In the first week of May the National Audit Office (NAO) published a report on out of hours care provided by primary care trusts (PCTs) in England.¹ You may have missed the story in the media; it came at the time of local government elections, a cabinet reshuffle, and Rooney’s metatarsal. Media reports described the service as a shambles.

In 2004 about 90% of PCTs in England became responsible for providing night and weekend cover as general practitioners (GPs) gave up an area of practice they had been responsible and accountable for since the dawn of the National Health Service. The NAO report measures the performance of the new system against several quality targets. Among other results, only 2% of services answered a phone call from the public within 60 seconds; only 8% of urgent cases were assessed within 20 minutes; only 15% of emergency face-to-face consultations at a health centre occurred within 1 hour; 21% of emergency and 13% of urgent consultations at home occurred within 1 hour and 2 hours, respectively; and only 39% of general practices received details of any out of hours consultations by 8 am the “next” day. Patient satisfaction surveys are reasonable tools to assess service quality. One in five of the public said that the care they received was poor. Another crude marker of quality comes from the Medical Defence Union. Complaints against the new service were up by 66%.

The NAO also reports on finances; the bottom line is that the budget was short by £70 million. There is a superficial geographical analysis. Rural PCTs had higher costs per head and were less likely to put the contracts for the new business out to tender. There is an important broadside; data recording was patchy with only about half of PCTs having any information to audit. With such inconsistent data the NAO comments that it is difficult to be sure that patient safety has not been compromised.

If a hospital trust or emergency department had failed to record data (as did half of the PCTs), we know the consequences. If a hospital trust or emergency department had failed to meet the agreed quality targets, we know the consequences.

No mention is made of the impact of these changes on workload for emergency departments. The report says zthat there has been some (but limited) integration with A&E departments [sic] and describes specific examples; there is an indirect recommendation that further planning and commissioning of services with A&E [sic] is needed.

Experienced emergency physicians, who know their local community and patterns of clinical activity, will have anecdotal or documented evidence of the impact that the restructure has had on their own department. Some consultants who are clinical leaders will have been (or still are) members of local committees briefed to set up and contract for out of hours services or find a means to integrate with the local emergency department. If it eventually works out that integration with emergency department services is a pragmatic solution to the problems of providing out of hours care then so be it. Careful and intelligent negotiation will be critical.

The findings in the NAO report will reinforce a hunch of some people, namely that these immense and complex organisational changes have been managed poorly. Naive, inexperienced, and floundering leadership will be the views of some. Optimists and spin doctors will say that the restructure has been reasonably successful considering its complexity and that it is still work in progress.

It is glib and facile to say that the reasons for this reorganisation stem from the new GP contract. If a sentinel or adverse events committee in a hospital trust was to investigate the poor performance of the PCTs it would complete a root cause analysis. For those of you who are interested I recommend reading NHS, plc by Professor Allyson Pollock.² It’s a salutary experience.