Focus on out of hours - BMA guidance note

Definition of out of hours
The out-of-hours period is from 6.30pm to 8.00am on weekdays, the whole of weekends, Bank Holidays and public holidays. [paragraph 2.18 contract document]

Transfer of responsibility
· Out of hours will be the responsibility of the individual GP until April 2004
· Between 1 April 2004 and 31 December 2004, practices can opt-out of out-of-hours where this is part of the PCO strategy.
· From 31 December 2004, PCOs will take full responsibility for making sure there is effective out-of-hours provision:
"PCOs will be required to have a contingency plan in place which can be put into immediate operation should an out-of-hours provider fail. The default option will lie with the PCOs, not practices as is currently the case." [Paragraph 2.22 contract documentation]

The PCO will not be able to transfer the out-of-hours responsibility back to GPs who have opted out, if the PCO has any problems providing or commissioning the services.

Opting out of out of hours
- Practices that do not want to have responsibility for out-of-hours, can opt out of providing the service from 31 December 2004 (or before 31 December if the PCO has put arrangements to allow this). The PCO will not have a veto on this. If you want to opt out from 31 December 2004, you can do this without the approval of the PCO. The only exception to this is those practices in very remote or isolated areas (see below).

- Practices currently providing out-of-hours services can continue providing those services if they want to provide them.

- PCOs will be able to consider a range of alternative providers for out of hours:
"PCOs will be able to consider a range of alternative provision for out of hours, for example, NHS Direct/24, NHS walk-in centres where available, GP co-operatives, partnerships between practices, paramedics, GPs and primary care nurses in A&E departments, community nursing teams and commercial deputising services." [paragraph 2.21 contract document]

- Accreditation standards will be developed and will be mandatory once in place. The ability to continue providing services will be dependent on meeting these standards. This work will be part of the implementation negotiations and further information and guidance will be produced. Individual GP practices and informal rotas of practices in England currently do not need to be accredited against the Carson requirements.

- Any practice that opts out of out of hours will not automatically be entitled to provide the service if they want to move back at a later date. Practices that opt out or new practices that want to provide out-of-hours services "will be considered alongside other potential providers" [paragraph 2.19 contract document]. All potential providers will have to show that they meet the accreditation standards.

- Opting out will not be possible on an individual doctor basis. As we move to a practice-based contract, the opt-out will be on a practice basis only. How a practice makes that decision will be subject to the arrangements in their partnership agreement.

- The new arrangements for out of hours won't prevent practices being able to offer surgeries or consultations during the out-of-hours period, nor would it prevent PCOs commissioning an out-of-hours service with longer hours of operation:

	- PCOs can pay for this as an enhanced service at the request of the practice
	- where the PCO asks the practice to open at any time during the out-of-hours period, the PCO must pay for this as an enhanced service
	- where the PCO does not agree to pay for this as an enhanced service, it will be paid for out of the practice's global sum.

 
The cost of opting out
The global sum calculation includes the cost of providing out-of-hours services.

Where a practice opts out, a UK-wide sum per practice as been agreed for 2004/05. This sum will be subject to the practice weighted population formula for each practice and works out at 6% of the global sum, or on average £6000 per doctor in a practice with an average weighted population. [paragraph 2.25 contract document]

This amount was negotiated to provide a realistic opportunity for those practices that want to opt out, and to allow those that chose not to opt out, not to lose out compared to their current earnings.

The money 'released' by those practices that opt out will be available to the PCO to provide out-of-hours services. The Out-of-Hours Development Fund will continue to be available to PCOs.

PMS practices are also entitled to opt out of out of hours. We understand that the same arrangements that apply to GMS practices will apply to PMS and that the calculation of the cost of opt-out will be on the same basis. All PMS practices should be given a Carr-Hill index in order that they can make this calculation.

Those who can't opt out
Practices in particularly remote and isolated areas may not be able to opt out of the provision of out of hours. This should only happen in exceptional circumstances and it is anticipated that very few practices will be unable to opt out. The categorisation of practices that fall into this group can only be determined locally. This should be done by agreement between the LMC and the PCO.

Practices in remote and isolated areas should discuss their options with their LMC and PCO, before giving any indication to the PCO about whether they intend to opt out.

Practices that cannot opt out "will be supported by the Out-of-Hours Development Fund" [para 4.23 (iii) contract documentation].

Paragraph 48 of the contract supporting information for Scotland sets out the arrangements that will apply to those few practices in the most isolated areas of Scotland, where after local determination and any appeal process, the opt out is not possible:

- the retention of the out-of-hours abatement
- payment of the weighted capitation share of the Out-of-Hours Development Fund and any increased investment by the NHS Boards for providing out-of-hours services
- an additional payment to cover any differential between the total of these and the locally determined premium payable to salaried GMS practitioners for providing out-of-hours services
 
The supporting documentation for Scotland can be found on the BMA website.

Practices and LMCs
We recognise that many LMCs will already have begun work on out of hours in preparation for the new contract. Some suggestions are set out here.

- PCOs will be responsible for planning provision of an effective out-of-hours service and should be considering this now. We suggest that practices consider now whether they want to continue to provide out-of-hours services or whether they want to opt out, and should give the PCO an indication as soon as possible about whether they are considering opting out. A final notice does not have to be given at this stage. There is no deadline but the earlier the PCO has an indication about what provision will be needed in their areas the better they will be able to plan ahead

- We have suggested that LMCs survey practices asking them whether they will be providing enhanced services. The same survey could cover whether practices plan to opt out of out of hours

- Fewer practices will be providing out-of-hours services in the new contract world. This is an opportunity for PCOs and for co-ops to review and consider the services they are providing and planning new ways of providing these services. Examples of innovative out-of-hours schemes are attached at annex 1. These can also be found in the contract supporting documentation

- LMCs could consider now working with the PCO to ensure that any service commissioned by the PCO will be of equal or improved standard to current out-of-hours services, and comprehensive enough to prevent increasing amounts of work cascading back to practices in hours

- LMCs could also consider what advice they can give to the PCO to commission the services, looking at earlier implementation times, and considering add-on services covering half days, protected learning time and home visiting services.

Annex 1- Innovative out-of-hours schemes