The past weeks have seen massive attacks upon general practice. Inspired by a Secretary of State peddling dodgy statistics, and the Undersecretary of State making questionable commentson the Today programme, the campaign intended to turn public opinion against GPs for their supposed failure to provide out of hours services. Of course, GPs know this is rubbish: over 40% of us are still involved in providing out-of-hours services, a not dissimilar level to our involvement pre-2004.
For 20 years there has been an incessant leftward shift of care pushing more complex elderly patients out of long-stay geriatric wards into inadequately staffed residential and nursing homes with the consequent medical responsibility passing unresourced onto GPs. This has been done in pursuit of the mantra ‘Care closer to home’ as well as a cost-efficient NHS - both laudable aims, but both delivered on the backs of general practice without new resource.
British general practice is resourced on an insurance-based contract with the assumption that patients would not consult more than 5.3 times per annum and twice in a lifetime out-of-hours. GPs know this is an outdated assumption, and if politicians are determined to constrain the NHS, then they must explain this to the public clearly.
Politicians have egged on the public (for reasons of electoral advantage) to believe that they can have whatever they want, free at the point of use upon demand 24/7. This is undeliverable. Where else can you see a fully-trained senior professional for at any hour of the day or night, without putting your hand in your pocket? Politicians must grasp the nettle and cease misleading the public.
Of course, in an ideal world, this is what GPs would seek to deliver, but the reality is we live in a resource constrained world where, even if we had the money, we do not have the clinical workforce to cover the type of 24/7 demand that the public have a for routine medical services.
The public must understand that the NHS has survived to meet patient needs (as opposed to wants) because NHS staff have been prepared to go the extra mile through dedication in the interest of patient needs. GPs cannot deliver that level of service unresourced merely to deliver patient desires.
An urgent need for integrated care
Much of the problem in emergency departments is an outflow problem, namely that there are no beds available. Patients requiring admission then have to access hospital services via emergency departments, rather than by direct admission to a ward. GPs are acutely aware that, for many elderly patients, a tiny change in their condition can be sufficient to prevent them living at home independently. Frequently such patients need nursing rather than medical care and a ‘low-tech’ admission to either a community hospital or to a social services bed. The volume of social services beds is simply not geared up to the number of elderly people in the community.
Successful out-of-hours care requires an integrated, unified single organisation providing call-handling including 111, out-of-hours medical services, district nursing services, community hospitals out-of-hours provision all in a totally integrated manner.
It would be operated ideally by a not-for-profit social enterprise, where the ethical motive drives the best outcome with the consequences being a lower than average hospital admission rate, a higher than average admission avoidance rate, and higher than average number of people dying in their own home when terminally ill. Such systems exist successfully in Derbyshire and Hertfordshire to name but two areas.
Last Friday, the Conference of Local Medical Committees reaffirmed its policy that GPs would not under any circumstances take back responsibility for provision of out-of-hours services. Furthermore they reaffirmed the GPC policy that 111 providers must be also providers of face-to-face out-of-hours primary care to the public so that they have to take direct responsibility for their 111 decisions.
It is not difficult to see why these policies exist and there is no chance of GPs, returning to the public’s ‘Dr Finlay’ perception of out-of-hours as providers of last resort. GPs know from bitter experience that the Government will break promises, drive up demand, and reduce resources available to the one professionwhere work-life balance seems not to matter in the eyes of the rest of society.
It is time we took a much more integrated, social enterprise-based approach to out-of-hospital out-of-hours care.
Peter Holden is the GPC negotiator with responsibility for urgent emergency and unscheduled care, and a GP in Matlock, Derbyshire.
