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GPs should provide personal out-of-hours numbers to dying patients as best practice, review suggests

GPs should take on the role of ‘named clinician’ for end-of-life care, and as ‘particularly good practice’ should provide personal contact numbers to dying patients and their relatives to ensure they are reachable out-of-hours, the independent review of the Liverpool Care Pathway has suggested.

The suggestion follows the Government’s announcement earlier this month that a single ‘named clinician’ will be accountable for the care of each older patient with complex health needs at all times when they are out of hospital from April 2014, with the scheme due to be extended to cover all patients in due course.

The review, which recommended yesterday that the Liverpool Care Pathway be phased out within six to 12 months, also called for GPs to be involved in discussions about end-of-life care when patients registered with their practice have no relatives or carers to act as an advocate.

Its main recommendation was that GPs or consultants should take overall responsibility for dying patients, echoing Mr Hunt’s announcement. It said: ‘Patients, their relatives and carers need to know who the senior responsible doctor in their care is. Dying patients must have a named consultant or GP taking overall responsibility for their care.’

It added: ‘In primary care, a patient is now registered with the practice rather than an individual doctor. Some families spoke about the reassurance they had when a GP told them that they were taking clinical responsibility for the care of a dying patient. In some cases, they told us that GPs had provided a telephone number so that they could be reached out of hours in the event of an emergency.

‘The review panel saw this as an example of particularly good practice, and recommends that a named consultant or GP should respectively take overall responsibility for the care of patients who are dying in hospital or the community.’

Dr Dennis Cox, the RCGP representative on the review panel and a GP in Cambridge, told Pulse it was vital that GPs were involved in end-of-life care decisions, particularly where patients had no other advocate. He said that in some cases patients admitted to hospital had been put onto the Liverpool Care Pathway inappropriately because no clinician with a good understanding of the patient’s history and mental state had been involved in the decision.

He said: ‘In those instances – we don’t want the junior doctor to do it, we want the consultant in the charge of their case, when considering whether to put an end of life care plan together, to phone up the GP and talk to them – to say “can you tell me about this patient who’s seriously ill?”, and to get a bit of evidence.’

He added: ‘And if [doctors] say that’s more work for us, then tough. This is what already happens - there are good examples of this.’

The review, chaired by Baroness Neuberger, found widespread failings in how the Liverpool Care Pathway has been used in hospitals and concluded that it should be phased out over the next year.

One key area of concern was accountability for care, with patients, relatives and carers sometimes unaware who the clinician in charge of their care was and when other specialists – particularly members of the palliative care team – would be called in.

But Dr Peter Holden, GPC negotiator, warned GPs were already the named clinicians for dying patients in the community and that it was good practice for hospital consultants to phone up the patient’s GP about potential end-of-life discussions.

‘I may well get a proper phone call from a consultant about a mutual patient who they are thinking about end-of-life care for, and we will have a mature discussion about the history and the pros and cons,’ he said. ‘That’s perfectly normal and proper.’

‘But in terms of giving out phone numbers, that is for each GP to make their own decision. You’ve got to remember there are already arrangements to provide care out of hours. It may not be physically possible to provide that care. It is for each GP to make their own decision on that and each of us has our own views.’

‘If a colleague wishes to do that, that’s within their gift. If a colleague wishes not to, that’s also within their gift and I’m not passing judgement on that. But if they think they’re going to lumber us with that, then that’s not on.’

Readers' comments (33)

  • I have given my phone number to my dying patients for 33 years and hope that when I die my GP will do me the courtesy of givng me their telephone number too.

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  • I'm sorry, these advisors don't live in the real world.

    I already work 50+ hours a week. Some days I hardly see my wife or daughter. And you expect me to be available 24/7 from now on? I know every dying person should have all reasonable effort made to make their passage easier but that does not mean GPs has to sacrifice his life instead.

    In which line of work do you have to be personally available 24/7? I can understand if you are required to provide a suitably qualified cover but to be personally available! It means I can never drink, go to concerts, have intimate moment or even go abroad in case I might be called.

    If this is enforced, I'll resign from general practice and I suspect a lot more people will.

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  • I have been giving my work mobile number to patients needing end of life care since Harmoni took over OOH from our CO-OP. The message is given that if I don't answer (phone is off) then call the usual number. I have a number of colleagues who follow the same procedure. If HMG want to enforce this then the ability to turn the phone off will be lost and I'll have to think about retiring as well.

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  • phone me any day on 55378008

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  • I think quite a few GPs do this voluntarily - I have done so for many years and it is a system that is not abused. However to make it compulsory for all GPs would be unacceptable in my view. We all live different lives and some would simply not find this possible.

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  • Wave goodbye to a life future GPs!

    Don't even think of going away on holiday, out to the cinema, having friends around for a drink, visiting your grandchildren out of area!

    Your patients need you 24/7 and nobody else knows them as well as you do.

    Yes I know this is bollocks and that is yet another reason to retire ASAP !

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  • what about gp's who live far away from their surgeries. and what if they are out or at home having a few drinks - should they really be talking to patients or relatives? or will drinking and having a life / seeing family not be an option in the future nhs for doctors?

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  • I think the intention is to return to the days of an interpractice rota to cover these patients in exactly the same fashion as the vulnerable elderly group.That way the DOH will say they are not expecting individuals to cover 24/7 but the practice,thus suggesting it will be manageable.

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  • as we are opted into OOH cover via a cooperative, I have no intention of giving my mobile number out to patients !! I trust my GP colleagues to look after my patients when they are doing OOH shifts as I do for their patients. The people who make these suggestions need to live in the real world !! and the LCP has unfairly received bad press when we have seen it working well in the community...throwing the baby out with the bath water ??

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  • Levels of work are not the same as they were
    Even 10 years ago ..
    It is now not possible to cover 24/7 ...
    Or it is but nobody wants to pay for it
    Ie to have enormous increase in numbers of staff.
    so as to decrease list sizes to manageable levels.

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  • "I have given my phone number to my dying patients for 33 years and hope that when I die my GP will do me the courtesy of givng me their telephone number too."

    That'll be 111 then.

    Seriously we are of a similar age and experience. I recall what we used to do as GPs in the 80s but when I go home now it is with the practice forgotten. Home is for family, no OOH, no telephone calls, no medicine. Am I bad? My conscience is clear. Day work now precludes night work.

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  • Sadly European working time directives will need to be adhered ( Gp's are only human, not to forget have a family and do not carry patients history on their mental hard disks) and not with 3 phone calls in nights-especially with young children. The way things are there will be no one left to do the luxrious demands of the Government. Drive a BMW at cost of a Polo

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  • Remind me who will see the 40+ patients the day after disturbed sleep and who will pay my additional indemnity costs...........oh me. I dont mind caring for patients but I didn't come into GP for some sort of social punishment

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  • This is clearly nonsense.
    It may be considered 'best practice' but it certainly NOT compulsory.
    If you advise your medical indemnity provider that you are on call 24 hours a day your indemnity costs will soar.

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  • For those who have a moral conscience this should not be an issue.

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  • Anon 6m.

    And what about your moral conscience to family, ensuring you rest etc!

    In particular your moral conscience to the 40+ patients seen next day after being up all night.

    Get back to your Dr Findlay video set and leave the real world to others!

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  • I give my number to those dying or that are seriously ill so I can hear how they are doing. However I do inform them that if the telephone is switched off it means I'm not in a situation to give any advice. I have been here since 730 this morning I have seen more than 45 patients and am about to start an evening surgery and other hour and 10 minutes before going on to a practice meeting. I expect to get home at 1130 tonight and will be on at 730 tomorrow for a full day of duty doctor. I would expect to see 50 or so patients. Did any of them want me to be disturbed overnight? My mobile will be switched off.

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  • Anon @6:34

    Please don't force your idealic dreams onto others. If you wish to have serious work force, rather than a handful of saints, you'd have to realistic. Expecting anyone to be available 24/7, sacrificing any and all private time is not really realistic.

    Have you ever worked in that manner? Do you know of anyone that does? Have you thought how you might feel if you were forced to do this? I doubt you even work 50hrs/week as many GP now days do.

    It's people like you who are destroying the doctor's moral. Thankfully, I still have a few patients who respects NHS and thanks me when they know I've gone above and beyond to help them. Now, that's a vocation!

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  • P.s. you don't actually know what Clare Gerada does outside of her political post of RCGP do you? Google Hurley group practices and you'll understand she's not exactly a kind of GP you turn up and see at a practice.

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  • @above:Have you ever wondered why the public has lost trust and respect for GPs?Why the intense anti-GP vehemence in comments posted on the Daily Mail,Daily Telegraph and even the Guardian?It's because we have started to put our own interests above those of the public whom we had sworn to protect.Now,you seem to imply that that is too high a standard for GPs to aspire too.Well if that's the case its no wonder we're being trounced in the public press as lazy,incompetent fat cats.The lack of morale that you speak of is mainly amongst those GPs for whom general practice was never their primary passion.Those doctors who couldn't progress further in hospital medicine and entered general practice as a fallback option.Clare Gerada should be applauded for suggesting that GPs take back 24/7/365 responsibility.This should be an implied term in the work contract.

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  • Yes I have. It's politically driven.

    If you truly believe GPs 15years ago commanded the respect of the public for the reasons you mentioned, you truly do need to wake up. Why do you think we accepted (and many applauded) the 2004 contract? Because the work load was unbearable then, and we only carried on because we had no choice, not because we believed it was a good thing!

    No wonder we are loosing the public's confidence with pipe smokers like you preaching the greater good, rather than facing the stark reality and making achievable decisions. Why dont you keep on sitting on moral high chair and shout out your delusions - you'll only con the guillible. IF you want to introduce self sacrifice as an essential GP character, go a head. You won't find any applicants from next year!

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  • Never. I will never do any out of hours work again and I will never give my personal number to a patient. The other 7 partners in my practice feel exactly the same.

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  • My wife has just informed me that if I give out my phone number then she will divorce me and take my kids away and live as far away as possible. That should work nicely as then I will have no more distractions and will be able to provide 24/7 care to all my patients and that will be my life. I'll cancel my TV licence and Sky subscription, give away my music collection and DVD collection, cancel my gym membership etc etc as I will have no more use for these things. I will leave in a bedsit as I will only ever sleep there for one or 2 hours a night and will therefore only need cheap accommodation.........

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  • Utter bullshit..are they in cuckoo land ? I Wonder the people who preach are ready to do 24/7 !!! I doubt it.....

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  • Why stop there? We should all go back to the days surgery operates from your house, patients can knock on your door any time for a consultations.

    Actually, why don't we all collect our money, build a big building where we stay and house the most ill patients there so we can look after them 24/7. I might the call the building........... Hospital??

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  • I understand that doctors have to work nights. Why are we expected to work day and night ? I have done over 400 weekends of 80 hours shifts, often with 3-5 hours sleep in the whole weekend and thousands of 32 hour days.
    Altruism is one thing, sleepless torture is quite another,
    Simple question, how many hours in a day is a doctor expected to work , for how years?

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  • Does Dr Gerada do OOH? How many hours does she think a GP should work in 24, how many patients should a GP see in a day?
    Does Dr . Gerada expect GPs to be up at night caring for 5% of patients who give 95% of workload, to work the previous and next day? Does she do thisherself?

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  • Sudheer Surapaneni

    GPs cannot expect to rule out out-of work cover. Every one in the hospital does provide out of hours cover. WHat's so special about GPs?
    But I agree there should be a cap on the amount of the work any GP can do in two weeks period.

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  • Anonymous | 16 July 2013 9:14pm

    Do not feed the troll.

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  • Sudheer surapaneni @2.10 There is ALREADY GP cover out of hours! This is provided by GPs who WANT to do OOH. The only thing keeping me sane is the fact I can relax once I arrive home (usually around 9pm after a day that starts in surgery around 8am) and can spend some time with my family at the weekend. Most of the hospital staff providing OOH cover do not have to work the day shifts before AND after their night duty. You clearly have no idea how primary care works.

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  • Drachula

    I give my number to dying patients. However, I hate being told that I must. This is a personal choice that I make to help people out when OOH are unable to help. I tell patients that I will respond if I can, and there will be times when I am not able to do so. I am rarely called, and the call usually comes once the patient actually has died as relatives prefer their own doctor to pronounce death than someone they do not know.
    Removing the choice makes it much harder to do as patients then have the expectation that you should be on call for them, rather than it being as a back up if all else fails. It is dangerous to do this - what if I have had a drink or two and I am over the limit to drive? What if I have had just one small glass of wine or pimms, or simply have not had a good night's sleep as I have been up caring for others? I could be unsafe to work and should not do so. What would the GMC say if I made a mistake in these situations? Should I never have any time off? Where does it stop? No holiday, no visiting my relatives? A reality check is required here.

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  • Families do abuse this in my own experience. 1yr after a cancer patient died, a family member phoned about his medical problem, out of the blue late one evening on my home number. From then on, I am incredibly selective about this and use a mobile number and give to spouse only with instruction not to share.
    We already delegate the care of all of our patients to OOH who are quite capable of managing palliative care (with special notes emailed to OOH about all our terminal patients)

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  • Sudheer Surapaneni

    Anonymous @8.35pm. But If every doctor has to do out of hours, as that is why we are doctors. We cannot just choose a clinical busy speciality and then come back and say, we do not do it as per the njorm unless some one somewhere decides to do it for financial reasons. it makes the locusm almost rich millionnaires overnight and the country and the NHS belly up in no time.

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