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Out-of-hours: how to cope as GPs opt out

t seems almost unbelievable that one year from now we shall all be able to opt out of 24-hour responsibility. Judging from straw-polls I have taken, the £6,000 buy-out figure is likely to lead to a stampede by GPs. But are primary care organisations (PCOs) ready to take out-of-hours upon themselves?

At present they are not, and with just a year to go, they need to hit the ground running. Out-of-hours services will be their first task and test as commissioners of primary care. That itself will be a challenge at a time when a recent NHS Alliance report showed secondary care commissioning was only just getting off the ground. Their success will depend on four factors.

 · First, PCOs will need the cash and those at the centre, who approve the contract, must ensure PCOs do not end up paying for their generosity. Even a reconfigured service with improved skill mix is likely to cost more than £6,000 per average practice population. We have been running out-of-hours on the cheap for many years, and PCOs need adequate funding for the new order of things, especially in rural areas where costs are higher.

 · Second, this should be an opportunity for trusts to ensure the right skill mix out of hours, but no one really knows yet what that is. Anything has to be better than the current system, where the GP (in my patch) is the only person on call out of hours. This could be the big shake-up involving nurse practitioners, paramedics, community psychiatric nurses and others, which will finally end the tradition that only GPs work through the night, while everyone else is in bed. The challenge for PCOs will be to attract and train the necessary staff and, if necessary, buy back enough GPs at what is likely to be an enhanced rate.

 · Third, PCOs will need to bring all the relevant providers together, and this in itself will be a positive outcome. With luck, that will see parties such as the ambulance service, NHS Direct, walk-in centres, community hospitals and co-operatives providing an integrated service with the local DGH.

 · Finally, PCOs will need to build on existing successful structures. For instance, where there is an effective co-op with suitable medical, managerial and clerical expertise, it might be better to adapt such a system rather than recreate a new one from scratch.

The result in a year's time could be a multitude of different models being launched by PCOs according to their population needs, geography, culture and historical means of provision. There will be co-ops in altered form sometimes spanning several PCOs over a large city. There will be out-of-hours services run by PCOs 'in-house'.

There will be PMS schemes for providing services and some PCOs are likely to sub-contract to the private sector. We may even see the emergence of a completely new animal ­ the equivalent of an Out-of-Hours Services Trust commissioned by the PCO but with operational control delegated to the new organisation.

For us GPs, it will be our first taste of PCO as primary care commissioner. This work will have vast implications for our future role as GPs and the nature of services that future PCOs will want to commission from us 'in hours'. This will be an important time for us to decide where we stand with the local PCO.

On the one hand, we can wash our hands of out-of-hours responsibility, and leave it all to the PCO. On the other hand, we can see the challenge facing our PCO as a challenge facing us too, and a matter for mutual support and co-operation.

Those who approve the contract must ensure PCOs don't end up paying for this generosity ~

Dr Mike Dixon expects a stampede away from 24-hours responsibility ­ the question is, will PCOs be able to cope?

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