Quelles solutions pour la garde en médecine générale? - KCE

104
8.4.2. After-hhours
care in Thhe
United Kingdo om
Items
Expert(s) interviewwed
- Quality Caree
Commission: Jo Williams,
Cynthia Bower. . Email: enquiries@cqqc.org.uk
The Care Quuality
Commission (CQ QC) is the independennt
regulator of all healtth
and adult social care
in England. They innspect
all health and aadult
social care serviices
in England, wwhether
they are provided
by the NHS, locall
authorities, private coompanies
or voluntaryy
organizations. Beforee
1 April 2009, this woork
was carried out by the
Healthcare CCommission,
the Menta al Health Act Commisssion
and the Commisssion
for Social Care Innspection.
Sean Boyle ( S.Boyle@lse.ac.uk)
Literature base
National and international publications
on the topic of aftter-hours
care in the UUK.
Characteristics off
the
health system with
relevance to out oof
hours services—
relevant data on aafter-
hours care
Situation before
reform
Drivers for systemm
reform on after-hoours
care
Affter-Hours
Primaary
Care
Results
KCE Reportss
171
Health care inn
England is provided to all residents througgh
the National Healthh
Service (NHS), includding
hospital and physsician
services and prrescription
drugs.
Health care iss
largely free at the po oint of use.
The NHS acccounts
for 87 percent of total health expenditure.
It is funded byy
general taxation (76% %), national insurancee
contributions (18%) , user charges (3%), and
other sourcess
of income (3%)
Health care sspending
per capita: 2.199
EUR. About one of 10 residents has supplementary
private insurance covering chhoice
of specialist andd
faster access to elecctive
surgery.
Eighty percennt
of the NHS budget t is controlled by 152 primary care trusts ( PCTs), which contracct
with physicians andd
hospitals to provide care to a geographiccally
defined population.
General pracctitioners
(n= 40 000) are mainly self-emplooyed
and operate undder
an annual nationaal
contract with a primmary
care trust. GPs aare
paid directly by PCCTs
through a commbination
of salary, ca apitation, and fee-for-sservice.
The 2004 GPP
contract introduced a comprehensive payy-for-performance
inittiative,
providing subsstantial
financial incentives
tied to achievemment
of clinical and otther
performance targets.
Since 2009, a proportion of the income
of GPs is conditioonal
on quality and innnovation.
After-hours services
have more inf formation and measurees
being routinely reported
than any other aarea
of primary care.
Around sevenn
million patients contact
GP after-hours services
in England each
year.
Since mid-19990s:
After-hours pprovision
was delegate ed to a third party (GP co-operatives or the pprivate
sector).
Apart from prroviding
after-hours th hemselves, GPs could join a practice rota orr
area cooperative, unnder
which they could pool their responsibiliity
through a rota system.
In addition GPs
could employ a co ommercial deputizing sservice.
These trends helped reduce the sccale
of GPs’ personal involvement, but personal
responsibility for the
service remained
unpopular among g GPs, particularly ammong
the growing numbers
of female GPs.
It was possibble
to contract out one e’s after-hourscare duuty,
depending on the type organization thaat
the GP joined. For eexample,
a GP belonging
to a large urban cooperative
couuld
give the revenue fr rom night house calls to the co-operative orr
pay a subscription to the co-operative (a non-profit-making
bodyy
managed by local GPPs).
The subscripption
could then be red distributed to the docttors
taking the rota duuty.
Thus it was possible
to pay to avoid woorking
after-hours. It wwas
also possible to ttake
more on-call sessions to increase one’s o income. The co-operative
could change
the subscription raates
and the price of roota
duty (raising fees in
the case of unattracctive
rotas) in ordeer
to balance supply an nd demand, and mostt
practices sought to reecover
their contributioons.
There was not
much information on overall quality, costs
or outcomes of aafter-hours
care provission.
There was aneccdotal
evidence that the
quality of care varied
considerably between different pro ovider types and different
geographical areaas,
and in early 2000, a rising number of coomplaints
and negativee
reports in the media led
to raise conceerns
about after-hours s services.
The existing model for after-hours care was considered iinefficient
by GPs andd
the government.
Main drivers from the GP perspective:
Dissatisfactioon
with workload during
out of hours period in GPs
Desire for separation
of work and private p life
Growing demmand
for services by th he public
Non-urgent innterventions
during ou ut of hours period
Complaints frrom
rural doctors abou ut workload and disprooportionately
low renuumeration
in comparisoon
with urban doctors
Lack of persoonnel
and logistic supp port