 2-3 months of 2004. Service plans were predicated on a need to deliver face-to-face contact either in Primary Care Emergency Centres or in patients' homes. The previous triage arrangements, either carried out by doctors or nurses, were dismantled following reassurance from NHS 24 that they would perform this function. The overall result was that when NHS 24 finally advised Boards in December 2004 that it was likely to have problems over the festive season (having previously sent out regular messages of assurance) there was then something not far short of chaos before Health Boards, to their considerable credit, came up with practical operational plans without which the problems facing the public who were calling NHS 24 during the festive holiday period would have been even more serious than was the case. In fairness to NHS 24 it met a substantial proportion of the additional related costs involved. However, that is unlikely to be sustainable or particularly desirable for the future.
We believe that, for a number of reasons, GPs in some areas are likely to be less willing to volunteer to cover some of these evening and night rosters in the future. In those circumstances, local Health Boards are seeking to recruit 'salaried' GPs (as distinct from traditional, independent GPs) and some doctors are being flown in from Europe to cover peak periods. But there is a growing realisation of the need to find, train and develop other appropriate professional staff (nurses, paramedics and other allied health professionals) to provide multi-disciplinary care options. In the early days of the new GP contract arrangements it clearly suited a number of Health Boards to have the same number of doctors come back in to work night and weekend shifts. But we think that all Boards must now recognise that that is simply not sustainable - not even for the medium term - because doctors available to work out of hours will progressively reduce in number and it is imperative that Boards progress as quickly as practicable to develop - and then support - nurses and allied health professionals who can play a very full and important role in unscheduled primary care in the community.
This work is already being addressed by the National Out-of-Hours Working Group which was established by SEHD as part of the GMS implementation programme and whose members are drawn from across the service. The Group, which is taking a lead role in supporting NHSScotland to deliver the OOH service changes, will continue to focus on achieving these vital workforce changes.
Nurses, Paramedics and other Allied Health Professionals
All 15 Health Boards in Scotland were aware even as early as the summer of 2003 that the NHS would almost certainly be faced with a shortage of doctors during out-of-hours periods. Many of the plans that Health Boards had to submit monthly to SEHD during 2004 were based on developing nurses and paramedics to become qualified "nurse practitioners" and "paramedic practitioners" to be available either for triage or for some of the face-to-face consultation work requested by NHS 24 out of hours. Unfortunately, as is often the case when we talk about "skills transfer", "up-skilling", etc, the intention is much more straightforward than the reality. There was a need for appropriate consultation and that took some time. NHS Education for Scotland (NES) has co-ordinated the development of a competency framework for out-of-hours practitioners. Again, not surprisingly perhaps, the stated objectives of some Health Boards back in the early months of 2004 that they would have nurse practitioners, paramedic practitioners etc, actually doing some deputising work (local triage and house visits etc) by the end of 2004, were somewhat optimistic.
NES estimate that in the financial year to 31 March 2005 nearly 250 NHS health professionals in Scotland (the vast majority of them nurses but with an increasing number of paramedics) were going through further training or development courses. Those courses are not, of course, restricted to additional needs in out-of-hours periods but perhaps around half of the trainees were undergoing training and development which would be appropriate for out-of-hours work. The numbers projected for the current financial year are rather lower - perhaps about 100 - but NES has now secured additional funding and there are signs that some Boards are keen to increase the numbers across a range of competencies.
It seems somewhat ironic to us, with hindsight of course, that just a few years ago nurses keen to advance would regularly seek out further training and development, often largely in their own time, only to find that NHS employers did not seem too interested in utilising those hard-won new skills and qualifications.