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Stop dilution of out-of-hours care

Our survey on out-of-hours provision provoked a lively debate – here RCGP chair Professor Mayur Lakhani argues GPs must pressure PCTs to end the 'unacceptable' substitution of doctors for nurses

Pulse's recent survey on out-of hours provision (12 April) – showing some PCTs are pursuing a strategy of 'role substitution' by using non-medical staff – set the alarm bells ringing.

I am a strong believer in teamworking and skill-mixing where this is done to support GPs. But replacing GPs completely is unacceptable and wrong; it increases the risks for patients and unfairly exposes non-medical staff.I am angry that GPs are still being blamed unfairly for the state of out-of-hours services and that we are continuing to shoulder responsibility for what is a failure of management by some PCTs.We can remember only too well the difficulties that the decision to opt out of 24-hour contractual responsibility caused the profession and how we agonised as individuals over the issue. Yet to hear the politicians you would think we had completely washed our hands of the system – and of our patients. The fact is that an appreciable proportion of out-of-hours care is still delivered by GPs and GP co-operatives.GPs have proven expertise in delivering urgent care and must continue to exercise a strong influence over those who are conducting triage and providing care out- of hours. It may be tempting to employ other professionals who may be cheaper than GPs but to do so may be a false economy.As experts in urgent care, GPs undertake fewer investigations and have less recourse to high-cost referrals to A&E or ambulance services than other health professionals. They can cope with a high throughput of patients and their efficiency is reflected by a high 'episode completion rate' per contact.

No going back

Assessing patients with undifferentiated urgent care problems requires a high level of clinical skill, experience and judgment. Any attempt to downgrade the role of GPs will lead to further diminution of quality and put pressure on other parts of the NHS – and we only have to read the newspapers to see what catastrophic and sometimes tragic events can result.

We cannot go back to the past. GPs rightly resist all attempts to force a return to contractual responsibility for 24-hour care, which was not a sustainable arrangement. GPs have welcomed the flexibility offered by the opt-out and it has helped GP morale, recruitment and retention.But I am concerned that the issue is proving damaging for the profession and it is important that GPs do not become complacent. Although GP practices are not contractually responsible for out-of-hours work, they should continue to champion optimal care for their patients. GPs and other members of the primary care team should be commended and supported for providing urgent care.PCTs must engage local GPs and recognise their pivotal role in leadership, planning and support for out-of-hours services; this could be achieved by incentivising voluntary GP involvement.Innovative ways of organising care should make it possible for more practices to participate in urgent care work – without the burdens that have occurred in the past.It can be done. There are already shining examples of areas where good-quality urgent care exists, where PCTs are engaging and involving GPs as the proven experts in its provision. But why are they the exception rather than the rule?PCTs must be held to account for the organisation and quality of their out-of-hours services. The RCGP has launched a 10-point plan urging trusts to take speedy and strong action to improve urgent care.Being ill in the middle of night is a frightening experience and patients need to be sure the NHS will be there for them. Access to good-quality urgent care should be the preserve of all, not the lucky few.If some PCTs are managing to get it right, why can't they all?

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