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At the heart of general practice since 1960

Why I have grave doubts about opting out of out-of-hours

Relief from out-of-hours has been the central plank in selling the contract to the profession and most GPs I speak to think it will be the salvation of general practice. I wonder if they are right.

Let me state my position. I am 58 and for 30 years I have worked in a semi-rural practice where first five, then six of us have been on a one-in-five rota for all out-of-hours work. This has been an enormous strain on all of us and I would not willingly go back to spells of emergency duty sandwiched between two normal (busy) days' work.

However, if I were a young GP I would be very careful about embracing the opt-out too enthusiastically, tempting though it seems.

First, I would be concerned about the effect of the opt-out on my pension. Even if the cost is only £6,000-£7,000 per partner, the effect on the pension of GPs opting out cannot be much less than a 10 per cent reduction.

How much better a system where out-of-hours is controlled by the practice (controlling it is not the same as doing it). Now the income becomes part of practice income and is superannuable, even if it is spent immediately on making other arrangements. If a co-operative is used as the provider then any sessions done working for the co-op are also superannuable. Surely this is much more satisfactory.

Second, I feel the profession should be worried at the political implications of giving up control of out-of-hours. Like it or not, the loss of moral high ground must be taken into account. From being responsible for 24-hour care of the population, GPs would now become just one of many people involved in the care of our patients. Others agencies ­ trusts or private providers to name just two ­ could offer to pick off bits of our work. It is not hard to imagine a community trust bidding for 'women's health care' or the community paediatric service bidding for 'children's care'.

There are many people in politics and even in health service management who have never understood primary care and are actually jealous of our standing with the public. Once primary care starts to be broken up who knows where it will end? In my view it will not be long before someone says: 'If a GP is only going to work nine to five, what makes them worth up to £70,000 a year?'

A third thing that worries me ­ and I think it should worry politicians ­ is public opinion. The public has not been consulted about any of these changes, and very profound changes they are too.

GPs may well experience a backlash from the public ­ most unfair of course, but it

could happen.

All the above issues seem so self-evident I am surprised at the apparent lack of awareness of our political representatives at the BMA. The promoting of the opt-out as risk free and without any possibly nasty implications seems to me a bit simple.

In the same way I am surprised at the complete silence, as far as I can hear, of the RCGP. The fact that the shape of our profession is being allowed to change so dramatically with so little discussion amazes me. The narrowing of the focus of the profession under the new contract to recording annually the smoking status of patients seems a far cry from the glories of general practice in the past.

I am concerned that the mad rush of massively stressed GPs to abandon out-of-hours control will lead to profound and as yet unseen changes in our profession, changes that could well be very much for the worse. I personally do not want to opt out.

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