Primary care out-of-hours services

Prepared for the Auditor General for Scotland
August 2007

Auditor General for Scotland
The Auditor General for Scotland is the Parliament’s watchdog for ensuring propriety and
value for money in the spending of public funds.

He is responsible for investigating whether public spending bodies achieve the best
possible value for money and adhere to the highest standards of financial management.

He is independent and not subject to the control of any member of the Scottish Executive or
the Parliament.

The Auditor General is responsible for securing the audit of the Scottish Executive and most
other public sector bodies except local authorities and fire and police boards.

The following bodies fall within the remit of the Auditor General:

•	departments of the Scottish Executive eg, the Health Department
•	executive agencies eg, the Prison Service, Historic Scotland
•	NHS boards
•	further education colleges
•	Scottish Water
•	NDPBs and others eg, Scottish Enterprise.

Part 1. Summary 
Background

1. For most people contact with the NHS begins and ends in primary care, mainly during the working day.12 People also contact primary care services during weekday evenings, weekends, bank and public holidays – known as out-of-hours care.3 Every year there are over a million contacts with primary care out-of-hours services across Scotland, and the cost to NHS boards of providing these services in 2005/06 was £67.68 million.4 The main users of primary care out-of-hours services are children, older people and people with long-term conditions, palliative care needs or mental health problems.5

2. The government, NHS managers and GPs across the UK considered that the pressure of the increasing on-call commitment outwith normal working hours deterred recruitment and retention in general practice and affected the sustainability of out-of-hours services. Increases in the demand for out-of-hours services also meant that the current service models could not be sustained. A new General Medical Services (nGMS) contract was introduced for GPs in April 2004 as part of a UK-wide move to reform pay and conditions across the NHS.6 As part of this new contract GP practices can choose not to provide out-of-hours services for their patients. The opt-out was seen by the four UK health departments as central to agreeing the nGMS contract. By 31 December 2004, 95 per cent of GP practices in Scotland had decided not to deliver out-of-hours services and responsibility for delivering these services transferred to NHS boards. 

3. One of the aims of the nGMS contract is to make it easier for the NHS to recruit and retain clinical professionals including nurses and GPs. The transfer of responsibility from GPs to NHS boards has led to changes in the way out-of-hours care is planned and provided. The main aims of these changes are to:

•	improve access to and quality of out-of-hours care for patients, with patients receiving treatment from the most appropriate professional
•	enable the NHS to better plan and manage out-of-hours services
•	improve joint working and information sharing to deliver better patient care.7
4. NHS boards can deliver out-of-hours services to patients in two main ways under the new arrangements. They can directly employ GPs or other staff with extended roles (for example nurses); and they can pay other providers such as independent GPs (including those GPs now reproviding out-of-hours care) or locum agencies to help deliver services.8

5. Strong links to other clinical services are important to deliver high-quality out-of-hours primary care. This involves links to organisations such as NHS 24 and the ambulance service but also to other NHS board services, specifically unscheduled care services provided by hospital Accident and Emergency (A&E) departments.

6. Although changes under the nGMS contract are significant, this is only one of a series of large-scale changes affecting out-of-hours services. Other changes include the development of NHS 24, which now functions as the initial contact for patients requiring out-of-hours services across Scotland; and new contracts for consultants, nurses, allied health professionals, pharmacists and most other 
NHS staff.

Key messages

•	As part of the nGMS contract over 95 per cent of GP practices have chosen to opt out of providing 24-hour care to their patients, with responsibility passing to NHS boards. This has been a major challenge for NHS boards but they have managed to sustain services for patients. The opt-out offers an opportunity for NHS boards to change the way services are delivered and to improve patient care, although this will take time to be used to its full potential.
•	Most of the funding for new out-of-hours services comes from NHS boards’ budgets. This has added to cost pressures for NHS boards, particularly in rural areas where they have had to meet a greater percentage of the costs. The cost to NHS boards in 2006/07 was approximately £67.93 million.
•	The overall impact on patient care of GPs opting out of out-of-hours services is not clear as it has been introduced alongside other changes. Due to the lack of national data available it is difficult to assess whether patients are benefiting, however over 80 per cent of patients are satisfied with the service they received. GPs are positive about being able to opt out and 88 per cent of GPs are relieved to no longer have 24-hour responsibility for patients.  
•	Other services have helped NHS boards to take over responsibility for out-of-hours care, including NHS 24 and the Scottish Ambulance Service. Links with these services are continuing to develop but must be strengthened to support the delivery of high-quality patient care. 
•	Out-of-hours services are under continuing pressure as fewer GPs are reproviding services. New ways of working are required as there is a significant risk that current models of service delivery are not sustainable in the long term.  The SEHD and NHS boards must adopt a much greater focus and commitment to investment in, and planning for, extended roles for health professionals and joint working.

About the study

7. In carrying out the study we:

•	collected and analysed data on activity and cost from all NHS boards
•	interviewed staff and reviewed relevant documents from the Scottish Executive Health Directorates (SEHD), the ambulance service, NHS 24 and a sample of six NHS boards (NHS Borders, NHS Grampian, NHS Greater Glasgow and Clyde, NHS Highland, NHS Lanarkshire and NHS Shetland)
•	conducted a telephone survey of 600 members of the public who had used out-of-hours services in the previous six months
•	surveyed all GPs in Scotland, seeking views on the impact of the new out-of-hours arrangements, with a 38 per cent response rate.
8. Our fieldwork was completed in 2006. We recognise that out-of-hours services are continuing to evolve and that this is an area where work is in progress. We reflect this in the main body of the report.  

9. We make a number of recommendations in this report aimed at supporting the development of primary care out-of-hours services. NHS external auditors will monitor progress against our recommendations.

10. A separate document aimed at non-executive members of NHS boards accompanies our report. This document highlights issues arising from this report which will support non-executives in exercising their scrutiny role.

Part 2. Setting the scene

Key messages

Taking over responsibility for out-of-hours services has been a challenge for NHS boards due to the timing and scale of the change and the additional costs involved. GPs voted in favour of the opt-out in 2003, and the nGMS contract was introduced in April 2004, although the transfer of out-of-hours responsibility did not have to be in place until 31 December 2004.
NHS boards initially focused on the practicalities of taking over out-of-hours services, while maintaining services and minimising any effect on patients. The opt-out provides an opportunity to improve services so that the most appropriate person sees and treats a patient, but this has not been the main focus to date. 

Significant changes have taken place in the delivery and management of out-of-hours services

11. There have been a number of changes to the way in which out-of-hours services are delivered, particularly since the implementation of the nGMS contract in April 2004 and the transfer of responsibility for out-of-hours care to NHS boards after December 2004. 

12. Before the introduction of the nGMS contract, GPs provided out-of-hours services in four main ways:

•	GP practices joined together in an area to form a GP cooperative (most out-of-hours care was provided in this way)
•	responsibility was transferred to a commercial deputising service 
•	GPs from several practices joined together to form extended rotas to cover the out-of-hours period
•	out-of-hours cover remained the responsibility of individual practices (this model was common in rural or remote areas). 
GP cooperatives covered around 75 per cent of patients in Scotland in the late 1990s, mainly in urban areas
13. GP out-of-hours cooperatives developed through the 1990s and had a significant impact on the delivery of out-of-hours care in urban and semi-rural Scotland. Understanding how these cooperatives developed highlights how the system for out-of-hours care was already changing and how the new arrangements are a continuation of these changes.

14. GPs owned and managed cooperatives, providing out-of-hours care for patients registered with a number of practices in an area. GPs participating in these cooperatives contributed to their running costs and may or may not have taken part in the out-of-hours rota. This means that under the cooperative system GPs were less likely to deliver out-of-hours care to their own patients than GPs who did not contribute to a cooperative.

15. GP cooperatives covered around 75 per cent of patients in Scotland in the late 1990s.11 The size and organisational structures of cooperatives varied, and there were few formal relationships with other health and social services agencies.12 They were less common in rural parts of Scotland because geography made them difficult to organise. A survey conducted in 1997/98 in Scotland demonstrated that while a cooperative in Greater Glasgow covered 98 per cent of the population, the population covered by a cooperative in Argyll and Clyde was only 61 per cent, in Lanarkshire 41 per cent and in Highland 27 per cent.13 

16. Exhibit 2 (overleaf) shows a typical model of the various possible routes for a patient accessing out-of-hours services before the implementation of the nGMS contract.

There are now different ways of accessing out-of-hours services

17. Since the introduction of the nGMS contract and the ability of GP practices to opt out of providing out-of-hours care, an increasing range of practitioners are involved in providing these services, including GPs, nurses and pharmacists. Patients can now receive care in a number of settings including Primary Care Emergency Centres, GP surgeries and at home.

Ninety-five per cent of GP practices are no longer responsible for 
providing out-of-hours care to their patients, with responsibility passing to NHS boards
18. Ninety-five per cent of GP practices in Scotland have opted out of providing out-of-hours care (2,578 GPs opted out in 2003/04).14 This is similar to England where 90 per cent of practices have opted out. By 31 December 2004, NHS boards had taken over responsibility for providing or securing the provision of out-of-hours care for their local population. 

19. Under the terms of the new contract some practices cannot transfer responsibility for out-of-hours care, such as those in remote parts of Scotland where it is not possible to put in place sustainable alternative arrangements. There are a small number of practices which have decided not to opt out of providing out-of-hours care. Practices which have not opted out receive a locally agreed premium in recognition of their continued out-of-hours responsibility.  The estimated population covered by these practices was 71,680 in 2005/06 (1.3 per cent of the total population).15

Over 1,400 GPs who opted out of providing out-of-hours care now reprovide sessions for a fee
20. There are two ways in which NHS boards can deliver out-of-hours services to their population: 

•	by contracting with a range of providers, including GPs16 17
•	by directly employing staff (such as salaried GPs).
21. Out-of-hours services are currently largely delivered by GPs who chose to opt out but now provide some out-of-hours sessions back to an NHS board for a fee. We refer to this as reprovision. Based on data gathered during our fieldwork, in 2006/07 1,440 GPs who opted out now reprovide out-of-hours services to NHS boards. A further 89 GPs are directly employed by an NHS board and provide out-of-hours care as salaried GPs. Exhibit 3 shows the GP registered population, the number of GPs who have opted out across Scotland and the number of GPs who reprovided out-of-hours services in 2005/06. Parts 5 and 6 look in more detail at the new arrangements for delivering out-of-hours services.

GP practices opting out of out-of-hours care took place at the same time as rolling out NHS 24 and implementing other new pay contracts

22. Other initiatives were introduced at the same time as the nGMS contract was being developed and implemented and these affect the way primary care out-of-hours services are delivered. This includes the development of NHS 24, the introduction of new pay contracts for other NHS staff groups, the implementation of Delivering for Health and the creation of Community Health Partnerships (CHPs).18 Although these initiatives are not the focus of this report, we refer to them where relevant.19 20

23. Other pay modernisation contracts also affect general medical services, including the new consultant contract, Agenda for Change and the new deal for junior doctors. Agenda for Change introduces a new pay system for non-medical NHS staff and has a major impact on how out-of-hours services develop as it affects the grading and pay for extended roles. We explore this issue further in Part 5.

24. As NHS boards assumed responsibility for out-of-hours services, their priority was to maintain delivery of this care. NHS boards have been successful in this despite the challenges presented by the majority of GP practices opting out of out-of-hours care.

NHS 24 is now the first point of contact for most out-of-hours services
25. NHS 24 was established prior to the nGMS contract but was still being rolled out across Scotland as NHS boards were taking over responsibility for out-of-hours services. NHS 24 is now the first point of contact for most primary care out-of-hours services. People contact NHS 24 through one central telephone number to either receive advice over the telephone or be redirected to another service.  

26. Exhibit 4 shows how patients access out-of-hours services under the new arrangements. People can access services such as A&E, ambulance, dental or palliative care directly during the out-of-hours period. Although it is not possible to give figures for how many patients directly access services in Scotland, as no data are collected, this is likely to be a small number.

NHS boards taking on responsibility for out-of-hours care at the same time as integrating with NHS 24 added to the pressures and risks associated with delivering these services
27. NHS 24 was initially designed to integrate with all GP out-of-hours cooperatives, A&E departments and with the ambulance service to provide a first point of access for patients requiring out-of-hours care. NHS 24 aims to play a key role in simplifying arrangements for the public to access a healthcare professional.21

28. NHS 24 services were rolled out to many NHS board areas at the same time as NHS boards were taking over responsibility for GP out-of-hours. This has added to pressures and risks around out-of-hours services, and meant that NHS 24 was under pressure at the same time as GPs opted out. The work required to integrate services, IT and staff had to happen in a short timescale. NHS 24’s original estimates were that 60 per cent of calls would be in the out-of-hours period. In practice, and with the changes to the GP contract, around 90 per cent of calls take place out-of-hours.22 As there have been extensive reviews of the development and activity of NHS 24, we did not audit NHS 24 directly as part of this work but have drawn on existing evidence where relevant.23 24

29. The pressure and complexity of rolling out NHS 24 to all NHS board areas and integrating with each of those very different local services has proved challenging. This was the first time all out-of-hours contacts had been coordinated by one central organisation. A similar organisation operates in England, NHS Direct, although this service only acts as a first point of contact for a proportion of NHS trusts in England.

Part 3. Planning for the new out-of-hours arrangements

Key messages

It is not possible to do a like-for-like comparison of the cost of the out-of-hours service before and after opt-out as services delivered under the new system tend to be very different from what went before. However, the SEHD carried out some work to calculate what was paid under the previous system and assessed the possible implications of agreeing various levels of claw-back. This work showed that GP practices received an average of £12,000 for providing out-of-hours services.
As part of UK-wide negotiations of the nGMS contract it was agreed that GP practices opting out of providing out-of-hours care forego an average of £6,000 of their funding each year per GP (known as the claw-back). The claw-back figure was a negotiating sum and not intended to be a precise reflection of the cost of providing out-of-hours services.

The new contract has changed how the NHS funds out-of-hours services

30. Prior to the introduction of the nGMS contract, out-of-hours care formed part of a range of services provided by GPs and costs were not collected or monitored separately. An annual out-of-hours allowance and specific payments relating to the number of out-of-hours call-outs formed part of wider payments to GPs. We cannot accurately report the cost of delivering out-of-hours services prior to the nGMS contract as the data held by the NHS give only a partial picture. The way services are delivered under the new system also tends to be different.

31. GP practices that opt out of providing out-of-hours services have their global sum payment reduced by six per cent.25 This equates to about £6,000 each year per GP and is known as the claw-back. The six per cent was based on the Department of Health’s (DoH) economic analysis of GP cooperatives in England and was a negotiating sum to encourage GPs to accept the nGMS contract.26 The claw-back was not intended to cover the cost of reproviding the out-of-hours service.
 
32. NHS boards now receive a specific fund for primary care services: a general medical services allocation (which is not just for delivery of out-of-hours services). An out-of-hours development fund was paid each year from 1995/96 to 2005/06. NHS boards reported receiving a total of £8.9 million in 2005/06.27 NHS boards have met the rest of the costs of out-of-hours services from their budgets.28 (See Part 4)

The additional cost of the new out-of-hours service was £31 million in 2005/06

33. The SEHD carried out some work prior to agreeing the opt-out to understand what was paid for the previous service and to assess the potential impact of agreeing various levels of claw-back. Before implementing the opt-out two separate payments were paid to GPs to deliver out-of-hours services – night visit fees and a night visit allowance. These two payments cost £18.3 million in 2003/04. The SEHD knew that the new service would cost more than this as GPs had been supplementing the service. It was clear that many GPs would opt out of providing out-of-hours care, and NHS boards would have to buy back this GP work for a fee. There would also be new additional costs for administering the service by NHS boards, and other infrastructure costs.  

34. We collected data from all NHS boards which show, compared with 2003/04, that the additional cost of the new service for 2005/06 was £31 million. There is no clear evidence to show how much the SEHD expected the additional cost to be.29

35. The work carried out by the SEHD to understand the cost of out-of-hours services in Scotland prior to agreeing the opt-out shows that the average cost of the previous service per GP practice was estimated as £12,000 in Scotland compared to £9,500 in England.  

The SEHD worked closely with the NHS to implement the new out-of-hours arrangements but strategic guidance on some aspects could have been better

36. Most of the guidance provided to the NHS in Scotland on preparing for changes to out-of-hours services was guidance that was issued on a UK-wide basis. The SEHD and the Scottish General Practitioners Committee (SGPC) of the BMA also issued some jointly agreed guidance to the NHS in Scotland on implementing the changes.

37. In 2003, the SEHD established a National Reference Group to assess progress on implementing the nGMS contract. This group was made up of members from NHS boards, the ambulance service, NHS 24 and the SEHD. An out-of-hours operational sub-group of the National Reference Group focused on operational issues and acted as a support and information network group for staff leading out-of-hours implementation in NHS boards.  

38. In the sample of NHS boards where we did more detailed work, opinion was mixed on the usefulness of the central out-of-hours groups and the SEHD guidance. Some found the groups helpful in assisting with specific operational issues but others felt the groups were more of a forum for discussion and a clearer steer from the SEHD was needed. Given the pace and scale of changes which had to be implemented for out-of-hours services, these central groups tackled issues as they arose, and the SEHD could have done more to share good practice and encourage the transfer of learning to other areas.  

39. There was a lack of central guidance from the SEHD on issues such as salary scales for salaried GPs, the range of pay rates for GPs and the development of extended roles for other staff. Although there were salaried GPs in the NHS prior to the nGMS contract this was the first time GPs could be salaried for out-of-hours. It would have been helpful to have arrangements in place to share this kind of information among NHS boards.

The lack of an indicative range of payments for GPs providing out-of-hours sessions has led to a lot of work for NHS boards to contain pay rates for this work
40. When GP practices initially opted out of providing out-of-hours services, there were often limited alternative arrangements. This meant that most NHS boards had little choice but to buy back the services of the GPs who had opted out under a separate arrangement. During UK-wide negotiation for the nGMS contract, government and employer representatives agreed not to set national GP rates or ranges for these rates, taking the view that setting a national rate could compromise local approaches to value for money. They felt that those NHS boards which could secure lower rates (such as urban NHS boards) would suffer, and there was a concern that a national rate would be toward the higher end of any payments that NHS boards could negotiate locally.30

41. Although it is impractical to agree a national flat rate for such work, given the regional variances in GP availability and activity, the SEHD could have done more to suggest a scale or range of rates to pay for these services. This has led to NHS boards facing challenges of changing services while taking part in lengthy local discussions over rates. This was particularly challenging in rural and remote areas where a limited number of GPs were available to reprovide out-of-hours sessions. By not setting out an indicative range of payments, market forces apply and NHS boards often have little control over rates particularly where there are few alternative service options available. Put simply, if a GP out-of-hours session cannot be filled the rate may need to be increased until someone is willing to cover it. In line with the National Audit Office (NAO) findings in England, our fieldwork interviews revealed concerns that NHS boards were subject to whatever rates GPs would take for working out-of-hours.31

Despite a lack of national data most NHS boards carried out detailed local planning prior to GP practices opting out of out-of-hours care, although planning for extended roles is not yet well enough developed

42. To assist local planning, all NHS boards carried out GP surveys to help understand how the service would operate when they took over responsibility. These local surveys showed that the majority of practices would opt-out. Although GPs in some areas indicated interest in participating in out-of-hours services in the future, the actual number was not known as this would depend on what fees were paid and how many other GPs were on the rota. NHS boards were therefore planning for the new service with some key unknowns and were aware of the risk that the fewer GPs available, or willing to fill out-of-hours rotas, then the greater the increase 
in costs. 

43. All six sampled NHS boards carried out an analysis of the management information that was available from the previous out-of-hours services to help plan their new models of out-of-hours care.32  Those NHS boards where out-of-hours services were covered by cooperatives had more information with which to plan and had less work to change services initially. They did however, carry out a lot of work to transfer cooperative staff onto NHS terms and conditions, such as drivers and administration staff. This was also at a time when Agenda for Change was reassessing the grade and pay for these staff.

44. NHS boards started from very different points depending on how coordinated the services were that they were taking over. However, all NHS boards lacked data on how the out-of-hours services worked with other services, such as A&E, as integration with other services  tended to be weak under the previous system.

45. All sampled NHS boards monitored implementation and prepared a project plan setting out key actions and milestones to help manage the implementation of the new out-of-hours arrangements.  Although NHS Shetland did not have a formal project plan in place, it regularly monitored progress with implementation. Sampled NHS boards carried out detailed financial planning based on an analysis of cost and activity data from the previous out-of-hours service, except NHS Shetland where overall financial planning was not robust due to several factors, including inadequate financial systems and poor data on the previous out-of-hours system.33  

46. All sampled NHS boards carried out option appraisals and consulted with the local community. There is also evidence that planning involved all relevant stakeholders including the ambulance service, NHS 24 and NES.

Recommendations

The SEHD should:

•	ensure that detailed national cost models based on accurate data are produced before implementing major schemes, and that these are used to inform negotiations and implementation
•	provide timely and effective guidance when implementing major new schemes, identifying actions that NHS boards are required to take and monitoring their impact 
•	identify performance measures and baseline information against which benefits for patients and the NHS can be clearly measured before implementing major schemes.

Part 4. Cost and quality of out-of-hours services

Key messages

Under the new arrangements, out-of-hours services cost £35.03 million in 2004/05 (part-year costs), £67.68 million in 2005/06 and were projected to cost £67.93 million in 2006/07.
The cost of providing out-of-hours primary care services varies across Scotland. The cost is directly linked to remoteness, with higher costs in more remote or rural areas. This is due to a range of factors such as sparse population and large geographical areas to cover. 
GPs who opt out but then decide to reprovide services to NHS boards are paid a fee.  These fees are negotiated locally and vary among NHS boards and according to the time and type of day. For example, rates paid over Christmas are higher than standard weekly rates. The hourly rate paid to GPs to cover nights during the week ranges from £50 to £80.91 in the mainland boards.
The claw-back from GP practices funded 30 per cent of the cost of the new service across Scotland in 2005/06. The rest mostly comes from NHS boards’ budgets, contributing to cost pressures, and from an out-of-hours development fund, which was paid up to 2005/06.  NHS boards covering more rural areas have had to find a greater percentage of the cost of the new service from their own budgets. For example, NHS Highland funded 80 per cent of the new service from its unified budget while NHS Greater Glasgow funded 26 per cent.
The cost to NHS boards in 2006/07 was approximately £67.93 million

47. The cost of out-of-hours services in Scotland from the time that NHS boards took over responsibility in 2004/05 up to 2006/07 is approximately £170.65 million.

48. The cost of out-of-hours services varies across Scotland and costs more to provide per head of GP registered population in more remote or rural areas. A fifth of people in Scotland live in rural areas and a significant number in very remote areas.34 Costs per head of population range from £7.61 for the Greater Glasgow area to £43.63 for the Argyll and Bute area. Costs in the Greater Glasgow area are lower due to a range of factors including the large and densely populated area covered by the NHS board. In contrast the Argyll and Bute area contains a number of small islands and a dispersed population, which make providing safe out-of-hours care in rural or remote areas challenging and more costly. This supports other work on the correlation of high costs of services and the rurality of NHS boards.35

49. Out-of-hours services also differ greatly in how they are delivered between rural or remote and more urban boards.

50 The largest proportion of the overall cost of the out-of-hours service is for the healthcare professionals providing care to patients, either through salaries or rates. GPs who reprovide out-of-hours sessions deliver the major part of the clinical work in the out-of-hours period. NHS boards may also use either locum or agency GPs or employ salaried GPs  to deliver sessions, who are all paid differently.

51. Fees paid to GPs for reproviding out-of-hours services are negotiated locally and therefore vary across Scotland. This is due to local factors such as pre-existing arrangements and availability of GPs willing to provide the service. For example, rates in areas where there are more GPs willing or available to reprovide some sessions tend to be lower than in those areas where there are less GPs willing or available to reprovide.

52. We collected data on a range of payments for reprovision since the opt-out. These payments do not represent the total payment to GPs for reproviding out-of-hours work as some NHS boards make additional payments for on-call work in addition to the rates shown here.36

53. Exhibit 8 (page 20) shows the payments for one of the most frequent out-of-hours sessions – a weekday evening. This shows that the work put in by NHS boards in negotiating fees and sharing information among boards for this time period has successfully led to a common approach. Around £50 per hour is paid across most areas, ranging from £45 in NHS Forth Valley and NHS Greater Glasgow to £60 in NHS Western Isles. This is in line with the average rate for weekday evenings paid in England at £58.36 per hour.37

54. Payment rates for other times in the out-of-hours period are less consistent across Scotland. Exhibit 9 (page 21) shows that payments for a weekday overnight per hour varied from £50 in NHS Dumfries and Galloway and NHS Forth Valley to just over £80 in NHS Tayside, NHS Grampian, NHS Lanarkshire and NHS Western Isles in 2005/06. This variation reflects local market forces at work in determining GP fees.

55. Payments at Christmas and New Year vary even more widely across Scotland, ranging from just under 
£81 per hour in NHS Tayside to £150 in NHS Highland and NHS Grampian in 2005/06.

On average NHS boards had to fund about half of the cost of the new out-of-hours service but rural NHS boards have had to fund more

56. Across Scotland in 2005/06 the claw-back funded 30 per cent of the cost of the new out-of-hours service, with 53 per cent of the funding coming from NHS boards’ budgets.  

57. The percentage of costs met from the claw-back to fund the new service varies across Scotland, although for rural NHS boards the pressure to fund the new service from the NHS board budget was far greater than for urban NHS boards.For example NHS Highland funded 80 per cent of the new service from its budget, while Greater Glasgow funded 26 per cent.  

58. In 2006, the SEHD stopped the development fund for out-of-hours and included this money within the overall budget allocation to NHS boards. Exhibit 11 shows that NHS boards expected to fund 63 per cent of the cost of the new service from their budgets in 2006/07. It also shows that the percentage of service costs met from the claw-back varies. The cost to NHS boards of delivering out-of-hours services has increased, with pressure being greater in the more rural areas.

NHS boards have largely met quality standards but there is scope to integrate out-of-hours services more effectively with wider NHS board systems

59. NHS QIS published a set of standards for primary medical services out-of-hours in August 2004.38  All providers were required to comply with the standards from January 2005. Three standards relate to the provision of safe and effective out-of-hours services:

•	access and availability at first point of contact
•	safe and effective care
•	audit, monitoring and reporting.
60. A review of NHS boards’ performance showed that they are largely meeting the NHS QIS standards.39 40

61. NHS QIS identified some areas for development that NHS boards had to address by July 2007, summarised in Exhibit 13. In its national report NHS QIS noted: 

”Our review set out to find out whether NHSScotland is on track to provide safe and effective care out-of-hours and we were impressed by the progress that has been made in every NHS board and by the constructive and pragmatic approach that has been taken to implement the new out-of-hour services.” 41

62. Although the NHS QIS standards are a useful start in defining a minimum standard for all out-of-hours service providers, a system of clear performance indicators focused on patient out-of-hours care is not yet in place. The NHS QIS standards explore the processes and procedures underpinning the delivery of out-of-hours care rather than assess the quality of services provided to patients. National work, led by NHS 24, is beginning to develop national performance indicators, with pilot work underway to develop indicators for stroke services. The aim of these indicators is to assess services provided to patients across various in-hours and out-of-hours services. 42

There is scope to improve contracts for out-of-hours services and to routinely consider value for money

63. The new out-of-hours arrangements offer scope for clearer accountability arrangements as most out-of-hours services are now delivered by NHS boards and providers have to comply with NHS QIS out-of-hours standards. There are still a small number of practices in Scotland which have not opted out and are still responsible for delivery of 24-hour care to their patients.  

64. NHS boards have been successful in sustaining out-of-hours services following the opt-out of GP practices, and are now starting to explore other routes of service delivery. Such as through contracts with partners, for example the ambulance service, an agency providing locum GP cover, or a neighbouring NHS board. To date, most of these contracts have not been reviewed for value for money.  

Recommendations

The SEHD should:

•	work with the NHS to share data on costs associated with out-of-hours services including costs associated with different models of care, and to reflect the impact of rurality.
•	NHS boards should:

•	share data on fees and payments to ensure value for money and monitor fee levels across Scotland
•	monitor contracts with other service providers to ensure value for money.
Part 5. Impact of changes on the delivery of out-of-hours services

Key messages

National benchmarking and monitoring of performance of out-of-hours services needs to be improved to give a clear view of the standard of services provided. There is no coherent national approach to monitoring the performance of out-of-hours services, although there is evidence of monitoring the process by which NHS boards are developing their out-of-hours systems. For example, NHS boards are monitored against NHS QIS standards for out-of-hours services. A national group involving NHS QIS, NHS 24 and NHS boards is currently developing national key performance indicators for primary care out-of-hours services.
Only one in ten GPs (11 per cent) responding to our survey feel that patient care has improved under the new arrangements. Over half (52 per cent) feel that patient access and the availability of out-of-hours services have not improved. Our patient survey, however, shows that over 80 per cent of patients who have accessed out-of-hours services are satisfied with the service they received, and understand how to access services through NHS 24.
Improving recruitment and retention of GPs were aims of the opt-out but, as the nGMS contract is with a practice rather than a GP, data on GP vacancies are no longer collected centrally. In 2006/07 the SEHD established an annual survey of GP practice staffing, including GP numbers, to measure changes in GP recruitment and retention, and to support workforce planning.  
Communication and sharing of patient information among the various providers of out-of-hours services could be better, for example NHS 24, the ambulance service, A&E and social services. However, the roll-out of the emergency care summary (ECS), which has made basic patient data available to health staff working out-of-hours, is a significant development since the opt-out.
The SEHD set out the initial benefits for out-of-hours care expected from the nGMS contract

65. The SEHD set out some wider benefits to patients, staff and the wider NHS that it expected from the nGMS contract. Some of these are related to out-of-hours services although these were not all specified until after the opt-out was in place. Exhibit 14 (overleaf) highlights the main expected benefits from the nGMS contract and, for out-of-hours, to what extent these have been achieved.

66. Some of the main anticipated benefits from the opt-out were to improve recruitment and retention of GPs. As the new GP contract is a practice-based contract there is no central requirement to collect data on numbers of GPs by NHS board or vacancies. Only four NHS boards across Scotland (NHS Fife, NHS Shetland, NHS Tayside and NHS Western Isles) were able to give us data on GP vacancies for 2005/06. Without this information it is impossible to say whether recruitment and retention of GPs have improved under the new out-of-hours arrangements. Also, the SEHD and NHS boards will not be able to carry out detailed workforce planning at national and local levels without this information. NHS boards are no longer required to submit data on numbers of other staff working in GP practices, further complicating workforce planning. To assist with this, the SEHD established an annual survey in 2006/07 to collect data on GP numbers and other practice staff.

Monitoring information for out-of-hours services is available locally at NHS board level but needs to be more developed at a national level
 
67. All NHS boards carry out some monitoring of out-of-hours services. All NHS boards make use of one of two data systems (Adastra or Taycare) which assist them in collecting and reporting on out-of-hours activity. Five of our six sample NHS boards have local performance indicators that they monitor and report regularly.44 However, the extent to which NHS boards monitor out-of-hours activity varies across Scotland and the approach taken by each NHS board   is different.

68. NHS 24 recommends that NHS boards monitor call response times for calls that NHS 24 has assessed and then passed on to NHS boards for action. Only six NHS boards reported that they monitor call response times, with three using NHS 24 recommended call response targets (the former NHS Argyll and Clyde, NHS Highland, NHS Lanarkshire) and three using their own local targets (NHS Lothian, NHS Orkney, NHS Tayside). Once a call is passed from NHS 24 to the NHS board a patient may require a home visit from a healthcare professional.  Seven NHS boards are monitoring NHS 24 recommended home-visiting response times and were able to provide details of their performance against their targets (NHS Ayrshire and Arran, NHS Dumfries and Galloway, NHS Fife, Greater Glasgow, NHS Lothian, NHS Shetland and NHS Tayside).  

69. There is no routine monitoring of how out-of-hours activity affects other services either at a local or national level. None of the six sample NHS boards routinely monitor referrals and activity between out-of-hours and social services and only one, NHS Lanarkshire, routinely monitors activity and referrals between out-of-hours services and A&E. This lack of monitoring will make planning for out-of-hours services and between different services less effective. In June 2007, the SEHD set up a steering group to review the changes in demand for unscheduled care services, including primary care out-of-hours services. Members include NHS boards, NHS 24 and the Scottish  Ambulance Service.

70. There is no coherent national approach to monitoring the performance of out-of-hours services.  However, there is evidence of monitoring the process by which NHS boards are developing their out-of-hours systems at a national level in three main ways:

NHS QIS reviews NHS boards against its standards for out-of-hours services.45
As part of monitoring the implementation of the nGMS contract, the SEHD’s pay modernisation team has asked NHS boards to assess themselves against ten strategic tests. One of these tests asks NHS boards to indicate to what extent they have reformed out-of-hours services.
As the opt-out was introduced as part of the nGMS contract, the central monitoring of benefits of the main pay modernisation contracts makes reference to out-of-hours services, namely benefits realisation plans. These plans are now in their third annual revision and give examples of service initiatives. They do not act as a coherent monitoring tool to establish benchmarks for out-of-hours services.
The emergency care summary has now been rolled out and is used for 4.4 million patients across Scotland

71. The Emergency Care Summary Programme aims to provide essential patient information to out-of-hours services including NHS 24. The project is sponsored by the General Medical Services Information Management and Technology (IM&T) programme (part of the programme to implement the nGMS contract) and is a recognised component of NHSScotland’s e-Health strategy. The project started in October 2003. The objectives of phase one of the project were to:

•	provide a technically robust method of demonstrating the extraction of GP summary information from GP clinical systems into a ‘store’
•	establish a GP summary record and determine the frequency of updates for each element of 
the record
•	share information and findings with the other UK nations.
72. Audit Scotland published a review of IM&T in November 2006 which sets out progress with the emergency care summary.46 We concluded that the programme is well structured with clear governance arrangements for the overall programme, but that there is no business case for the programme or a defined set of anticipated benefits.  

73. The emergency care summary was set up to support the changes to out-of-hours services which would take place following the GP opt-out. The summary gives healthcare professionals access to basic patient information such as current medication, allergies and demographic information. Information is copied from the GP patient record and updated twice a day if there are any changes. The system currently covers 4.4 million patients, whose GPs use the GPASS computer system. Work is underway to include the details of the remaining patients in Scotland whose GPs use different IT systems.  

74. Currently the data can be accessed by staff at out-of-hours medical centres and NHS 24. A&E departments have access to these data but they are not all using it. In the future ambulance staff may be able to access these records. Patients are asked to give approval before anyone can access their information in this way.

Patients are generally satisfied with the out-of-hours service 
they receive

75. There have been changes in the care patients receive out-of-hours, specifically who provides the care and how patients are dealt with.  There is scope for this to change further as services develop. Exhibit 15 (overleaf) shows a summary by NHS board of the care patients receive in the out-of-hours period.   

76. We carried out telephone interviews with 600 members of the general public who had used out-of-hours services in the previous six months. Results from our patient survey are very positive with 85 per cent indicating that overall they were satisfied with the service they received. This included the manner in which staff dealt with them, information provided to them, the time they waited to speak to someone and the time spent treating the problem. Furthermore, overall satisfaction levels with each potential service used were very positive (eg, primary care treatment centre, NHS 24 or A&E).  

77. In instances where further treatment was required after contacting NHS 24, a majority of respondents felt that they received treatment promptly – 62 per cent of those who received a home visit from a GP or another healthcare professional waited less than an hour; the average wait to be treated by a doctor or nurse at A&E was 43 minutes.  

78. The small numbers of respondents who commented on the need for improvements to the out-of-hours service highlighted the need for a more speedy response in dealing with their health-related problem; that advice could be more thorough; or that they would like to have seen a doctor.

79. Patients travel either to a primary care treatment centre or to A&E to receive treatment out-of-hours. This was not raised as a concern by the majority of patients – 16 who had to attend A&E found difficulty in getting there, and only six had any difficulty in getting to the treatment centre.

GPs are positive about the opt-out for themselves but do not feel the changes have improved care or access for patients

80. One of the main purposes of allowing GP practices to opt out of providing out-of-hours care was to give GPs more control over their work and improve working conditions.  However, the benefit of opting out will be less for those GPs who previously worked as part of an out-of-hours cooperative or engaged a deputising service.

81. GPs are generally positive about the ability to opt out of providing out-of-hours care. Eighty-eight per cent of GPs who replied to the survey said they are relieved that they no longer have 24-hour responsibility for patients, and 66 per cent feel that a career as a GP has become more attractive.

82. GPs do not feel the new arrangements have led to improvements for patients. Only 11 per cent of those who responded to our survey felt that patient care had improved under the new arrangements. A further 52 per cent felt that patient access and the availability of out-of-hours services had not improved.

Recommendation

The SEHD should:

•	develop performance measures for out-of-hours services to support NHS boards to compare their out-of-hours services as they continue to develop them.
Part 6. Sustainability of the current service

Key messages

In areas with fewer GPs and a more dispersed population, GPs were less keen to reprovide out-of-hours services. NHS boards in these areas had to seek more innovative ways of sustaining these services, such as developing extended roles for nursing staff. In some particularly remote areas, such as parts of NHS Highland, some practices have not been able to transfer responsibility to their board as it is not possible to put in place an alternative service. 
The number of GPs from opt-out practices who then reprovided some level of out-of-hours care for a fee fell from 1,696 in 2004/05 to 1,440 by 2006/07. This makes it harder for NHS boards to fill out-of-hours GP rotas – five of the six sample NHS boards in our study reported difficulty in filling rotas. Increased practice income under the wider nGMS contract means that any financial incentive offered to GPs to carry out out-of-hours sessions is less attractive. Between 2003/04 and 2004/05, the average income of nGMS GPs in Scotland increased by 24.9 per cent to £82,696.
The way in which services are delivered must change if out-of-hours services are to be sustained. NHS boards have been developing extended roles and involving a range of staff in delivering out-of-hours care, although progress is variable. There has been an increase in the use of salaried GPs from 61 in 2004/05 to 89 in 2006/07, but the use of staff with extended roles is more limited.
The additional cost and time to train extended role practitioners to be able to pick up clinical sessions means that the costs of out-of-hours care are likely to rise in the short term. 
There is a significant risk that current models of out-of-hours service delivery are unsustainable 

83. The SEHD and NHS boards need to make a greater commitment to developing extended roles for nurses, paramedics and others to continue the development of skill mix in the out-of-hours period and in light of the fragility of relying on GP reprovision. For most NHS boards the number of GPs from opt-out practices who are reproviding out-of-hours services has remained relatively stable since the new contract was introduced. However, for three NHS boards, each with a large remote area to cover, there has been a significant reduction in the number of GPs providing this service (NHS Ayrshire and Arran, NHS Borders and NHS Dumfries and Galloway). At each of these NHS boards the number of GPs reproviding any out-of-hours sessions has almost halved. This may in part be due to a planned approach to reducing reliance on sessional GPs to reprovide out-of-hours work. For example, NHS Borders has moved quite quickly to a fully salaried GP rota for out-of-hours care because of the pressure on filling GP rotas (Case study 2). 

84. In 2004/05, 1,696 GPs from opt-out practices had reprovided some level of out-of-hours care for a fee. In 2006/07 this number had reduced to 1,440. This affects some NHS boards more than others and makes it harder for them to fill out-of-hours GP rotas. Under the wider nGMS contract practice income has increased so there is less financial incentive to work out-of-hours. Between 2003/04 and 2004/05, the average income of nGMS GPs in Scotland increased by 24.9 per cent to £82,696.47 48

85. Although the number of GPs willing to reprovide sessions has remained largely stable for some NHS boards, overall GPs tend to reprovide fewer sessions. This contributes to pressure in filling out-of-hours rotas.  Exhibit 17 shows the frequency of GPs who have opted out of providing 24-hour care to their patients who then decide to deliver out-of-hours sessions for an NHS board.  

86. NHS boards are already reporting difficulties in filling GP out-of-hours rotas, including five of the six sampled NHS boards.49 If this pattern continues NHS boards will experience further difficulties in filling out-of-hours sessions and will need to find other solutions. Some NHS boards have also used agencies to supply GPs to deliver out-of-hours sessions although this is marginal in terms of both cost and activity (£1.09 million in 2005/06), and not all NHS boards have used agencies so far.  

87. Since GPs are no longer required to deliver out-of-hours care, there is a risk that they will choose not to. This makes it difficult for NHS boards to plan how out-of-hours services might be delivered in the future.

NHS boards are developing new ways of delivering out-of-hours services but should do more to develop the skill mix

88. Out-of-hours services can best be provided by using an appropriate mix of clinical staff and providers. NHS boards employ salaried GPs to carry out some out-of-hours work, and all NHS boards have begun to develop extended roles for NHS staff so that staff such as paramedics and nurses can contribute to the effective care of patients in the out-of-hours period.  

89. Exhibits 18 and 19 show the percentage of direct clinical activity delivered by GPs, NHS staff and locums in 2004/05 and 2005/06.  Both charts show the variation in how services are delivered across Scotland. This is due to a number of distinctly local factors such as how services were configured prior to the opt-out, success in recruiting salaried GPs and the extent to which the NHS board has trained and employed nurses with extended roles. This situation has evolved because of what is available or possible locally, rather than any SEHD guidance on a preferred model or skill mix. The exhibits also show a small percentage of unfilled out-of-hours sessions in four NHS boards (NHS Borders, NHS Grampian, NHS Forth Valley and NHS Tayside). NHS boards have contingency plans to cover these hours by moving other staff working out-of-hours to cover sessions 
as required.

90. Exhibits 18 and 19 show that in 2004/05 there was relatively limited use of other staff to provide out-of-hours activity. The nGMS contract makes explicit provision for NHS boards to appoint salaried GPs for the out-of-hours period. NHS boards have taken different approaches to the use of salaried GPs, but across Scotland as a whole there is an increasing trend to employ salaried GPs. In 2006/07 there were 89 whole time equivalent (WTE) salaried GPs providing out-of-hours care employed across Scotland, a rise from 61 WTE in 2004/05.50 51

91. Most NHS boards have not yet used other healthcare professionals to cover out-of-hours work. For those boards which have started to use other healthcare professionals in this way, there was a small increase in the amount of work they did in 2005/06. More use has also been made of locum GPs.  

92. There have been complications in moving forward with this skill mix approach to out-of-hours work. These options do not, in the short term, represent a cheaper way to deliver the service and it is costly to train and pay for staff working in these extended roles. It is not possible to replace a GP directly with another healthcare professional – using a greater skill mix is about making better use of the skills of healthcare professionals. However, one of the benefits of using other directly employed staff is that the NHS board will have more control and therefore be better able to plan and use resources as they are needed. Salaried GPs and nurses are tied in to the service and therefore offer a more predictable way of providing the service than GPs who currently reprovide some sessions but may decide not to in the future.

93. A further complication is in identifying the staff to carry out these roles. For example, some NHS boards have reported difficulties in recruiting salaried GPs. The implementation of Agenda for Change has also complicated the development of extended roles. Agenda for Change is one of the main strands of NHS pay modernisation, introducing new contracts for nursing, administration and other staff. The contract is still being implemented and all staff in these groups are having their jobs assessed and graded. This inevitably means a sense of uncertainty for staff potentially making them less likely to take on an extended role. Furthermore there have been differences in the way some extended roles have been graded either between professional groups (eg, paramedics and nurses) or in the grading that some extended roles have been given under Agenda for Change (ie, they are not paid much than a standard grade). 

A greater focus on workforce planning, education and training   is required

94. Although all NHS boards now have a workforce plan in place, the plans do not always provide details of numbers and types of staff required to deliver and develop the out-of-hours service. The number of sessions delivered out-of-hours by GPs has reduced and NHS boards have reported pressures in filling GP rotas. In light of this, and the fact that GPs are no longer responsible for delivering this care, NHS boards need to be more proactive in planning how the service will be delivered. The SEHD should support this by developing a clear overall strategy for the continued development of out-of-hours services.

95. Although there are many training courses and schemes for training staff in skills necessary for out-of-hours work, there is scope for these to be better funded and coordinated. NES has led the creation of a new framework to support the development of new roles and skills that out-of-hours practitioners will need and has provided some funding to support this.52 This is linked to a new integrated approach to workforce planning which aims to organise workforce planning around service themes set out in the Kerr report. This includes identifying numbers and types of staff required to deliver out-of-hours services, over a three, five and ten-year period and the actions required to meet any gaps identified. A group has been set up by the SEHD to share good practice and take a strategic approach to the development of extended roles for out-of-hours and they are expected to publish a report in late 2007.

New ways of working with NHS 24 and the ambulance service have helped NHS boards take responsibility for out-of-hours care

96. Although the cost of out-of-hours services delivered by NHS boards in 2006/07 was approximately £67.93 million, a range of other agencies support NHS boards in the delivery of out-of-hours care to their patients, most significantly NHS 24 and the ambulance service.

97 A review of NHS 24 carried out in 2005 found that 90 per cent of calls to NHS 24 take place in the out-of-hours  period.53 The cost of running NHS 24 was £42.6 million in 2004/05. Exhibit 20 highlights the increased activity of NHS 24, reflecting its changing role as it was rolled out across Scotland as the first point of contact for out-of-hours services.

98. There are times when NHS 24, under agreements with NHS boards, will transfer calls untriaged directly to local NHS boards to deal with. This is usually at times of peak out-of-hours activity.54 Only four NHS boards do not take untriaged calls (NHS Ayrshire and Arran, NHS Dumfries and Galloway, NHS Orkney and NHS Shetland).

99. In addition to taking untriaged calls from NHS 24 many NHS boards re-triage some calls passed to them by NHS 24. This means that the patient is re-assessed by the NHS board after NHS 24 has already assessed the caller’s needs. This could raise concerns that NHS 24 assessments are not always appropriate or that carrying out another assessment or triage delays patient treatment. The main reason NHS boards gave us for re-triaging calls is to ensure that they can best manage clinical priorities with available local resources when demand is high. Ten NHS boards re-triage calls that are passed on from NHS 24 but stated this happens occasionally or during peak periods of activity.55 Exhibit 22 shows that over half of respondents to our survey had to explain their health-related problem more than once before receiving the care they required.

100. Exhibit 23 shows changes in activity of the ambulance service before and after the opt-out came into effect. The ambulance service is about to carry out more detailed work to understand the reasons behind the increases in its activity. 

101. Changing the availability and location of out-of-hours services has a direct impact on the work of the ambulance service, such as how long it takes to transport a patient to hospital and where ambulance stations are located. While the Scottish Ambulance Service is continuing to work with individual NHS boards to contribute to local services, it is also analysing resource implications of changes to out-of-hours services. 

There is no evidence to suggest that the changes in how out-of-hours services are delivered has affected A&E activity

102. Changes in out-of-hours services have also led to changes for A&E services, and there is often a perception that A&E activity levels have increased as a direct result of the nGMS opt-out. For example, 48 per cent of respondents to our GP survey feel there has been an increase in attendances at A&E since the opt-out. However, there is little evidence at a national level that A&E activity has been affected directly by the opt-out. A&E activity was increasing before the opt-out and has continued to do so since.

103. ISD collects national data on A&E activity through its annual waiting times survey. It is not possible to 
use these data to show trends in activity over time as data were collected for different hospitals and over different time periods in 2003, 2004 and 2005.

There is now more demand for out-of-hours community pharmacy services

104. An internal report by the Scottish Pharmaceutical General Council (SPGC) shows that community pharmacists have seen an increase in demand for emergency supplies, particularly on a Saturday morning when GP surgeries are now closed, and also on public holidays.56 The report shows that 35 per cent of all NHS 24 calls are pharmacy-related, which has an impact on the work of community pharmacists, and indicates that the pressure is greatest over the weekend and bank holidays.

Recommendations

The SEHD should:

•	provide clarity about the way forward for primary care out-of-hours services, for example by investing in the development of extended roles for NHS staff to build on work carried out by NES and the SEHD strategy group
•	review the impact of the changes to out-of-hours care on other services, specifically pharmacy, A&E and the ambulance service to inform planning around how out-of-hours services develop in the future
•	ensure data are collected on a consistent basis to allow comparisons over time.
NHS boards should:

•	continue to integrate primary care out-of-hours services with unscheduled care services, so that best use is made of available resources and patients can receive a more joined-up service
•	monitor the implementation of extended roles for staff and GP reprovision rates to support accurate workforce planning for out-of-hours services and to inform service improvement.
Footnotes

1	Partnership for Care: Scotland’s Health White Paper, Scottish Executive, 2003.
2	National Overview Out of Hours, NHS Quality Improvement Scotland, October 2006.
3	The out-of-hours period is from 6.30pm to 8am on weekdays, the whole of weekends, bank and public holidays. Local arrangements may vary. The out-of-hours period may be categorised differently for non-primary care staff.
4	Audit Scotland data, 2007.
5	Out-of-hours: mapping and supporting new roles for practitioners in unscheduled care, NHS Education for Scotland, August 2004.
6	British Medical Association evidence to the House of Commons Health Select Committee’s inquiry into the potential impact of the GP contract on the provision of out-of-hours services, June 2004 (www.bma.org.uk).
7	Delivering the benefits of pay modernisation in the NHS in Scotland, Health Department Letter (2005) 28, 1 July 2005 and Implementing the new GMS contract in Scotland, NHS Scotland, February 2004.
8	We refer to reprovision or reproviding to describe when a GP has opted out of providing out-of-hours care then provides some out-of-hours sessions back to an NHS board for a fee.
9	Our National Health. A plan for action, A plan for change, Scottish Executive, 2001.
10	The Provision of Safe and Effective Primary Medical Services Out-of-Hours, NHS QIS, August 2004.
11	GP Out-of-hours Services Working Group Report, The Scottish Office, 1998.
12	Evaluation of the introduction of NHS 24 in Scotland – final report, David Heaney, Catherine O’Donnell, Anne Wood, Susan Myles, Joanne Abbotts, Gill Haddow, Iain Armstrong, Stephanie Hall and James Munro, December 2005.
13	Evaluation of the introduction of NHS 24 in Scotland – final report, David Heaney, Catherine O’Donnell, Anne Wood, Susan Myles, Joanne Abbotts, Gill Haddow, Iain Armstrong, Stephanie Hall and James Munro, December 2005.
14	Audit Scotland data, 2007.
15	Audit Scotland data, 2007
16	General Medical Services contract, April 2004. 
17	This includes GPs who opt out of providing out-of-hours care for their own practice population and then deliver some out-of-hours sessions back to an NHS board, referred to here as reprovision.
18	Delivering for Health, Scottish Executive, November 2005.
19	Building a Health Service Fit for the Future – A National Framework for Service Change in the NHS in Scotland, Scottish Executive, May 2005 (also known as the Kerr report).
20	Delivering for Health, Scottish Executive, November 2005. 
21	The three core services NHS 24 provides are: nurse-led consultation, aided and enhanced by clinical decision support software; 
referral where appropriate to a range of integrated and interfaced services; health information provided by Health Information Advisers.
22	Annual Report 2004/2005, NHS 24, 2005.
23	Review of NHS 24, NHS 24 Independent Review Team, September 2005.
24	Evaluation of the introduction of NHS 24 in Scotland – final report, David Heaney, Catherine O’Donnell, Anne Wood, Susan Myles, Joanne Abbotts, 
	Gill Haddow, Iain Armstrong, Stephanie Hall and James Munro, December 2005.
25	This represents six per cent of a practice’s global sum. The global sum provides for the delivery of essential and some specific additional services, staff costs and locum reimbursements. It is calculated on the basis of the needs of the population served by the practice regardless of the number of GPs in the practice.
26	The BMA reported that over 80 per cent of doctors would leave the NHS if negotiations were not successful, so there was pressure to reach an agreement.
27	NHS Shetland is not included as this information was not provided by the NHS board.
28	The SEHD allocates each NHS board a budget. Services to patients must be delivered within these funds.
29	Our calculations of additional cost are based on the SEHD assumptions of the cost of the previous system, specifically night visit allowances and payments, amounting to approximately £18 million. 
30	Primary Care Out of Hours, Chief Executives Meeting, August 2005.
31	The Provision of Out of Hours Care in England, National Audit Office, May 2006.
32	NHS Borders, NHS Grampian, NHS Greater Glasgow and Clyde, NHS Highland, NHS Lanarkshire and NHS Shetland.
33	The board’s financial management system is not robust enough to support planning and delivery of services, as the ledger system is outdated and the board relies on a separate spreadsheet system to track out-of-hours expenditure.
34	Rural Scotland key factors 2005: People and communities, services and lifestyles, economy and enterprise, Scottish Executive, September 2005.
35	Scottish Economic Report, Scottish Executive Health Department, 2004.
36	Sessional rates exclude superannuation contributions and where possible NHS boards have excluded national insurance contributions. Hourly rates are not directly comparable across Scotland for several reasons but they are useful to give a broad picture of differences across Scotland. Some NHS boards pay ‘sessional rates’ to GPs who may not be working through the out-of-hours period but instead are on-call or standby, while some other boards that have on-call or stand-by arrangements categorise these rates separately and pay much less. For example, NHS Borders pays a stand-by fee for 4 hours of £75.  Some boards having difficulties covering out-of-hours sessions have also introduced other incentive schemes to encourage GPs back into the service but these incentive payments are over and above the basic sessional rates. For example, NHS Dumfries and Galloway has a bonus scheme.
37	The Provision of Out of Hours Care in England, National Audit Office, May 2006.
38	The Provision of Safe and Effective Primary Medical Services Out-of-Hours, NHS QIS, August 2004.
39	Where boards were directly providing out-of-hours services themselves they were assessed by the NHS QIS review teams. Where NHS boards were contracting with another provider to deliver the service, the NHS board was responsible for carrying out the assessment, in line with the NHS QIS assessment process, and reporting back to NHS QIS.
40	All NHS boards were given a registration status which set out to what extent they had achieved the standards.
41	National Overview; The Provision of Safe and Effective Primary Medical Services Out-of-Hours, NHS QIS, October 2006.
42	‘In-hours’ refers to all services delivered in normal working hours, ie everything that is not delivered in the out-of-hours period.
43	The PMS allocation supports provides which have agreed Primary Medical Services (PMS) contracts with NHS boards. These contracts are locally negotiated and agreed annually between an NHS board and a GP practice. The PMS contract aims to provide primary care professionals with freedom to improve services to patients and shape services to meet the needs of the local population. The PMS contract aims to provide local flexibility with a simplified payment scheme. 
44	Only NHS Shetland had not agreed local performance indicators. However, due to the way the service is provided in Shetland local monitoring of A&E, where most of the primary care out-of-hours activity is handled, is appropriate. 
45	The Provision of Safe and Effective Primary Medical Services Out-of-Hours, NHS QIS, August 2004.
46	Informed to care, Audit Scotland, November 2006.
47	GP Earnings and Expenses, NHS Information Centre, 16 July 2007.
48	GP income based on self-assessment income tax return to HM Revenue and Customs. 
49	NHS Greater Glasgow and Clyde reported that it has successfully filled GP out-of-hours rotas.
50	Workforce data, ISD, February 2006.
51	WTEs adjust headcount staff figures to take account of part-time staff.  
52	Out-of-hours: mapping and supporting new roles for practitioners in unscheduled care, NES, August 2004.
53	Evaluation of the introduction of NHS 24 in Scotland - final report, David Heaney, Catherine O’Donnell, Anne Wood, Susan 
	Myles, Joanne Abbotts, Gill Haddow, Iain Armstrong, Stephanie Hall and James Munro, December 2005.
54	Untriaged calls are calls from patients who have not had their needs assessed or a decision made about any treatment required.
 55	Boards which do re-triage calls once they have been passed to them from NHS 24 are: NHS Borders, NHS Dumfries and Galloway, NHS Fife, NHS Forth Valley, NHS Highland, NHS Grampian, NHS Greater Glasgow and Clyde, NHS Lanarkshire, NHS Lothian and NHS Tayside.
56	Scottish Pharmaceutical General Council (SPGC) Performance Monitoring Survey, June 2005

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