Was the out of hours opt-out a mistake?
Professor Roger Jones believes the opt-out from out-of-hours care, along with resistance to extending hours, has left GPs looking lazy and greedy. But the GPC’s Dr David Bailey insists the out-of-hours opt-out was essential, and that it is funding cuts that are responsible for the decline in services
Professor Roger Jones believes the opt-out from out-of-hours care, along with resistance to extending hours, has left GPs looking lazy and greedy. But the GPC's Dr David Bailey insists the out-of-hours opt-out was essential, and that it is funding cuts that are responsible for the decline in services
During the consultation on the new GP contract, in which we withdrew from out-of-hours care, our negotiators presented us with a choice about as difficult to make as being asked whether we would prefer a holiday in Blackpool or Barbados.
No Centre Parcs option, no time-share in Marbella. Black and white, in or out.
In retrospect, this was a mistake. It would have been much better to have provided us with a range of options, tailored to individual GPs and their practices, accompanied by appropriate funding, for continuing to provide personal out-of-hours services.
Instead, in many parts of the country we now have out-of-hours services that are increasingly dislocated from mainstream general practice and often provided by doctors without appropriate training in UK primary care.
There is a strong suggestion that over the last three years, as a result of our retreat from out-of-hours commitments, hospital casualty attendances and patient complaints about calls have risen sharply, amid questions over the adequacy of out-of-hours provision.
The position in which general practice now finds itself is anomalous and unsatisfactory in many ways. Anomalous because of the increasing emphasis placed in hospital medicine on consultant-led services, particularly in A&E, where it is recognised that the sickest patients should be seen by the most skilled doctors, not the most junior.
There are increasing calls for a consultant-led obstetric service and on-call residency for consultants working in this and other high-intensity specialties.
The European Working Time Directive has meant that junior staff in hospitals experience too little acute and emergency medicine to be adequately trained, and this will affect GP training, particularly if the five-year training period proposed in the Tooke Report is implemented.
It is unsatisfactory because the management of acute and urgent care outside the surgery is a valuable training opportunity, which is gradually being lost. Indeed, one of the most important GP skills is the ability to identify the minority of patients with serious disease.
Our diagnostic antennae can only be developed by seeing and dealing with sick patients in difficult circumstances.
Although I don't have evidence for this, it seems very likely that doctors who are inexperienced and unskilled in out-of-hours care are likely to be less skilled in the detection of serious problems presenting in daytime surgeries.
Dislocation of services is also potentially dangerous, because crucial clinical information about patients needs to be passed in a timely and accurate way between the out-of-hours service and the practice.
There is already evidence of failures of communication, and when practices have less personal investment in out-of-hours services, this situation is likely to deteriorate further.
We find ourselves, I believe, in an awkward situation. We are being paid handsomely for providing high-quality chronic disease management and daytime services while turning our backs on the need to continue to provide access to primary care when we have shut up shop.
While I don't believe that all GPs should do out-of-hours throughout their careers, or a busy morning's surgery after a night of broken sleep, I do think that in the early years there are advantages to taking a share in a local out-of-hours rota.
We have already lost ground with our patients, who are our most important advocates, and the profession's recent response to the access issue has
done us no credit. The combination of idleness and avarice is an unattractive one, but it is a caricature we are in danger of deserving.
Professor Roger Jones is professor of general practice at King's College London and a part-time GP
Unusually in a head-to-head debate I find myself agreeing with much of what Professor Jones says – it's his conclusions I disagree with.
It is worth going back briefly to the 2003 contract negotiations and remembering the shared aims of the GPC and the Government.
There were three principal ones:
• to halt the unsustainable spiralling workload in practice caused by the ‘John Wayne' contract
• to reverse years of poor recruitment among young doctors unwilling to accept the perceived workload
• to deliver a pay rise to allow GPs to catch up other comparable professionals.
Two and three have been achieved – though for how long is open to doubt – but the Government seems intent on compromising the first, despite its desperation to achieve a Yes vote in 2004.
In this context, the out-of-hours opt-out was key in persuading the profession that a better work-life balance was possible.
Unfortunately when cash-strapped PCOs tried to replicate the service we gave, it became starkly apparent how far GPs had been personally subsidising the out-of-hours service.
Hospital trusts, used to swallowing 90% of the NHS budget, then complained about the knock-on effects. Evidence, certainly from Wales, has failed to show a speeding up of the underlying increase in A&E work since 2004.
But in any case, no one appears to have tried the simple solution to out-of-hours problems – diverting money from secondary to primary care to fund a first-class service.
Many GPs, myself included, writing about these issues safe in our urban practices, forget they also freed a small hard-working group of doctors from a spiralling personal commitment and a huge recruitment crisis.
Rural doctors were unable for logistical reasons to join the co-operative revolution in the 1990s and were left in many cases to provide 24-hour personal care alone or in small rotas, while coping with an ever more intense in-hours workload.
Their situation was untenable and they would not want to turn back the clock.
Professor Jones's point on training is of course also pertinent and correct – and this is something that I think all sides support.
However, I fail to see how five-year GP training will make it worse.
Unfortunately, in their zeal to save money, many PCOs have not factored in the cost of training when signing contracts with out-of-hours organisations.
Many GPs are still keen to work out of hours and for some the decision not to is based more on the perceived risks of an understaffed service than an unwillingness to engage in acute care sessions. Indeed even now many out-of-hours organisations are unable to accommodate all those who wish to work simply because they are not funded to provide a doctor-led service that is adequately staffed.
Professor Jones is absolutely right that these services, particularly triage, are best provided by the most skilled people available and arranging services where this occurs is mainly a matter of adequate resourcing by PCOs.
It is worth remembering that this is exactly what does happen in general practice by and large and that hospital services are only now catching up.
It's easy to criticise contract negotiations that delivered exactly what they set out to do rather than direct fire on the true cause of poorer services – the unwillingness to properly commission them.
The huge majority of out-of-hours care is still provided by qualified GPs trained and working in the UK and the dilution of medical input is entirely cost-led. The blame for deteriorating out-of-hours services lies fairly and squarely with a Government that undervalues our patients.
Dr David Bailey is chair of GPC WalesCall handler Jones
The combination of idleness and avarice is not an attractive oneBailey
The contract negotiations delivered exactly what they set out to.