Better support and leadership needed for out-of-hours health services

(Title Image: ITV Wales)

Public Accounts Committee
Out-of-hours Primary Care Services (pdf)
Published: 24th July 2019

“We are deeply concerned at the low morale among the staff delivering these services and sympathise hugely with staff who are often working alone and under pressure due to unfilled posts across the country.


“There are examples in Wales of health boards taking a different approach to out-of-hours, often with multi-disciplined teams to share the load and broaden the expertise on offer. We would like to see these examples of best practice shared across the country and urge the Welsh Government to continue its efforts to provide a service which works for staff and patients.”
– Committee Chair, Nick Ramsay AM (Con, Monmouth)

This inquiry was triggered by a report from the Wales Audit Office, which you can read here (pdf).

1. There was a positive impression of out-of-hours services, but there were concerns about “gaming the system”

Despite the gloomy picture, but there was a bit of good news: patients were said to be generally positive about out-of-hours services and one of the main problems was a lack of awareness – though the Committee concluded that patients shouldn’t be blamed for any poor performance of the service itself.

In a slight contradiction, there was a suggestion some patients “game the system” by using out-of-hours services to get around the fact they can’t get an appointment through normal channels. Out-of-hours services are generally only supposed to be used for urgent consultation when a GP or dental surgery is shut.

The 111 service (a merger of NHS Direct and out-of-hours) was said to be a potential benefit to out-of-hours because it would integrate out-of-hours with other healthcare services – but it’s taken far longer to introduce than originally expected and isn’t due to be fully rolled-out until 2021-22.

2. Funding for out-of-hours services has remained static

In 2017-18, £35.8million was spent by the Welsh NHS on out-of-hours primary care services and the British Medical Association (BMA) said this was inadequate and has been for several years. Some health boards increase GP pay rates at short notice to fill shifts, which was said to discourage GPs from signing up for shifts in advance.

The Committee was concerned that funding hasn’t kept pace with service demand, largely remaining the same since 2004-05. They recommended the Welsh Government reviews how it funds out-of-hours services and shares good practice; Aneurin Bevan health board was singled out for praise by focusing more on practical support for GPs (i.e. overnight district nursing services) than pay.

3. Out-of-hours GP and dental services are under pressure and need to be made more attractive to recruit and retain staff

Morale amongst the out-of-hours workforce was said to be poor, with perceptions of under-staffing (caused by lone-working) alongside the antisocial hours and lack of career development. Standards for out-of-hours services were also said to be set artificially higher than daytime practice.

The Welsh Government said it’s been working with health boards to find ways to make out-of-hours services more attractive to staff, but the Royal College of GPs warned that the GP workforce wasn’t growing fast enough to meet demand, while there was no national strategy for out-of-hours services.

Hywel Dda health board introduced changes which improved morale, such as moving staff to new bases. Some health boards said that moving services away from A&E departments could help because co-location encourages walk-in patients to go to A&E instead of the out-of-hours service, while out-of-hours staff often step in to help A&E during busy periods.

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