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Should GPs take back out-of-hours?

It's a fact that the best out-of-hours services are GP-led and it's time for GPs to take responsibility for them everywhere, says Dr Krishna Korlipara - but Dr David Lloyd says the out-of-hours opt-out came at the right time

It's a fact that the best out-of-hours services are GP-led and it's time for GPs to take responsibility for them everywhere, says Dr Krishna Korlipara - but Dr David Lloyd says the out-of-hours opt-out came at the right time


When the new contract started, some PCTs continued to delegate responsibility to GP-led organisations whereas others took over the control and started providing services in-house. As commissioners they are invariably driven by the Government agenda, but as providers they should be expected to put patients first. The way in which patients' needs can be compromised is illustrated by what happened in my area.

The first GP co-operative in the UK, which evolved into Collaborative Medical Services (CMEDS), provided care from a building at the heart of the town. But now it has become one of the latest casualties of a PCT takeover and the services have been moved to the edge of town.

Here a large polyclinic has been built - well ahead of Lord Darzi's grand designs - to accommodate several doctors, nurses, physiotherapists, dentists, pharmacy and a few other community-based clinics. It is one of seven polyclinics or supercentres built in the town - at a cost of £64m - by private developers whose income is guaranteed by long leases stretching over 20 to 25 years.

The fact is, large numbers of patients who live at the other end of the town can't easily get to the place - especially at night when there may not be even public transport available. It is well nigh impossible for the elderly and the infirm to get there without help from their neighbours or family members. Many of these vulnerable elderly patients living alone at home are unable to travel to a centre far away, and their lives must be at risk if they can't get to the doctor in a time of need. For some it must be too late to wait to see their own doctor the next morning.

It's ironic that this Government, while talking about improving access, is presiding over a policy of opening new medical centres inaccessible to most patients.

I am not surprised at all to read in last week's Pulse that not-for-profit out-of-hours care organisations led by GPs have been found to fare better than profit-making organisations or PCT-led services.

By their very nature, not-for-profit organisations led by GPs will always provide the highest standards of care, because they are driven by the motive of serving the local population, rather than by the need to make profit.

They achieve their goal of excellence of standards by the maximum participation of local GPs, who know the area and the local needs well, without having to rely too much on locum doctors who make their career by working at different places through the week.

Services organised by PCTs are driven more by the need to save costs and often achieve their 'success rates' by employing other healthcare workers like nurses and healthcare assistants who do not have the experience or the skill of doctors, with their many years of training.

In effect, many PCT organisations with no previous experience of providing out-of-hours care directly are putting their financial goals ahead of the needs of the patients.

The only way to remedy the situation and regain the trust of the public is to hand back the responsibility for out-of-hours care to GPs.

Even though not all GPs may want to work out of hours, I am sure most of them would be willing to take back the responsibility for commissioning out-of-hours care, which can then be delivered by a collaborative organisation owned and run by the GPs collectively. Those who agree to work out-of-hours shifts will be rewarded handsomely for their contribution outside their normal working hours, but all GPs will be the shareholders of the organisation and could be involved in providing their advice and expertise whenever necessary.

Dr Krishna Korlipara is a GP in Bolton, Lancashire, and founded the now-defunct National Association of GP Co-operatives


The first advantage of the opt-out is that the performance of out-of-hours care is now detailed and transparent in a way it never was before. But it has also unearthed the unmet primary care needs of our patients.

Boundaries between primary and secondary care are breaking down, which means that out-of-hours services now tend to involve a much wider team of clinicians.

Another major advantage of the new system is that commissioning against national standards, with regular retendering, drives improvement and cost-effectiveness. And let's not forget that GPs who opted out can conserve their energy for daytime work.

In my 30-year career I have seen things come and go. I joined a practice that subcontracted its work to a private out-of-hours provider. The quality was so bad that we went back to providing our own service. For the next 16 years I was on call one night in four and one weekend in four.

By the 1990s we were worn out. At my first GP co-operative conference, co-op pioneer Dr Mark Reynolds encapsulated the problem with a simple graph. We were dealing with the same amount of illness but hugely increased demand and worry - and he called it the 'triage gap'.

GP co-operatives saved many of us from early burnout. Where I work in Harrow, north-west London, we had to entice GPs back to working out of hours by training our practice nurses to triage using decision-support software. It was all new and exciting, but it was without standards and it needed someone like Dr David Carson - director of the Primary Care Foundation - to set some benchmarks.

And just when we thought it was sorted, along came the huge burden of dealing with chronic diseases - now renamed 'long-term conditions'.

During my working day I endlessly balance complex treatment regimes in some very ill and very old patients. I've no time for the worried well or minor illnesses.

Different skills are needed for out-of-hours work - it's usually one acute problem and emotions usually run high. Don't get me wrong - both jobs are equally challenging, but day by day they become more different. The teams are different too. Telephone skills are at a premium out of hours, whereas an ability to persuade recalcitrant patients to change their behaviour is a must in the daytime.

We need to be 'boundroids' in out-of-hours, working across boundaries with other emergency services to make sure the sickest get to the right bit of the system and the least sick don't clog it up.

The jobs are now different and the opt-out came at the right moment. There is now a natural split between daytime practice and out-of-hours.

The turmoil of the past year or two has highlighted the need for strong commissioning and out-of-hours is one of the areas that will benefit first from 'world-class commissioning'. National standards give us something to be measured against and the regular retendering of services helps to improve care and contain costs. By all means, shift the commissioning back to GPs in their PBC role if they can do it, but the days of the co-operatives are over.

Larger, leaner, hungrier organisations that can integrate unscheduled care are the flavour of the month.

No, the opt-out was a good thing and saved general practice - for a bit, anyway.

Dr David Lloyd is a GP in Harrow, north-west London, and joint medical director of private provider Harmoni

Should GPs take back out-of-hours? yes quote

GPs are motivated by serving the local population rather than making profit

'no' quote

There is a natural split between daytime practice and out-of-hours

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