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Exit out-of-hours stage left

Dr Richard Cook

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I am considering hanging up my boots – not from my weekly parade around the hockey pitch, or even my day job, but from the ongoing soap opera of providing out-of-hours care.

I feel like a screen writer must feel with writer’s block, in that the plot seems the same each week and the cast are struggling to make it interesting.

I am not sure how many of our readers regularly perform on the out-of-hours stage, but if our local area is anything to go by, the answer will be ‘not many’. The rota has become more and more difficult to fill as the work has become more intense, the risk of litigation seems to be rising, and many consider the financial rewards to be inadequate to put themselves through the mill on a regular basis. We are faced with a ‘skill mix’ of doctors, paramedic practitioners, urgent care practitioners, advanced nurse practitioners and empty shifts with varying frequency.

In my experience, there is still a huge need and role for doctors on the ground in the out-of-hours setting. In many ways it seems a shame others will miss out on the unique opportunities provided by out-of-hours work, and I have some fond memories that I will cherish. As I sit there each week, trying to sort the wheat from the chaff, and spot the one truly sick patient amongst the cast of thousands, I often reminisce over challenging and rewarding cases. From suicide to childbirth, mania to deep depression, shortness of breath to no breath at all, there is never a dull decade when working out of hours.

There is still a huge need and role for doctors in the out-of-hours setting

Some have even been amusing. One of the most interesting encounters I had was when we were driving back across the city at 3am and came across an unconscious man on a zebra crossing with a bike beside him, a taxi driver standing over him, and a few spectators. It was a bit like one of those riddles that the kids present you with – you know, with an empty room, a pool of water and a discarded wig on the floor, and you have to work out how the hamster escaped.

It all got a bit Monty Python as the passers-by (there were many) started effing and blinding at the taxi driver who it turned out was an innocent bystander and had simply stopped his cab to help.

Whilst waiting for paramedics to arrive, I tried to establish whether the man had suffered a head injury (probably not) or was heavily intoxicated (definitely was). As he slowly came to his, moderately impaired, senses, he started to ‘communicate’. After myself and the paramedics had tried to convince him to attend A&E, he turned to the paramedic and said ‘can you tell him (gesturing at me), to f*£@ off?’. At this point we got back in the car and chuckled off to our next call.

It’s not all fun and games though. The role is vital in our overall cash strapped NHS, but needs experienced clinicians if it is to work properly. If total redesign is on the cards again, then getting rid of NHS 111 and having a single point of access to urgent care seems the obvious option (with effective triage).

With current arrangements, funding levels and working risks, it will be nigh on impossible to attract new cast members, and when the final curtain falls on unfilled rotas it will be too late.

No doubt up and down the country commissioners are looking for ‘locally driven solutions’, and our STPs will have various different plot lines being in development.

Let’s just hope that as the play progresses the audience will not be left with a huge feeling of anti-climax at the ending.

Dr Richard Cook is a GP partner in Hurstpierpoint, West Sussex. You can follow him on Twitter @drmoderate

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Readers' comments (6)

  • Just Your Average Joe

    Sadly - even if out of hours paid all indemnity and double the current hourly rate - the risk and stresses involved will not attract many back to the fold of Out of hours care.

    It is so badly staffed, it makes you laugh, and that was when it is fully staffed! The endless procession of 'private' providers who are all looking to make a quick buck from running the service - are simply pulling out cash, and swapping doctors for allied professionals, and now dipping into unqualified staff reading from protocols on computers.

    They are no longer running a OOH service but instead running it into the ground. It is not all their fault, but the DOH has funded the service so poorly in the past, that reinventing the wheel so many times has led to it falling off.

    111 is the straw that may break in hours primary care - as well as OOH, if they keep pushing the stupidity of letting 111 directly book into surgery appointments - as almost nothing they send my way or to A&E is of concern, and the ones they don't occasionally turn out to be potential disasters.

    Not the fault of the poor operators, but google doc/protocols are no replacement for a GP who knows his a75e from his elbow.

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  • What Now?

    Only ONE GP
    is required at any venue
    so that everyone else will have someone to pass the buck to and scapegoat
    and the service can continue
    Remember the Bawa Garba case
    is it safe for me to be working here
    will staffing be taken into consideration
    should there be an adverse outcome
    No it will not

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  • What Now?

    Sometimes you may be offered "pay and a half"
    Only to realize that you are turning up
    to do the work of two or three
    It should have been double or triple pay
    Do not fall for it

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  • A real worry is that Jeremy will use the collapse of OOH as an excuse to foist responsibility back on to GPs. The current rush to the exit would become a stampede.

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  • David. That genie is well out of the bottle. It would now be impossible to foist it back.

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  • OOH is the canary in the coal mine. So few doctors are now covering they are surrounded by 'Noctors' who see all the easy trivial stuff and the poor doctor is left with the difficult desperate cases likely to cause legal regress. Who in their right mind would want to work as a doctor under these circumstances? Enhanced access Jeremy's pet project will be the final nail in its coffin. They are paying more than OOH (locally £160/hr)to do really mindless simple cases at a rate of 4/hr. This will soak up any available medics prepared to work non core hours making OOH unable to fill empty slots.

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