Main Report of the National Review of Primary Care Out of Hours Services

5 Main Findings

The Views of the Public

The views of the public on primary care out-of hours- services were drawn from several sources. The Health and Care Experience Survey of 2013/14 provides a detailed source of public opinion on health services and care provision:

http://www.gov.scot/Topics/Statistics/Browse/Health/GPPatientExperienceSurvey/Survey1314

The Review also commissioned a specific public engagement process by the Scottish Health Council, based on local discussion groups held in territorial Health Boards areas. Thirdly, the Review received a number of written comments from members of the public following announcement of the Review and subsequent press releases, either in writing or by submission to the Review website/email address. This was advertised by a number of press releases as the Review progressed.

Findings from the Health and Care Experience Survey 2013/14
Patients' overall experience of their care

As for other aspects of NHS care, the majority of patients using OOH services report positive experiences of their care. However, OOH services receive a clearly less positive rating compared to other health services, as covered by the National Patient Survey 2013 -14 (see Table 5.1 below).

Table 5.1

Aspect of Care	% positive
Radiotherapy care and treatment	97%
Maternity Care (labour& birth)	93%
In-patient care and treatment	89%
GP daytime care and treatment	87%
Social care	84%
OOH care and treatment	71%

OOH versus daytime/in-hours general practice care

The aspects of care that those seeking help from OOH services were most positive about were 'being listened to' and things being explained 'in a way that they could understand'. However, these are less positive than the equivalent questions for daytime GP care. Similarly, low scoring questions such as staff having 'all the information required' were less positive for OOH care than for care from a doctor or nurse at their GP practice during daytime hours (see Table 5.2 below).

Table 5.2

Question	% positive
GP care - the doctor listened to me (note: the remainder of GP entries refer to GP daytime care)	95%
OOH - I felt I was listened to	84%
GP - the doctor talked in a way that helped me understand my condition and treatment	90%
OOH - Things were explained to me in a way I could understand	85%
GP - I felt that the doctor had all the information needed to treat me	90%
GP - I felt that the nurse had all the information needed to treat me	93%
OOH - I felt that the person had all the information needed to treat me	74%

Variation in responses

• Patients' OOH experiences varied depending on which service they were ultimately treated by. The least positive overall rating came from patients that ended up being referred to GP practices next day rather than being seen in the OOH period. The Scottish Ambulance Service and paramedic practitioners received the most positive overall rating. A&E services received the least positive scores for OOH time waiting. NHS 24 consistently received the lowest scorers across all OOH questions but was also the service that received the highest demand.
• Those who rated their health as fair or bad as opposed to good reported significantly poorer experience of OOH services.
• Those in large urban areas were more likely to be positive about their OOH care than those in remote and rural locations.

Patient and public areas of concern

Patients were not asked explicitly for suggested improvements. However, they were given the opportunity to provide unguided comments on the care they received. A number of themes came through in these comments, highlighting particular areas of concern.

Waiting: Patients' experience of accessing OOH experience were often characterised by waiting: waiting for NHS 24 call back, waiting for visits and then waiting at a clinic or A&E department if they visited. Often there was a cumulative effect from waiting at different stages. It was also clear from comments that these waits were often anxious.

NHS 24 and repetitive questioning: A considerable number of patients commented on what they felt to be an excessive degree of questioning from NHS 24. Whilst some recognised the need for some form of triaging, many found the questions - by different members of staff at different stages - overly repetitive, arduous and seemingly irrelevant.

Remoteness and rurality: A concern amongst patients, living in these areas, was a sense of distance from OOH services. A number of comments quoted the unsatisfactory length of time needed to access services

Children: As in the comment above, children frequently featured in the stories received through the survey. There were plenty of positive examples recounted by appreciative parents, but it was also clear that parents experienced heightened levels of anxiety around children - more so than for their own health. There was a general expectation that unwell babies and young children should be seen quickly

Practicalities and facilities: There were also a range of comments touching on further practicalities like the location, lack of parking, premium phone call rates and other difficulties in getting transport to OOH care.

GP practice opening times: The survey found that 15% of patients felt that their GP practice opening times were not convenient. Across the survey as a whole (the survey also covers daytime GP care) accessing GP services was the biggest concern for patients.

Negotiating the system: A few comments reported difficulty or dissatisfaction with OOH services as currently set up, while others requested clarity. The main complaint was with 'having' to go through NHS 24 first. This was in light of the criticisms of NHS 24 above, but it was also because patients 'knew' what care they needed or 'just wanted to speak to a doctor'. It seemed an unnecessary step to justify this through NHS 24's questions. Others reported being told-off for seeking medical help at clinics or hospitals directly.

Common themes arising

• Knowledge of who to turn to, what to do in the event of feeling unwell when the doctor's surgery is closed and which service to turn to first
• Experience of using the service
• Comparing the experience with that of using general practice surgery during normal working hours
• Regarding using OOH services, participants were asked whether this was something they would normally go to their GP about and if so why did they not go to a GP during normal working hours?
• From experience of using the OOH service, people were asked if they could offer suggestions on how it could be improved

Findings from Scottish Health Council Engagement Programme

• The Scottish Health Council organised a series of 13 discussion groups (one each health board area in Scotland with the exception of Orkney which had to be cancelled due to local factors) to gather feedback to inform the Review. A total of 112 people took part who considered a number of pre-set questions which aimed to elicit views on their experience of using our of hours services.
• A wide range of feedback has been gathered as a result and a full report be published on the Scottish Health Council's website simultaneously with publication of the Review Report. It is available on the Scottish Health Council website.

Summary of some of the common themes which emerged from the local discussion groups is listed below:

• The feedback does not seem to suggest that there were any significant differences in views or experiences brought about by geography although a couple of issues (such as transport, travelling distances and service awareness of local circumstances/arrangements) were mentioned in most (if not all) rural areas and Island communities. Also and significantly, a number of people who had used the OOH services were very complimentary about the service being provided and of their experience and treatment.

Common themes arising

• Knowledge of who to turn to, what to do in the event of feeling unwell when the doctor's surgery is closed and which service to turn to first
• Experience of using the service
• Comparing the experience with that of using general practice surgery during normal working hours
• Regarding using OOH services, participants were asked whether this was something they would normally go to their GP about and if so why did they not go to a GP during normal working hours?
• From experience of using the OOH service, people were asked if they could offer suggestions on how it could be improved

Based on the feedback received from the 13 public discussion groups, the Scottish Health Council offered five specific recommendations in their summary report:

• Shared records: Although there have been some efforts to move to a system where patients' medical records can be shared across all services, this continues to be an issue that causes great frustration and dissatisfaction with users and carers. Therefore efforts need to be redoubled to ensure real progress is made.
• Locality awareness: There needs to be increased awareness of NHS 24 about local geography and care locations, so that patients are not unnecessarily travelling long distances when accessing OOH centres.
• Better access for people with specific needs: Improve access and address barriers to using OOH services (NHS 24, in particular) for people with sensory impairments, people from ethnic backgrounds, people whose first language is not English, older people and those with dementia - and generally people with support needs, their carers and relatives.
• Better understanding of how best to access and use services: Implement a sustained, longer term programme of awareness raising across Scotland to include how people should access OOH services and for what purposes. This programme should address patient expectations and include all sources of out of OOH support, including third sector agencies.
• A commitment to a seamless service with regular evaluation: Sufficient resources and priority should be dedicated to ensure that seamless OOH services are being provided for all patients, their families and carers. Regular evaluation of patients' experience of OOH services is recommended which would include measuring public confidence in any new models of service provision.

The Views of Professionals

The views of health and social care professionals working in OOH services were taken account of in a number of ways. Firstly, the structure and process of the Review itself was inclusive and designed to capture as wide a perspective as possible. Views and opinions were captured during visits to Board areas, NHS Special Boards, at Officer Groups and meetings, in workshops, and at a national consultation event. Secondly, the Review sought contributions from specific professional groups and organisations. Thirdly, as for public views, professional views were sought in writing or electronically, via the Review website: http://www.gov.scot/Topics/Health/Services/nrpcooh

Formal submissions received from:

• Jointly, the Royal College of General Practitioners, Scotland and the Scottish General Practitioners' Committee (SGPC) of the British Medical Association, together with separate letters from each organisation.
• The Chief Nursing Officer, endorsed by the Scottish Executive Nurse Directors (SEND) and the Royal College of Nursing
• Jointly, Community Pharmacy Scotland, the NHS Scotland Directors of Pharmacy and the Royal Pharmaceutical Society, Scotland
• The National Allied Health Professions Advisory Committee
• The National Out of Hours Operations Group
• The Scottish Social Services Council
• Social Care, on behalf of the independent sector
• Chief Officers of Integrated Joint Boards

In addition:

A report on the role of the third sector in OOH services was commissioned and is available on the Review website.

The above formal submissions and reports are archived in full on the Review website.

Extracts from these documents, including recommendations and principles offered are summarised in Annex D.

NHS Health Scotland submitted a document regarding addressing health inequalities in the context of OOH Services and is summarised in Annex E. The full version of the document is available on the Review website.

To complement these submissions and activities the international literature review of OOH services and GP focus group qualitative research, which was commissioned from the Scottish School of Primary Care (report produced, which is summarised in Annex F and available in full on the Review website) provided additional evidence.

As part of the engagement programme, NHS 24, the Scottish Ambulance Service, NHS Education Scotland, NHS National Services Scotland and Healthcare Improvement Scotland all offered contributions to the Review, regarding their potential contributions to OOH Services, going forward.

Scottish Ambulance Service Paramedics