1.  The Department of Health (the Department) failed to make clear whether it regarded out-of-hours care as an urgent or unscheduled service. It was therefore difficult for Primary Care Trusts to plan or commission services according to the type and volume of demand for out-of-hours care. The Department needs to decide which kind of service it wants to provide, and give Primary Care Trusts a definitive statement so that they can plan or commission services for the future.

2.  The new contract allowed GPs to opt out of responsibility for the out-of-hours service at an average cost of £6,000, less than half of the cost to the Primary Care Trust of providing the service. This sum was the outcome of a negotiation which was not rigorously conducted by the Department, and which was based on a serious under-estimate of Primary Care Trusts' likely costs. In future negotiations the Department needs to improve value for money for the taxpayer by being a lot better informed on the likely impact of decisions under consideration.

3.  By acting as an 'observer' in the new General Medical Services contract negotiations, the Department was poorly placed to achieve the best outcome for taxpayers. Although the Department ultimately approved the outcome of negotiations, their importance meant that it was not enough for the Department simply to observe the negotiations that were being conducted by the NHS Confederation. To reflect its accountability for the cost, the Department should be a principal in future contract negotiations.

4.  Inadequate performance measurement means that some Primary Care Trusts do not know how good a service they are providing for their patients. Two thirds of Primary Care Trusts taking on out-of-hours services in 2004 found that management information on the service either did not exist or was of poor quality. Primary Care Trusts should report their performance against all of the Quality Requirements.

5.  Quality Requirements relating to access are of most interest to patients, but performance against them is poor. Fewer than half of all Primary Care Trusts are meeting the required standard on measures of speed of access to advice and treatment because of the combination of inadequate performance measurement and poor performance. Primary Care Trusts should improve their performance against all these measures, with priority given to Quality Requirements (9a, 10a, 12a and 12b) relating to emergency and urgent cases. They should, for example, plan out-of-hours staffing levels to match the peaks and troughs of demand.

6.  Primary Care Trusts remain unclear whether they and their providers should aim for 95% or 100% compliance with the Quality Requirements. In order for Primary Care Trusts to know on what basis to commission and performance manage services, the Department needs to make clear what level of compliance is acceptable.

7.  It did not occur to the Department that ending GPs' Saturday morning surgeries would reduce the service at a key time of the week for patients. The Department should encourage Primary Care Trusts to use the contractual arrangements for primary care at their disposal to re-instate Saturday morning surgeries where there is the demand for them.

8.  The £70 million gap between departmental allocations for out-of-hours services and actual expenditure has forced many Primary Care Trusts to incur further deficits or raid other parts of their budgets in order to maintain a safe out-of-hours service for their patients. The Department should rigorously evaluate the financial impacts of proposed initiatives in advance, for example by forecasting the likely impact on pay rates that might be caused by changes in a service, so that they do not unintentionally lead to deficits or adversely affect other services provided by Primary Care Trusts.

9.  Comparisons between Primary Care Trusts suggest that many could reduce their out-of-hours costs without diminishing quality. If every Primary Care Trust provided its service at the same cost as the most cost-effective in their classification £134 million could be saved, while £53 million could be saved if the most expensive 50% of Primary Care Trusts reached the average performance level in each category.[2] The Department should set a timetable for Primary Care Trusts to benchmark their services against their peers, require Strategic Health Authorities to report on their performance, and hold to account Primary Care Trusts whose costs remain seriously out of line.