Quality standards for deputising servicesBMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6969.1630 (Published 17 December 1994) Cite this as: BMJ 1994;309:1630
- David Cragg,
- Lesley Hallam
- Department of General Practice and Centre for Primary Care Research, University of Manchester, Rusholme Health Centre, Manchester M14 5NP, lecturer in general practice, research fellow.
- Correspondence to: Dr Cragg.
- Accepted 22 November 1994
New proposals for remunerating general practitioners for out of hours services seem likely to reverse the decline in the use of deputising services that followed the introduction in 1990 of two rates of fees for night visits. In 1989, 46% of night visits were undertaken by deputies.1 By 1993 only 34% of night visits attracted the lower fee paid for calls made by deputies or those in a cooperative service.2
Guidelines covering the use and operation of deputising services have existed since 1984. They give family health services authorities the duty of ensuring that “out of hours care in general practice, however it is provided, be of no less standard than that provided in hours.”3 We investigated the standards set by authorities, how they were monitored, and their relevance to current developments.
Method and results
Data on the operation of deputising services and the participation of family health services authorities in recruiting staff and in setting and monitoring standards were collected during a telephone survey of authorities' knowledge of current provision of out of hours care.2 Results are based on the responses of the 81 authorities in England and Wales that had one or more deputising services within their area of responsibility. Sixteen had no service, and one did not participate.
Almost all authorities required that general practitioners should notify them if they intended to use a service, but few (21) routinely collected data on the timing and extent of use. Limits on use were imposed by 66 authorities, 61 of which monitored compliance by randomly checking the fee claims for night visits. Limits predominantly specified maximum call rates per 1000 patients per month and ranged from six to 50. There was some restriction on periods of cover, but this was rarely onerous—for example, services could not be used every night or every weekend. Monitored use was well below the limits set.
The extent and nature of liaison between authorities and deputising services varied, and was complicated by arrangements between authorities about services across boundaries. Fifty seven authorities reported that they had or shared a designated liaison officer; 44 reported that they had an active deputising services subcommittee; 42 produced an annual report; and 68 were represented at regular meetings with deputising service managers.
Participation in the recruitment of deputies was widespread. Sixty authorities interviewed and appointed candidates, and the minimum standard for applicants set by 28 authorities exceeded current guidelines. In a further 12 cases the authority's participation was considered to be unnecessary as almost all the deputies were registered principals.
Although a large proportion of authorities reported setting and monitoring performance standards (table), for many such standards related only to response time to calls. Exceptionally, six authorities had produced detailed service specifications, and the degree of compliance with them governed reaccreditation.
The 1984 guidelines have been selectively implemented. Not all authorities have active deputising services subcommittees. Although most have accepted responsibility for monitoring deputising services, initiatives vary from collecting data on limited aspects of activity to producing and implementing detailed service specifications. Restrictions on use are not as rigorous as was originally intended. Permitted levels are rarely reached and will not prohibit general practitioners from using deputising services in the light of changes in remuneration. Indeed, some authorities argued that the value of limiting access to a high standard, well monitored service was questionable.
Although concerns remain about the quality of care given by deputising services,4 deputies are now doctors with at least six months' experience of general practice rather than hospital doctors.5 Monitoring activities are generally sufficient to identify and correct obvious examples of poor response times. The setting and monitoring of more comprehensive standards should take priority, with authorities who have given it a high profile acting as models for those who have not.