Buckman bites back over out-of-hours care

By Steve Nowottny

GPC chair Dr Laurence Buckman has issued a robust response to mounting criticism over out-of-hours care, warning that giving back personal responsibility for its delivery to GPs would be ‘dangerous to patients.'

An inquest into the death of a patient given a fatal overdose by German locum GP Dr Daniel Ubani has prompted a storm of negative coverage in recent days, with two highly critical columns in the Independent and in the Times, and renewed calls from Conservative health spokesman Andrew Lansley for GPs to be ‘collectively responsible' for out-of-hours care.

Independent columnist Mary Dejevsky chided GPs for working ‘office hours', and questioned whether ‘those who effectively clock on at 9am and off at 5pm really deserve the status the rest of us reserve for committed professionals.'

‘It is surely no coincidence that as GPs have fled out-of-hours working, more and more people have resorted to A&E departments,' she wrote on Friday. ‘If the NHS wants to improve A&E, it should start by demanding more of GPs.'

But in a letter to the Times, which has yet to be published, and the Independent, published today, Dr Buckman insisted he had ‘never worked a 9-5 day' and strongly defended the decision of most GPs to opt out of responsibility for out-of-care.

‘The current out-of-hours sytem desperately needs improving, but we can't go back to where we were before 2004 where doctors were on call 24 hours a day, meaning many were operating in a constantly sleep-deprived state,' he wrote.

‘We are where we are now with out-of-hours because right from the start of the new contract many primary care trusts were more concerned with cutting costs rather than ensuring patients go the best quality care.'

‘The BMA wants to see primary care trusts commission out-of-hours care with the involvement of local GPs. There also needs to be better investment and more rigorous monitoring, but there must not be a return to the system we had before the new contract.'

‘That would just mean replacing the current, poor system with a potentially dangerous one.'

In the wake of the Ubani case the Conservatives have reiterated their pledge to hand back overall responsibility for out-of-hours care to GPs.

Mr Lansley said: ‘When Labour took responsibility for out-of-hours care away from GPs they made a serious error.'

GPs ‘are best placed to ensure patients are treated properly and that these awful events are never repeated again,' he added.

Dr Michael Dixon, chairman of the NHS Alliance, has also entered the fray, insisting that GPs are best placed to deliver OOH care.

'Recent cases have highlighted the importance of local responsibility for out-of-hours services, ideally manned by local doctors and nurses, who are familiar with their communities and the services that support them,' he said.

Letter to the Independent

Dear Sir or Madam,

Like everyone I have great sympathy for all those involved in the Ubani case and I agree with Mary Dejevsky that the current out-of-hours service for patients is nowhere near what it should be, but I am afraid she misses a vital point when she compares GPs to other professionals (Note to GPs: some jobs have to be 24/7, Friday 15 January 2010). As this case highlights, when doctors make mistakes the consequences can be tragic, and a tired doctor is a dangerous doctor.

The current out-of-hours system desperately needs improving, but we can't go back to where we were before 2004 where doctors were on call 24 hours a day, meaning many were operating in a constantly sleep-deprived state. Ms Dejevsky's suggestion that we work shifts is not an unreasonable one, but it would make it very difficult for our regular patients, such as the elderly and those with chronic conditions, to see the same GP twice. They tell us, time and time again, that they value continuity of care.

I am afraid I do have to take issue with Ms Dejevsky's sweeping and unfair generalisation that all GPs work 9 – 5. I have never worked a 9 - 5 day in my surgery and I don't know any other doctor who has either. All surgeries are open from 8am till 6.30pm, as a minimum, and I (like most GPs) am there from 8 to 8 doing things for patients.

We are where we are now with out-of-hours because right from the start of the new contract many primary care trusts were more concerned with cutting costs rather than ensuring patients got the best quality care. The BMA wants to see primary care trusts commission out-of-hours care with the involvement of local GPs, there also needs to be better investment and more rigorous monitoring, but there must not be a return to the system we had before the new contract. That would just mean replacing the current, poor system with an unsustainable, potentially dangerous one.

Yours faithfully,

Dr Laurence Buckman
Chairman of the BMA's GPs Committee
BMA House

Letter to the Times

Dear Sir or Madam,

I understand why, as a patient, Libby Purves wants to see a return to ‘the good old days' when, if you got ill, it was your family doctor who visited you in the early hours of the morning (If you must get ill, make sure it's before 6pm, Monday 18 January 2010). I also agree that the current system needs changing, however, Ms Purves is viewing the past through rose-tinted glasses. For doctors, being on call twenty four hours a day, seven days a week took its toll; individual GPs were left permanently exhausted and the profession was facing a recruitment crisis. Those nearing retirement were getting out early and those looking to enter general practice were put off when they saw how burnt out they too would become. That is why most family doctors handed over responsibility for out-of-hours care when it was offered them; with the number of out-of-hours calls rising all the time they couldn't physically do it any more.

The old system meant many doctors were tired and therefore potentially dangerous to patients and it is for that reason that the BMA, and the GPs it represents, would resist a return to doctors taking back personal responsibility for delivering care out-of-hours. However, some sort of middle ground needs to be reached as patients deserve better than they are getting now. The BMA wants to see primary care trusts commissioning out-of-hours care with the involvement of local GPs, better investment and a focus on more rigorous monitoring of out-of-hours services. But we can't go back to a potentially dangerous old system which would, once again, have an impact on the quality of care patients receive in-hours and was therefore good for no-one.

Yours faithfully,

Dr Laurence Buckman,
Chairman of the BMA's GPs Committee
British Medical Association