Out-of-hours services in the UK have been fragile for a number of years. So it came as no surprise when the BMA declared last month that GP staffing for these services in Wales had reached ‘crisis point’ after continued announcements of weekend out-of-hours services being cancelled.
The problems have been growing in other parts of the UK as well. At the end of last year, the sudden collapse of a private out-of-hours provider in Birmingham exposed the potentially severe consequences.
GPs were left in the lurch when Primecare, part of the troubled Allied Healthcare group, gave just 10 days’ notice to more than 20 practices for which it directly provided out-of-hours cover that it would be ceasing its services.
GP-led cooperative the Badger Group came to the rescue, taking over the contract less than a week later.
But while the financial problems appeared solved, the group was quick to point out the greatest threat to out-of-hours services remained – staffing: ‘Altogether we are taking on 270,000 extra patients… and that’s right before Christmas. We have no additional clinical workforce to do it’.
In the face of ongoing wider GP shortages, a Pulse investigation reveals gaps in GP out-of-hours cover are getting worse in the hardest-hit regions.
As a result of the risk and reduced staffing, I am personally no longer willing to work in triage
Dr Alan Woodall
At the same time, the number of serious incidents recorded by providers has risen by more than a quarter in the space of a year. Some GPs have told Pulse the resultant pressures mean they are unwilling to work out of hours in certain roles because of the risks involved.
Pulse’s findings – which include responses to freedom of information (FOI) requests from 79 CCGs and health boards – reveal that six regions, including three in Wales, reported occasions in 2018 where there was no GP to cover out of hours.
Understaffing is becoming worse: the total number of shifts with no GP available rose from 57 in 2017 to 146 last year.
And it is likely to be even more; some commissioners who have previously acknowledged problems provided no data, such as NHS Greater Glasgow and Clyde, which had c losed out-of-hours centres on more than 100 occasions in the 12 months to May 2018.
In Pulse’s latest investigation, based on the CCGs and health boards that did respond, Hywel Dda, which covers 384,000 patients, fared worst – with 125 occasions in 2018 with no GP cover, up from 42 the year before (see table, below).
The figures could be far higher, as the board only started collecting data halfway through 2017 – and, until November 2018, limited collection of data to instances of closure at weekends.
The board’s director of operations and deputy chief executive Joe Teape says GP shortages are a ‘familiar trend across the country.’ He says the health board is using paramedics and advanced nurse practitioners to support the service.
Abertawe Bro Morgannwg University Health Board and Aneurin Bevan University Health Board also struggled to fill GP shifts on a number of occasions in 2018, as well as the year before.
Dr Alan Woodall, chair of GP Survival and a GP in Montgomery, blames staffing problems and lower rates of pay. He says some staff are also refusing to work out of hours due to the risks for patients.
He says: ‘Wales, in general, pays GPs poorly in terms of out-of-hours rates, and given locums are in demand and can earn more in the day for less risky work, people are no longer willing to do it.’
There’s a GP in Blackpool giving advice to a patient in Doncaster
Dr Dean Eggitt
In England, two CCGs reported struggling to fill out-of-hours shifts in 2018: Tower Hamlets in east London, serving 331,000 patients, experienced the problem three times in 2018, and North East Lincolnshire, which covers 169,000 patients, had two instances last year.
In Scotland, one health board – NHS Borders, which has a population of 115,020 – responded with figures showing the problem is worsening. Across 2016 and 2017 it had only two occasions of no GP cover; this figure rose to eight in 2018.
An NHS Borders spokesperson says: ‘On each occasion GP support was available by telephone for the nurse practitioner team and any patient requiring face-to-face medical consultation was seen by the Borders General Hospital medical team.’
The health board says more nurse practitioners are being recruited and different shift patterns being offered to help deal with GP rota gaps.
But former BMA GP Committee urgent care lead, Derbyshire GP Dr Peter Holden, who regularly works out-of-hours shifts, says greater reliance on other healthcare professionals to plug gaps only increases safety risks.
He says: ‘What people forget is that a fully trained GP has… knowledge, skills and expertise that gives the margin of safety when you are doing general practice.
‘I think this is where the public are being conned.’
Other regions are also restricting services rather than risk having no GP cover. Pulse reported earlier this year that a plan to reduce the amount of GP cover out-of-hours in Fife was being extended by six months owing to GP and nurse shortages.
Dr Woodall says: ‘Generally one can see across most services a reduction in the use of experienced staff, as GPs are considered too expensive. There are closures or reduced opening times, and increasing vacancies on rotas, creating more pressure on those remaining.’
At Urgent Health UK, we encourage colleagues to bring serious incidents so the learning can be spread out
Dr Simon Abrams
He adds: ‘As a result of the risk and reduced staffing, I am personally no longer willing to work in triage for my local out-of-hours service in Shropshire. I restrict myself to work where I can see patients directly.’
Doncaster LMC medical secretary Dr Dean Eggitt adds: ‘I know they struggle so much for GP cover that they will get someone from Blackpool to cover because we don’t have anybody in Doncaster. There’s a GP in Blackpool giving advice to a patient in Doncaster.
Another factor in the shortage of out-of-hours GPs is in-hours workload.
Liverpool GP Dr Simon Abrams chairs Urgent Health UK, which represents out-of-hours providers. He says: ‘We’re in a national recruitment crisis. If you’ve got a day job there’s a lot of pressure that makes being available to do out-of-hours even less likely than it used to be.’
GPs’ patient safety concerns about the effects of a lack of GP cover are justified. Pulse’s investigation also found a rising number of serious incidents reported by providers between 2017 and 2018.
Data provided by 109 CCGs and health boards across the UK to FOI requests show 108 serious incidents were reported across 44 CCGs in 2018, against 84 serious incidents in 2017 – an increase of more than a quarter.
These stretched resources have an effect on in-hours care, too. Dr Eggitt says: ‘It’s had a huge impact on our day workplan… When it comes to weekends or a bank holiday, it’s a crisis, not just a problem.’
He adds: ‘It is not just Monday morning. I would say this is a seven-day a week problem. Even coming to work on a Tuesday morning, the patients who needed help on Monday night didn’t get help.’
However, Dr Abrams suggests the increase in serious incidents in out of hours may also reflect a greater willingness to report problems.
‘We’ve become more safety conscious. At Urgent Health UK, we encourage colleagues to bring serious incidents so the learning can be spread out,’ he says.
But the reality is official reports – and previous Pulse investigations– have long warned about the problems. A CQC review of urgent and out-of-hours primary care providers in 2018 found ‘a growing risk’ due to ‘the value of contracts not reflecting the true costs of delivering them’.
It said recruitment was ‘often difficult as urgent care work is intense… and rates of pay cannot compete with the private sector’.
But for GPs, the problem comes back to the fundamental undersupply of family doctors – while the NHS continues to promise an increasingly ambitious service.
Dr Holden concludes: ‘We have fewer GPs now than 10 years ago, and we’re trying to do more in the day and to give the public a 24-hour service – it doesn’t add up. It is pandering to demand.’