GPs’ out of hours arrangements are not to blame for pressure on emergency departments, MPs hear

BMJ 2013; 346 doi: (Published 22 May 2013) Cite this as: BMJ 2013;346:f3363
  1. Adrian O’Dowd
  1. 1London

Growing pressure on hospitals’ accident and emergency departments in England have not been directly caused by GPs’ arrangements for out of hours care, experts have told MPs.

Speaking at the parliamentary health select committee on 21 May, expert witnesses said that many factors had contributed to the worrying level of pressure on emergency departments.

The committee, holding the first evidence session of its inquiry into emergency services and emergency care, asked witnesses whether they agreed with the view of the health secretary for England, Jeremy Hunt, that the main reason for rising attendances at emergency departments was changes to the GP contract in 2004 concerning out of hours work.

Mike Farrar, chief executive of the NHS Confederation, which represents organisations that commission and provide NHS services, told the committee, “I would say the evidence of a direct correlation between GP out of hours care contractually being the requirement of GPs and the A&E [accident and emergency department] performance isn’t necessarily proven by statistics.”

After the meeting, Farrar added, “With specific regards to the contractual arrangements for GP out of hours care, we do not see a correlation between the changes to the 2004 GP contract and the NHS four hour waiting standard for A&E departments.

“In fact, for the vast majority of the last decade A&E waiting time standards have been improving. It is in recent years where the pressures have started to bite, and there have not been any discernible structural changes to out of hours GP contracts during that time.”

During the meeting Mike Clancy, president of the College of Emergency Medicine, also giving evidence, said, “The deterioration in performance [in emergency departments] hasn’t corresponded [to] an alteration in the way out of hours has changed. Its contribution to the present problem is not obvious to me.”

Fellow witness Patrick Cadigan, registrar of the Royal College of Physicians, said, “One of the big challenges is out of hours care, and the problem is that A&E is the recognisable brand, and that’s where patients will go because they will see someone who is expert and will see them often within four hours and they will receive treatment.

“Patients will go where the lights are on. In many of the alternatives, the lights are not on after 5 o’clock in the evening or at the weekends.”

MPs asked the witnesses whether they agreed with a recent view put forward by David Prior, chairman of the NHS regulator the Care Quality Commission, that pressure on emergency departments was “unsustainable and out of control.”

Clancy said, “A multitude of factors have led to a deterioration in the performance of type 1 emergency departments [those that aren’t minor injuries units and walk-in centres], which have been under sustained pressure for a long time and have reached the limits of their compensatory capacity.”

Factors included a major imbalance between the workforce and workload, inability of the whole system to meet demand, lack of bed capacity because of high occupancy rates, and overcrowding.

All urgent care services—emergency departments, minor injuries units, and walk-in centres—had seen a 50% rise in attendances between 2001 and 2011, Clancy said, and the latest data from the Department of Health showed that there had been 250 000 more attendances this year than last year.

He added, “There are also a lack of clear alternatives to emergency departments that patients trust and want to use.”

Asked about staffing levels, Clancy said that the NHS did not currently have enough trained emergency physicians.

He said, “Junior doctors are choosing not to do this kind of work. This is difficult, unsociable, intense work, and the fill rate into our higher training programme is half what it was.”

More had to be done, he argued, to tackle that problem and to ensure a better workforce-workload balance, with appropriate remuneration.

The inquiry continues.


Cite this as: BMJ 2013;346:f3363

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