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Out-of-hours needs the local touch

Dr Ozan Adali's experiences working for two contrasting out-of-hours providers have convinced him that 'lean working' is dangerous for patients

Dr Ozan Adali's experiences working for two contrasting out-of-hours providers have convinced him that 'lean working' is dangerous for patients

Gordon Brown apparently plans to step in and save GP out-of-hours services. A tragic critical incident – the death of 41-year-old Penny Cambell from septicaemia – seems to have turned the clock back on the perennial debate over out-of-hours work.

I spend the occasional evening and weekend (not nights now, the staffing levels don't make me comfortable) working for a rather large out-of-hours service provider. My plan is to book shifts whenever I have nothing much better to do, with familiar concerns that my shifts may overrun and eat into my weekends, but the expectation that it will at least pay off this year's holidays.

Lots of doctors and nurses work for this company. It covers huge areas of the country and I might, at any time, be on the phone to a patient 50 miles away. I will never see them, or the doctor who I decide needs to visit them. The computer screen is inundated with calls, showing in a vibrant mixture of red, yellow and white colours, and we are always very busy. Patients wait and wait to hear back and see a doctor.

Saturday afternoon visits routinely run late. Management principles such as 'lean working' and 'maximising efficiency' encapsulate the culture here.The area where I do out-of-hours work is not where I live, nor is it where my practice is. I don't know these patients. I will never have a relationship with them. I will not know what has happened to the Mr X who I sent to casualty at 4am today. I can't even remember his name.

But recently I have had the privilege of working for the out-of-hours service where I live. I have had a lot of difficulty getting my first shift, not because of the rota system, but because the service is so well supported by its local doctors. The service is manned, guarded and protected by a small group of local GPs that have provided an exceptional service to their patients.

Small is beautiful
My plan now is that I will book shifts when I can; my concern is that I won't get many shifts as the local doctors have taken them all. But my expectation is that all of the doctors will know exactly who saw their patient overnight and they had better have done a good job of it. The GPs here also do not know Mr X at 4am – but they certainly know and work closely with his GP at the surgery down the road. They have a relationship by proxy with the patient and an ownership of the situation.

The computer screen has the same colours on it, but far fewer of them. Patients don't wait long to be called, seen or visited. Work is calm and under control. Ideas such as communication encapsulate the culture here.

Money-wise, it is cheaper to run a service at a constantly busy level. But putting efficiency first means patients get a worse deal. If you push a stretched service to its limits, mistakes happen. Doctors do not pay enough attention to the fact that the patient has already called three times with vague symptoms. It's not the flu or gastroenteritis, it's toxic shock syndrome. Mistakes will always happen. This does not mean that we have to push for an environment that is biased towards the potential for tragedy.

The contracts locally are up for renewal. If money and not quality decides who my local out-of-hours service provider will be, patients in my part of the world are going to be in for a huge shock. If Gordon Brown wants to establish a model for out-of-hours care in the UK, he should come and visit us here. Don't send Patricia Hewitt. Size does matter. Small is beautiful.

Dr Ozan Adali is a GP in Edgware, north London

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