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Independents' Day

It's time for GPs to take back out-of-hours

We have never been in a stronger position to negotiate a realistic sum to renew our provision of out-of-hours, argues Dr Martin Busk.

It’s Monday morning. The phone begins ringing incessantly when the appointment window opens at 8am sharp. In three minutes of whirling insanity, every appointment has gone and my receptionists are pulling their hair out as they reiterate ‘I’m sorry, we are fully booked. Is it an emergency for today? My computer screen fills up with the names and telephone numbers of the disappointed.

I pick the sheets of paper off the fax machine: messages from the out-of-hours service. Your patient Elspeth Humdinger was seen by a locum doctor out-of-hours, and was admitted to CDU by ambulance with a diagnosis of ‘unwell generally’. Her discharge summary is there as well. Overnight they made the diagnosis of tonsillitis and gave her some antibiotics.

We have made it so difficult for our patients to get to see us that they go to A&E, dial NHS Direct or 111 where (if they manage to get through at all) they are seen by inexperienced anxious doctors who over-treat them because of a fear of litigation, causing havoc in the emergency departments and dissatisfaction to many patients. All of this comes at a great cost to the taxpayer.

But the problem does not end there. Evidence is now emerging that outcomes are worse as well. The obstacles to treatment are causing people to present late with serious pathology and they are doing worse as a result.

The current out-of-hours service is not fit for purpose. This has caused a media backlash and an urgent political necessity to ‘do something about it’.

The pressure of being ‘on-call’

I have been a GP for over 30 years. In the early years I worked a four-in-five rota – yes, really. I worked our out of five nights and four out of five weekends: it was a nightmare.

I slept fitfully, ate my meals embarrassingly quickly, always aware that the phone might ring at any time. Socialising was a rare and somewhat intense experience. My moods varied from irritable to downright diabolical. My wife used to tell me about how the children were doing; I rarely saw them. My health was on a downward spiral along with my marriage and everything else that the modern GP values - never, never again.

The patients were happy, though. They got a doctor they knew at all times of the day or night, this gave them a confidence that made them paradoxically less demanding. I actually got very few calls. It was the pressure of being ‘on call’ that was draining me, as opposed to the work itself.

Any doctor who has even a hint of altruism cannot continue a system that is detrimental to the wellbeing of his/her patients. Two weeks ago at our practice we opened up the appointments system. We now let patients book exactly what they want, as far ahead as they want, although we keep a few appointments for emergencies each day.

My partners and I decided that we would cope with the occasional heavy day where we might need to fit in multiple extras. We had to remove the obstacles to care. It is going OK so far.

Let’s jump - before we’re pushed

How then are we to deal with the out-of-hours system? Going back to individual 24-hour contracts is impossible and I am sure would be illegal.

But I remember clearly a system that worked well. Before the 2004 contract took away our responsibility for out-of-hours care, many GP practices had organised into out-of-hours cooperatives, where the members provided the care on a sessional basis, paid the drivers and the receptionist, rented the building, and supplied the computer systems themselves.

All this was paid for by the GPs who were charged according to their usage of the service. The financial details would not be difficult to work out, and at CCG level it could be ensured that greater funds went to the more disadvantaged areas as these patients make greatest use of the out-of-hours service.

If the Government had valued the OOH service at more than £6,000 when they imposed the 2004 contract, none of us would have opted out.

We have never been in a stronger position to negotiate a realistic sum of money to renew our provision of the out-of-hours service to give the Government and the patients what they want in a way that we can control.

I think we would be wrong to lose this opportunity for it is likely, given the political imperatives detailed above, that something else might be imposed upon us.

Dr Martin Busk is a GP in Woodchurch, Kent

Readers' comments (36)

  • Very valid points, Martin: The current system is extremely unsatisfactory for patients and doctors alike.

    OOH should be organised and provided on a local level: We know the frequent callers, we know the local colleagues, we know local procedures - and we don't have to ask the patient 100 miles away were his nearest Hospital is!

    Local knowledge - local triaging!

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  • if you think we are in a strong situation to negotiate a reasonable amount then you have clearly forgotten the pension changes and recent contract imposition.

    it is more likely that the government would offer more than £6000 but well below the £12,000 to £20,000 per GP a quality OOH would cost to run. The result would be that, yet again, we would find ourselves subsidising the OOH care of our patients. ( in 2003 I was spending £10,000 per year on COOP charges)

    GP's are already responsible for the commissioning of OOH through CCGs. If we want to improve OOH provision, surely that is the mechanism to use rather than entering into risky negotiations with a government that has already shown it is happier imposing than negotiating.

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  • As above. CCG are groups of local GPs commisioning care, including OOH care. Simples. What else do "they" want???

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  • Why are all the appointments booked up. First of all get rid of all the unnecessary QOFS and performance indicators--let patients come to see the doctor when they need to. This will save doctors asking seemingly inane questions to certain patients--just because its got to be done. If general Practice itself was better resourced there it would be possible to offer more appointments. Why has everyone forgotten the Govts. drive to rid the world of single handed and 2 GP practices who used to provide excellent care to their own patients? What about all who called for the bigger the better?

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  • Dear Dr Busk

    I am afraid I completely agree with Julian Spinks and find your argument overly optimistic.

    One fact you failed to mention is that existing GP cooperatives did not simply vanish overnight after the 2004 contract. Many soldiered on but found it increasingly hard to balance the books in the face of ever increasing demand from patients and a rigid finance contract.

    OOH demand has been relentlessly fueled by successive governments and the Kings Fund report highlights the increase in demand for primary care OOH services (i.e. rising walk-in and urgent care centre use) with relatively stable use of genuine A&E emergencies.

    Basically, demand for OOH primary care provision has gone up massively and continues to rise. If OOH was not funded appropriately before 2004 what makes you think it will be now that there are even greater restrictions on the public purse?

    An underfunded system will not be able to pay the staff an appropriate wage for unsociable hours which will lead to a shortage of clinicians. The result?

    GPs will have to work shifts (whether they want to or not) to meet the contractual obligations.

    I think our only real option is to reject this fully now and if that means resigning en masse, so be it.

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  • We are mugs and we never learn. What, I pray, and why is an imposed contract ?

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  • Are you crackers? Look at what your wife and children went through?

    There is NO WAY that I am putting my family through that.

    Frankly the great British Public need to be told an unpalatable home truth - their unreasonable demand is the problem.

    It is time that charging for appintments, and ramped charges for OOH and home visits were instigated. That way I wouldnt have my surgeries filled up with people seeimingly unable to cope with a sniffle for 30 minutes.

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  • Hopelessly naive - I really do dispair.

    This kind of blinkered thinking is exactly why this kind of "contract" will probably go through. And then the govt will tighten the screws for the next 5 years (a la GMS2, QOF, extended hours etc etc) and then we'll be back to where we started.

    It's absolutely shocking that people (GPs) never learn.

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  • If they give us OOH back they can do it without me. I feel like a fascinated bystander, almost ambivalent to what they want to do. My mind is made up.

    If they give OOH back I will resign and in my late 40s with my mortgage paid off a new opportunity awaits - the rest of my life.

    I might emigrate, i might just do international locums and see the world, or I might retire. What I will not do, is work in this servitude.

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  • "Let’s jump - before we’re pushed"

    That statement pretty much sums up your entire philosophy to life.How pathetic When are you going to learn to stand up for yourself?

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