Letter to the Independent
Dear Sir or Madam,
Like everyone I have great sympathy for all those involved in the Ubani case and I agree with Mary Dejevsky that the current out-of-hours service for patients is nowhere near what it should be, but I am afraid she misses a vital point when she compares GPs to other professionals (Note to GPs: some jobs have to be 24/7, Friday 15 January 2010). As this case highlights, when doctors make mistakes the consequences can be tragic, and a tired doctor is a dangerous doctor.
The current out-of-hours system desperately needs improving, but we can’t go back to where we were before 2004 where doctors were on call 24 hours a day, meaning many were operating in a constantly sleep-deprived state. Ms Dejevsky’s suggestion that we work shifts is not an unreasonable one, but it would make it very difficult for our regular patients, such as the elderly and those with chronic conditions, to see the same GP twice. They tell us, time and time again, that they value continuity of care.
I am afraid I do have to take issue with Ms Dejevsky’s sweeping and unfair generalisation that all GPs work 9 – 5. I have never worked a 9 - 5 day in my surgery and I don’t know any other doctor who has either. All surgeries are open from 8am till 6.30pm, as a minimum, and I (like most GPs) am there from 8 to 8 doing things for patients.
We are where we are now with out-of-hours because right from the start of the new contract many primary care trusts were more concerned with cutting costs rather than ensuring patients got the best quality care. The BMA wants to see primary care trusts commission out-of-hours care with the involvement of local GPs, there also needs to be better investment and more rigorous monitoring, but there must not be a return to the system we had before the new contract. That would just mean replacing the current, poor system with an unsustainable, potentially dangerous one.
Yours faithfully,
Dr Laurence Buckman
Chairman of the BMA’s GPs Committee
BMA House
Letter to the Times
Dear Sir or Madam,
I understand why, as a patient, Libby Purves wants to see a return to ‘the good old days’ when, if you got ill, it was your family doctor who visited you in the early hours of the morning (If you must get ill, make sure it’s before 6pm, Monday 18 January 2010). I also agree that the current system needs changing, however, Ms Purves is viewing the past through rose-tinted glasses. For doctors, being on call twenty four hours a day, seven days a week took its toll; individual GPs were left permanently exhausted and the profession was facing a recruitment crisis. Those nearing retirement were getting out early and those looking to enter general practice were put off when they saw how burnt out they too would become. That is why most family doctors handed over responsibility for out-of-hours care when it was offered them; with the number of out-of-hours calls rising all the time they couldn’t physically do it any more.
The old system meant many doctors were tired and therefore potentially dangerous to patients and it is for that reason that the BMA, and the GPs it represents, would resist a return to doctors taking back personal responsibility for delivering care out-of-hours. However, some sort of middle ground needs to be reached as patients deserve better than they are getting now. The BMA wants to see primary care trusts commissioning out-of-hours care with the involvement of local GPs, better investment and a focus on more rigorous monitoring of out-of-hours services. But we can’t go back to a potentially dangerous old system which would, once again, have an impact on the quality of care patients receive in-hours and was therefore good for no-one.
Yours faithfully,
Dr Laurence Buckman,
Chairman of the BMA’s GPs Committee
British Medical Association
Readers' comments
I am not sure about rose coloured spectacles, but like many practices we had a co-operative between 1996 and 2004 which was disbanded with the new contract. I cannot remember being given any choice when the new contract came in - it would have been financially crazy to continue the GP owned (limited by guarantee) company of the co-operative when that was costing the practice more per month than the money the government wanted to take away for giving up out of hours. You could earn the money back by doing shifts for it. GPs ran the co-op and did the shifts. No locums were used. Sometimes there was difficulty filling shifts, but they always got filled in the end, because responsibility reverted to the practices in extremis. It never happened in the whole 8 years. The basis of this problem is the pricing of the out of hours service before the new contract which meant that HMG could hardly take more money off us for not doing it than we were were already being paid to do it. I would be more than happy to go back the co-op system, where the doctors and nurses knew the local services and each other and there was even a handover for patients causing concern. Is this an old fashioned view to be consigned to the dustbin? It is more expensive than what is currently in place comparing like for like, but if you include the unecessary admissions and A&E visits, it must surely save money and provide a better service in the end. The problem is - more GPs would be needed to do the work in the surgery the day after a night shift, because I for one would never go back to that. With enough GPs rota flexibility would allow a decent sleep after a night shift. PBC groups may be ideally situated in some areas to start this conversation with their local PCT, provided even more money is not taken out of the day time primary care budget to pay for it.
The system in Bedford is near ideal. Based on the pre 2004 Co-op, the PCT commissions BEDOC. Largely staffed by local GPs, it is universally valued by patients and GPs. As elsewhere, bring the weakest up to the standard of the best rather than ritual doctor bashing.
Everyone has forgotten the most important fact that OOH demand has been increasing exponentially In 1988 I did 2 night visits in 3 months but by 1996 when we changed to the deputising service it was normal to have 2 calls a night. The other main factor to remember is that we work much harder these days with modern standards.
Is the current OOH service so desperately bad? If so is this universally so? I doubt it. There were horror stories when GPs were responsible for OOH also. There are horror stories about A&E and secondary care OOH care. Sadly there will always be mistakes and while we should try to reduce these the answer is not to press-gang the already hard-working day/evening GPs into doing the night shift as well - unless, as now, they feel able and choose to. As it is I would argue that we see too many patients in the day shift to provide a really safe service and when our consultations are distracted by the need to tick-box some dubious QOF target or DES requirement safety is further compromised. I wish these points would be more forcibly made by our negotiators.