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At the heart of general practice since 1960

The Department of Health is responsible for out-of-hours care, not GPs

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Here’s Jeremy, in reply to a Labour MP’s question in Parliament on 16 April:

‘The reason why there is so much pressure on A&Es is the disastrous GP contract negotiated by the hon. lady’s party in government, since when - I do knot know whether she was listening to what I said earlier - an additional four million people every year are going to our A&Es. That is what is causing the huge pressure, and that is what we are determined to put right.’

Is he right?

Let’s recap. In 2004, Labour and the BMA negotiated a deal which allowed GPs to opt out of  out-of-hours for £6,000 per year. There was a recruitment crisis in general practice, and GPs at the time said they opted out because of the stress, the exhaustion, and the impact on family life.2

However, many GPs were already working in GP co-operatives which had been set up in order to provide safer working environments, often with drivers to take GPs to patients unable to travel to the surgery, better equipment, and which were organised so that calls could be triaged appropriately.3 The truth is that the demand was unsustainable. The NHS Charter, originally published in 1991, had enshrined patients rights, and reflected the social market which the Conservatives wished to create within the NHS.4 Night calls were no longer about suspected heart attacks or strokes, or care of the dying, but about people who had run out of medication, or people who wanted an opinion on a longstanding rash, or reviews of children with minor viral illness. Demand on this scale did not allow doctors to function safely the following day. Instead, high intensity working required GPs to work in shifts.

So where is the evidence that this change - GPs now working in shifts - represented the cause of the rise in numbers of people presenting to GP?  In 1995, the average practice held 21,204 consultations with patients; by 2006, it was 29,446. By 2008, it was 34,200.5,6 We are not doing less, we are doing more. GPs cannot be blamed for wishing to organise themselves safer to deal with governmentally unchallenged patient demand on out of hours staff.

Nor is it clear that A&E attendances are genuinely increasing. The King’s Fund has produced data showing that attendances in type 1 units - major A&Es - have fallen, but attendances in minor illness and walk in centres have increased.7 As for why A&Es are too busy and why beds remain in
corridors: an RCP report found that bed numbers in the NHS have reduced by a third over the last 25 years; on a background of an aging population, this has to be described as unsustainable.8

Some GP co-operatives have worked extremely well. Many were set up by and run by local GPs who wanted to create a sustainable service. Others have failed; for example, in Cornwall, Serco was contracted to provide out-of-hours from 2006. They were found to have been understaffed, and to
have changed performance data.9 Nor does there seem to be any joined-up policy on behalf of government. When we know that over a third  of A&E attendances are related to alcohol, it is notable (if not tragic) that commitment to alcohol minimal pricing in England was missing from the Queens’ Speech.10

I used to like working in the local GP co-op. Friendly faces, a sense of camaraderie, and a feeling that I was part of a team. But who will want to create profit for a company which cares most for the bottom line and which will cut staffing to save money? Politicians must realise that doctors are working to jump through the endless contract hoops they have created, and feel dismayed by the constant political sniping and degrading of their profession every day. We, as well as our patients, need to be cared for and allowed rest, time with our families, and not to be overburdened. We  cannot do more with less - we can scarcely do what we are currently asked. There is a breaking point.

It is the Department of Health that is responsible for out of hours care, and not GPs. We should not be blamed for what we aren’t responsible for. Neither are our politicians taking responsibility for reducing the disease burden to start with with fair public health law. We cannot go on pouring gallons to pint pots. Most of the time, it is the professionalism of staff which keeps the NHS afloat. Erode that with the current morale-sapping anti-GP media campaign, and we all start to sink.  Tread carefully, Mr Hunt, because the flight of doctors out of partnerships, to Australia, retiring early, or retraining entirely, may be nearer than you think.

Dr Margaret McCartney is a GP in Glasgow

References

1 Hansard. House of Commons, oral answers to questions, health. 16 April 2013. www.publications.parliament.uk/pa/cm201213/cmhansrd/cm130416/debtext/130416-0001.htm

2 Independent. Who’d be a doctor these days? www.independent.co.uk/life-style/whod-be-a-doctor-these-days-1590381.html

3 BMJ. GP cooperatives can improve lives of doctors and care of patients. www.bmj.com/content/314/7085/975.2

4 Farrell C. The Patient’s Charter: a tool for quality improvement? Int J Health Care Qual Assur 12/4/1999 129-134

5 Information Centre. Trends in consultation rates in general practice 1995 to 2006: Analysis of the QRESEARCH database. https://catalogue.ic.nhs.uk/publications/primary-care/general-practice/tren-cons-rate-gene-prac-95-06/tren-cons-rate-gene-prac-95-06-rep.pdf

6 Information Centre. Trends in consultation rates in general practice 1995 to 2008: Analysis of the QResearch database. https://catalogue.ic.nhs.uk/publications/primary-care/general-practice/tren-cons-rate-gene-prac-95-09/tren-cons-rate-gene-prac-95-09-95-08-rep.pdf

7 The King’s Fund. Are accident and emergency attendances increasing? www.kingsfund.org.uk/blog/2013/04/are-accident-and-emergency-attendances-increasing

8 Royal College of Physicians. Hospitals on the edge? The time for action. www.rcplondon.ac.uk/sites/default/files/documents/hospitals-on-the-edge-report.pdf

9 National Audit Office. Memorandum on the provision of the out‑of‑hours GP service in Cornwall www.nao.org.uk/wp-content/uploads/2013/03/Out-of-hours-GP-services-Cornwall-Full-Report.pdf

10 Institute of Alcohol Studies. The impact of Alcohol on the NHS www.ias.org.uk/resources/factsheets/nhs.pdf

(All sites accessed on 21 May 2013)

Readers' comments (31)

  • This article tries to blame the overall increase in patient consultations on patients. Typical!

    In the 1990s, I was never called to the GP practice about my chronic disease. Now I am called twice a year for a tickbox, clinician-centred, QOF-point collection exercise.

    The consultations are of no use to me as I manage my disease in an exemplary fashion in spite of these consultations, however the consultations do serve a financial purpose for clinicians.

    Before blaming patients for their 'unchallenged demand' consider the real reasons for why you call patients in.

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  • good article. unfortunately blaming GP's is a political game with its own agenda and the truth or evidence (or lack of) to support their claims are irrelevant

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  • Anonymous | 21 May 2013 4:17pm - spot on here!

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  • oh gosh sorry ms /mr anonymous - I do not blame patients - I do blame the QOF for as you say, needless trips for many patients - esp patients with two or three conditions. Many people get little benefit - but we are told to do it.
    But out of hours - there are many people who will only call the doctor if they think they are seriously unwell. But many others don't. With walk in centres, NHS 24, 111, the problem is that patients get moved about without continuity and end up with a worse deal. And this has gone unchallenged - rather than the government saying this isn't a good direction of travel- it has been allowed to get worse. I think it makes it even more difficult for people who are very sick out of hours as they have to get through a system where most other people are not as seriously unwell.
    I think everyone loses in the current system, basically

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  • @Anonymous 3.47pm. This is a website and forum for GP's. Why don't you s*d off to the Daily Wail.

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  • Anonymous 3:47pm - you are not called twice a year for a clinician-centred tick-box exercise, you are called twice a year for a DoH-centred tick-box exercise. Believe me, nothing is more depressing for us than having to sit in a room with a patient asking increasingly irrelevant questions that insults both their and my intelligence. Unfortunately, if this does not happen, the practice does not earn any income and will cease to exist (and don't think it's because we're taking all the profits despite what the Daily Mail tells you (who do you think controls their agenda?)).

    An excellent article!

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  • Anonymous, these chronic disease clinics are run by practice nurses or health care assistantss adhering to strict protocols, they don't take any available gp appointments in our surgery,
    The problem is that the definition of an emergency has changed over the years and out of hours care is partly to blame for this, I often get letters rom out of hours for a patient attending after midnight for a minor illness such as a sore throat,
    The problem is there aren't enough appointments in a day to deal with increasing demand due to media driven health drives making the wborried well even more worried.
    I spent. Ten years working full nights and weekends then having to run full surgeries next day, this isn't sustainable for anyone and will lead to a workforce shortage as those who can retire will and other may leave altogether

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  • Mark Struthers

    @ Anonymous | 21 May 2013 3:47pm

    You are spot on here! QOF has made carrot chasing asses out of GPs.

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  • Dear Dr McCartney,
    I have to say that was one of the best written pieces on the out of hours debate that I have seen. It's evidence speaks for itself and the bottom line of the Department of Health being responsible for out of hours care couldn't being any clearer.
    My only wish is for this story to be published in the general press and the televised media to educate the public. However,I get the feeling that the 'politically controlled media' won't let this happen as each successive government seems to have their own personal agenda to fragment and eventually sell off the NHS to 'any qualified provider'.

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  • Vinci Ho

    (1) Truth- Nicholson challenge together with his creator have lost their credibility
    (2) Truth - the so called efficiency saving is just a political sound bite and proved to be a lie. The blind cost cutting has led to the 'crisis' in A/E we are talking about today. In fact , A/E is only tip of the iceberg .
    (3) Truth- our work load is rising because people and hence patients are suffering more under this government 's economic policy. How many more reports we had to write to support our patients' appeals against DWP's decisions . How many more depressed patients we had to see because of job losses , stressful working envirnoment due to cost cutting?
    (4) A person with no virtue occupying a high post spread evils through the most ......Mencius (372-289BC , ancient China)

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