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At the heart of general practice since 1960

Caring for patients when you've opted out of out-of-hours

Opting out need not mean GPs give up a continuous interest in their patients' welfare, says Dr Bob Button

he thing that clinched a Yes vote on the new contract was allowing GPs to abdicate responsibility for the provision of out-of-hours services.

This has led to a rethink of the relationship between GPs and patients. No longer is an individual patient registered with an individual GP but instead with a practice. The decision to opt out of out-of-hours must be that of a practice as a whole.

Some GPs feel the end of their 24-hour relationship with patients strikes at the root of all they have done in their professional lives.

But giving up responsibility for providing out-of-hours care does not mean GPs give up the continuous interest they have in patients' welfare. What it the point in working flat out to benefit patients all week if the GP then allows things to go wrong out-of-hours?

Rather it is now a matter of GPs' out-of-hours input being used discriminatingly and to best effect rather than being a wasteful 'catch-all' facility.

Traditionally GPs had responsibility for providing out-of-hours care because there was no one else to do this. They had no option.

What we are looking at now is a change so that other parties may participate, with GPs being involved as one of a number of elements. The key thing about efficient provision of out-of-hours is determining the patients' real need. GPs refer to this as triage but of course it is much more than merely assessing priorities for treatment.

What GPs are actually doing is determining whether or not care is needed at all during the out-of-hours period. PCOs are finding you cannot run an out-of-hours system that involves no GPs. There are some things that doctors, and only doctors, can do.

What needs to be achieved therefore is a system that involves GP but that uses them as little as possible and as efficiently as possible, reducing their out-of-hours workload.

The PCO taking responsibility means they should be able to weed out patients who do not actually need to see a doctor.

Success of GP co-operatives

The great success story of recent times has been the development of GP co-operatives, but these suffered from having only doctors as the purveyors of care.

But things might change for the better in the future. Joint working between PCOs and co-ops could lead to nurses, paramedics and NHS Direct being used to provide out-of-hours and this would obviously reduce the demand on GPs.

The way to reduce night-time visiting has also been shown by the use of primary care centres where not only GPs but also other professionals can be utilised.

One of the most difficult of the new concepts for many GP to accept is the idea of the walk-in centre. But this in fact is what a surgery was 40 years ago.

The difference now is that it does not always have to be a GP in the building – an alternative person is often able to deal with patient demands – a change for the better!

The key thing therefore is to reduce the GP out-of-hours involvement as much as possible without at the same

time trying to avoid the use of GPs altogether.

GPs are able to work under conditions of extreme uncertainty and still give pragmatic solutions. This is a skill only achieved by virtue of their long training – it cannot be expected from others without a similar level of experience.

Most GPs derive satisfaction from doing something only they can do, and some will also welcome the chance to earn up to £70 an hour for work using these skills. But too much out-of-hours work can reduce

efficiency during the day and the practice may have something to say if day work is influenced such that it compromises practice profit.

Maintaining innovation

To conclude, we must beware of inhibiting innovation. One of the great successes of general practice across all its activities is its ability to make the impossible happen.

Innovation of all sorts has always been something GPs are good at, and this should remain the case.

One of the things the Government – and the PCOs that are their agents – fears is making mistakes during the innovatory period when the new contract is run in. As GPs we are used to innovation.

We must remain involved to give them the confidence and support to continue to look for new ways of delivering care, and not only that needed out-of-hours.

Bob Button is chief executive of Wessex LMCs

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