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It's time for GPs to take back out-of-hours

We have never been in a stronger position to negotiate a realistic sum to renew our provision of out-of-hours, argues Dr Martin Busk.

It’s Monday morning. The phone begins ringing incessantly when the appointment window opens at 8am sharp. In three minutes of whirling insanity, every appointment has gone and my receptionists are pulling their hair out as they reiterate ‘I’m sorry, we are fully booked. Is it an emergency for today? My computer screen fills up with the names and telephone numbers of the disappointed.

I pick the sheets of paper off the fax machine: messages from the out-of-hours service. Your patient Elspeth Humdinger was seen by a locum doctor out-of-hours, and was admitted to CDU by ambulance with a diagnosis of ‘unwell generally’. Her discharge summary is there as well. Overnight they made the diagnosis of tonsillitis and gave her some antibiotics.

We have made it so difficult for our patients to get to see us that they go to A&E, dial NHS Direct or 111 where (if they manage to get through at all) they are seen by inexperienced anxious doctors who over-treat them because of a fear of litigation, causing havoc in the emergency departments and dissatisfaction to many patients. All of this comes at a great cost to the taxpayer.

But the problem does not end there. Evidence is now emerging that outcomes are worse as well. The obstacles to treatment are causing people to present late with serious pathology and they are doing worse as a result.

The current out-of-hours service is not fit for purpose. This has caused a media backlash and an urgent political necessity to ‘do something about it’.

The pressure of being ‘on-call’

I have been a GP for over 30 years. In the early years I worked a four-in-five rota – yes, really. I worked our out of five nights and four out of five weekends: it was a nightmare.

I slept fitfully, ate my meals embarrassingly quickly, always aware that the phone might ring at any time. Socialising was a rare and somewhat intense experience. My moods varied from irritable to downright diabolical. My wife used to tell me about how the children were doing; I rarely saw them. My health was on a downward spiral along with my marriage and everything else that the modern GP values - never, never again.

The patients were happy, though. They got a doctor they knew at all times of the day or night, this gave them a confidence that made them paradoxically less demanding. I actually got very few calls. It was the pressure of being ‘on call’ that was draining me, as opposed to the work itself.

Any doctor who has even a hint of altruism cannot continue a system that is detrimental to the wellbeing of his/her patients. Two weeks ago at our practice we opened up the appointments system. We now let patients book exactly what they want, as far ahead as they want, although we keep a few appointments for emergencies each day.

My partners and I decided that we would cope with the occasional heavy day where we might need to fit in multiple extras. We had to remove the obstacles to care. It is going OK so far.

Let’s jump - before we’re pushed

How then are we to deal with the out-of-hours system? Going back to individual 24-hour contracts is impossible and I am sure would be illegal.

But I remember clearly a system that worked well. Before the 2004 contract took away our responsibility for out-of-hours care, many GP practices had organised into out-of-hours cooperatives, where the members provided the care on a sessional basis, paid the drivers and the receptionist, rented the building, and supplied the computer systems themselves.

All this was paid for by the GPs who were charged according to their usage of the service. The financial details would not be difficult to work out, and at CCG level it could be ensured that greater funds went to the more disadvantaged areas as these patients make greatest use of the out-of-hours service.

If the Government had valued the OOH service at more than £6,000 when they imposed the 2004 contract, none of us would have opted out.

We have never been in a stronger position to negotiate a realistic sum of money to renew our provision of the out-of-hours service to give the Government and the patients what they want in a way that we can control.

I think we would be wrong to lose this opportunity for it is likely, given the political imperatives detailed above, that something else might be imposed upon us.

Dr Martin Busk is a GP in Woodchurch, Kent

Readers' comments (36)

  • The problem is that demand is so great in the week that I already have to go in on weekends to do the admin stuff I can't do at other times. What Dr Busk is proposing is little short of serfdom. This will only exacerbate the brewing recruitment crisis as you would only need to loose a small percentage of the workforce to create serious systemic problems. The solution lies in pushing out of hours work into the daytime by properly funding general practice.

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  • no it isn't martin

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  • It isn't about money Martin it's about the fact that most GP's can't take on anymore. I also went through the bad old days of excessive hours but what you have to realise is that by accepting responsibility back at a practice level means we are he last port of call. I would respectfully guess you might be at he tail end of your professional life and I find I fascinating that folk that are close to or have retired suddenly become interested in agreeing to things that will primarily affect the generations to come. Ask a younger practitioner who's pension has just been sliced how he or she feels about ou of hours -- they are the future not you or I. Patients might go to a and e where you are because they can't get an appt but they don't where I work where in keeping with many areas we have a good responsible out of hours service staffed chiefly by local gp's.
    It s ve clear at he recent LMC conference that there was overwhelming rejection of what you are proposing by he profession. If the govnment chooses to impose it they have been clearly warned what he potential outcome might be

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  • "My partners and I decided that we would cope with the occasional heavy day where we might need to fit in multiple extras. We had to remove the obstacles to care. It is going OK so far...... In three minutes of whirling insanity, every appointment has gone and my receptionists are pulling their hair out".

    Well if this is "OK" you ideas on OOH must be great!

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  • Martin
    I thought you had already retired, but clearly not so far! I am sure that you will do so soon, do we really want to leave our successors on call, even if there will be enough GPs to do it!
    Your local colleague
    Robert Cullen , Romney Marsh

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  • 3 years to retirement for me - or less if GPs such as the saintly Dr Busk have their way.
    It nearly killed me once (or rather OOH nearly drove me to suicide). Never again.
    A 57 year old GP.

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  • Oh dear, why do people lok at their past with rose tinted glasses. The demand has changed, population has changed, the attitude to general practice has changed. If I was contactable 24/7, I'm sure that is exactly what will happen. I already have patients telling me they are my pay master as a tax payer and I should do what they want - do you honestly believe these people will care about doctor patient relationship or the fact you've already worked 48 hours with almost no rest?

    I'm not old enough to have done 24hour on calls as GP but I have done it as junior grade in hospital and I'm sure it's no less exhorsting to sleep for 4 hours/day and work for 20 hours with only one hot meal in that time in primary care setting. I could do it aged 28, I won't manage it now.

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  • My work was quoted in the divorce petition of my first marriage as a major factor.
    This goverment or any other will not pay the market rate for OOH cover - it is naive to think otherwise.
    When I talk to patients I point out that they can see me at 7 in the morning or 7 at night but not at 3 o clock in the morning without exception they are ok about that.
    I have no problem working in a rota Saturdays and Sundays but never ever at night again

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  • Martin
    I have always supported OOH and continued to do it post 2004 , so I was a 24/7 GP that would come in at short notice to save the day and never asked for a penny more than the going rate , but it came at a huge personal cost to me , hence I now severely restrict my availability and would not encourage anyone to do what I did . Please remember that if you do OOH you are classified as a high risk doctor and will pay your MDO a surplus for the priiveledge to see your patient after 1830 . You are at risk of increase adverse outcome simply because you see a lot more patient in a set up that you do not control . The concern I feel by most GP's is that the second we take back responsibility , funding for OOH will be slashed and GP partners will need to fund the rest , please bear in mind that the work force coming into the profession is salaried and locums, I don't blame them , I would do the same , but they only take money out , don't put any money in , and if you think OOH is a crisis , wait till premises funding comes to the front of the line .premises are heavily in debt to pay off outgoing partners like yourself making repayment crippling for the remaining few , some practices are beginning to buckle under pressure and OOH cost will crash some of them I'm sure

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  • The problem is not between us and the government. Anyone who knows me will know that I have no respect for politicians their ideas or their thinking. I am certainly capable of standing up for myself and thinking outside the box
    It is between us and the patients that we have taken on the responsibility to care for, It is about responding to real evidence that shows outcomes are worsening, I accept no blame for this, but think we need to find some solutions.
    What is happening at the moment is doing nobody any favours.

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