GP and Labour MP for Stroud Dr Simon Opher on the disintegration of the GP role in out-of-hours services, and how the profession could take back control
GP out-of-hours (OOH) services have become something of an enigma. They are still funded by ICBs across the country but have become increasingly fragmented and illusory. Where do GP OOH services sit in the urgent care pathway? How do they relate to 111, to MIU to A&E departments and ambulance services – and does this need to change?
I am a doctor who has worked as both a GP and trainer in Dursley, a small but diverse market town in Gloucestershire, for about 30 years. In July last year I was elected as the Labour MP for our constituency, Stroud. One of my main reasons for getting involved in the dirty game of politics was the decimation of GP services in the last 14 years, and the state of the NHS overall.
I need to emphasise that I have no direct control or any special knowledge about the thinking of the Department of Health and Social Care. Being a back bencher is a bit like being a new houseman: you think you are going to be all-controlling, but the reality is that you have very little say at all.
Wes Streeting says that he wants to get care more firmly based in the community. Broadly I agree, but we should be clear about what he actually means, especially regarding urgent and OOH care.
Firstly, a few facts and figures. In 2004 the Labour Government gave GPs a new contract which allowed them to opt out of OOH care. It cost GPs £6,000 at the time but almost all GPs that I know took the hit on income to clear themselves of the commitment. For 14 years I worked in OOH, mostly on a one in 10 rota. We worked all day in surgery and then all night with a bleep, and at that time a huge mobile phone – a genuine brick that didn’t work very well. We all hated it, but patients got an amazing service; they were one call away from speaking to a GP.
Since 2004, medical admissions have increased by 50%. GPs are only involved in 20% of these admissions, and it is no surprise that the removal of a vast slice of primary care experience has led to acute services (A&E, ambulances, etc.), becoming overwhelmed. We spend some £9bn on these admissions and many could be prevented.
There is no way that I would wish the OOH component back on to GP contracts. It was one of the best days of my life when the OOH rota was removed. However, looking at how we manage acute care in the NHS, it is clear this change has been a disaster. I genuinely believe that the then-government didn’t understand what we did and the consequences of the changes they made.
And it clearly hasn’t worked.
How can a 111 call handler with six weeks training and an algorithm replace a fully trained GP? How can, for example, paramedics make subtle decisions about a 90-year-old with heart failure, atrial fibrillation and COPD, who is a bit more breathless than usual?
A&E is generally staffed by doctors more junior than those that work in primary care. Their ability to absorb risk is inevitably lower than most GPs, and their ability to fully grasp the background to patients who present is obviously not going to be as good as that of a patient’s own GP. That’s essentially what we do: it is our unique selling point. We are good at making judgements and taking risks. Positive risk taking and understanding the social determinants of health are hard wired into our training.
So, what is to be done with urgent care?
I believe that with proper renumeration, we (as primary care specialists), should take back control of medical care after the surgery has closed. For too long, decisions have been made by under-qualified staff. Decisions that are difficult and complex, and in the end follow a path of least risk that inevitably means admission.
Yet, perversely, an older person who lives alone and is at risk of falling, can actually be more at risk in hospital than when they are left at home. Hospital is not necessarily the healthiest option – so many medical admissions are unnecessary and can occasionally do more harm than good.
What do we want to do as a profession? We have unique skills that are not being fully utilised. Patients are being harmed because primary care physicians, those best placed to make the call, are not involved in 80% of decisions to admit patients.
Yet none of us would go back to those overnight shifts either. They were awful and exhausting.
I believe we should offer an extension to GP contracts that require absolute medical cover until, say, 10pm – in return for proper financial reward. Data shows that the 10pm to 8am shift has the lowest demand, so late night and weekend cover could be based in neighbourhood health centres/doctors in MIUs. And we should have ambulance services working alongside us and rid ourselves of 111 services completely. Is this really too radical?
A final thought. Is it time to look at closing hospital A&E departments to all walk-ins, and instead make it a referral only service, with medical admissions and trauma treated separately – with funding flowing into primary care? Or do we not want to touch this with a barge pole – and leave OOH services to lower grade, less experienced staff, so that our working day, involving patient contacts, finishes at 6.30?
If we were in charge, we could easily transform the NHS.
But would we actually want to? That’s another question altogether.
Dr Simon Opher is the Labour MP for Stroud
I agree with every word of this. More power to your elbow. Simon.
They will never come up with proper remuneration for this. Its is just wishful thinking
I also dont know any GPs that would opt for it either.
It’s a no from me. Most GP surgeries struggle to staff 8 to 6.30. 8. To 10 is pie in the sky unrealistic and not possible thinking. If you want to cover my surgery between 6.30 and 10 for £65 an hour, we can discuss it.
Ridiculous idea. Never. Ever.
Maybe full-time GP Partners would be unable to opt in to this, due to the in-hours commitments, but there are currently many fully trained, and well-experienced, locum GPs available, and even new GPs or ‘first 5’s may be willing to take up portforlio postions in this sort of service.
First step is to cover the overnights, and then the evenings (and weekends), may be something that Practices would wish to take on, if the service is funded, and maybe through taking on more of the underemployed GPs.
But currently the priority for any Practice is to restore funding sufficient to cover the day services, before anything addition can be sustainably considered.
PS I would be willing to do some shifts overnight for this locally. The reason I kept declining our local OOH service requests was because they rigidly wanted shift to start at 1830, 75 minutes from home, after I finish a day ‘in-hours’ that would be unpredictably finished around 1800. Impossible without time machine!
I agree with the first premise but not the second. A pm shift, say 2-10pm could be funded and prevent burnout of super-long days. I agree that 111 etc create significant failure demand and increase costs to the system and the patients. The callcentre Medicine paradigm should be rolled back before the AI chatbot corporates get to have their field day.
However, blocking A+E walk-ins is a bad idea, one which NHSE was keen to implement. A+E attendance rates remained fairly stable over decades and ‘inappropriate’ attendances not the key problem. Failure demand has taken the system into the current spiral of patients not getting the care they need, where it’s then easier to blame ‘the ageing population’ rather than the demise of GIRFT.
Good to hear Dr Opher with some breadth of institutional memory of what good care looks like.
I was a GP partner in 2004 when OOH was removed from contract . We provided an excellent service staffed by all local partners on a rota .
I did enjoy the gossip from the drivers and networking with other local GPs.
I would consider evenings and weekends but definitely not overnight if remunerated well.
Of course that’s easy for me to say as I am now a Salaried GP so would not be responsible for costs of running the service.
Great lateral thinking but I’m afraid this proposal is based on the assumption of a robust resilient experienced GP WF of yester-year. Not only is the attrition rate of experienced GP beyond tipping point but also the accelerating real need/demands of the ageing population has not been taken into account 🙁
I’m not sure if you’ve noticed, but most GP’s are now part time, on the whole because the day job can’t be done in the hours provided while remaining sanity intact. The idea there is appetite to take more work on is pure Alice in Wonderland.
Thoughtful analysis. I agree GPs are better at OOH than anyone else, 111 etc, and that under Bliar the 2004 contract opened the door to decline in the NHS. But no contractor will now want to go back to providing OOH.
I’m still waiting for backbench Labour MPs to get angry enough and demand an immediate uptick in NHS funding.
If Labour can’t communicate a great story to the public about what they are by radical action in fiscal and distributive justice, then they deserve annihilation at the next election. We don’t need any more bluesky thinking/change/reform in the NHS……And stop listening to the horrific TBI on any matter..
This is not only a wishful thinking but also pretty unrealistic. Modern general practice that is undertaking day to day firefighting work for last 2 decades has lost its focus on managing medical complexity and prevention long time ago Majority of GP workforce is part time and overwhelming majority of this workforce opted to become a GP due to flexibility of working during those hours that are compatible with their family life. In last 20 years patient’s expectations, chronic underfunding of primary care and appealing unfunded shift of secondary care work to primary care has created a perfect recipe of disaster for GPs. Any such attempt to extend core GP hours will result in mass exodus of GP workforce in the form of early retirements and further cutting down in regular GP work by colleagues and these so called EA shifts will be manned by Locum staff with no difference to patient care.
Oh dear. Just stick to those back benches mate where you might be more in touch with reality
Oh dear. I think that you should stay on those back benches where you would be more use
The government in 2004 thought they could easily replace the under appreciated GP-run OOH service with a cheaper and better alternative…….then realised to their horror that they had in fact created an expensive inadequate disaster that has had a huge knock-on effect on A&E.
It has long been the goal of government to correct this grievous error and dump the whole mess back on to Practices.
Don’t forget that when PCNs formed they snuck in a paragraph about returning OOH care to GPs via the PCN back door.
And now a backbench MP with access to Wes’s ear is trying to persuade us to take it back, with the usual promises of limited hours and generous funding. Don’t be fooled again.
Dear Dr Opher,
Wes really needs to hear your words.
I believe the issue is linked with NHS/ 111 having as it’s leaders a predominantly administrative general management that call themselves leaders.
NHS is a professional services company,any general manager needs to have at least the skills of the team they lead, so yes include nurses, ahp’s, but also doctors, and not in subservient medical director roles, as minority.
If the health service is to deliver medical care, drs voice needs to be very dominant.
If it’s only now to deliver a lower service, then those skilled and capable of delivering a defined lower level service need to be in charge. The failure to plan manpower and medical training for the future is another deathknell to medicine as core of NHS .
The set up and structure of DOH when NHSE is terminated is critical here.
Drs leading on strategy, manpower planning is critical. Not the noctor or general management hierarchy of NHSE.
We need HR, finance etc but as support services. We need nursing,and Ahp as medical support services. It’s poor medicine without good nursing and Ahp.
It’s poor NHS without medicine.
I’m an underemployed GP, supporting Ahp to do jobs they are unskilled to do, in the Afc environment!
Moral injustice for me everyday, poor care or preventable death for my patients!!
I think the days of the GP partner prepared to do OOH on top of their daytime workload have long since gone. GP partners are no longer predominantly male and the main or sole earner for their family. Doing OOH reduced locum payments and kept income in the practice for the partnership.
The last 20 years have seen a fundamental change and many GP’S now are part time and female and have family and other responsibilities. They are not going to want to do extra evenings and weekends on top of the day job.
GP’S were better at managing OOH but I think it is too late to turn the clock back
I’m afraid there are far more fundamental problems to address than this. I have complete confidence that Labour will not solve them. Sorry maybe in 5 years look again.
Excellent idea, however, two ways it can go.
1. Partners taking control and fill OOH with PA and Nurse Practitioners, shooting their income above £200k (and that’s what all private companies who run OOH do now)
2. Decent partners take control of OOH and employing multiple “Unemployed GPs- old and young” to do OOH .
This debate highlights the future issues clearly- how do we provide care and continuity in primary care( best for most patients) given practices do not want the responsibility and are stretched to capacity? I was freed in 2004 and enjoyed a family life at last. The answer must be team based OOH primary care using all resources, including close co-ordination with our secondary care colleagues. As doctors we can shape this ahead. We must have OOH teams that provide improved continuity. Then our terminally ill will not die on a corridor and our elderly will not be waiting in an ambulance queue.
Most of the 111 reports I get are dental emergencies—
PA s who have replaced locum GPs can be used in ooh services so they GPs are employed again
Pre opt out GP co-ops had increasing difficulty filling shifts and it was rare that you would see your own patients whilst covering the local patch.
Inflexibilty and lack of clear thinking by the DOH through the 1990s resulted in virtually all GPs giving up OOH care in the same way that a drowning man takes a big lungfull of air when he pops up to the surface. The ridiculously low figure of £6000 for the value of OOH care by DOH resulted from chronic undervaluation of the service whilst negotiating with the BMA re pay. For once the BMA out manoevered them, or did the government just get hoisted by its own petard?
With portfolio careers and 6 sessions per week the norm I cannot see the modern GP agreeing to a modified version of the old way of working.
That ship has long sailed.
What is stopping ICBs employing (properly renumerated) GPs fulfilling this role now ?
It’s the money isn’t it ?
What is stopping ICBs employing (properly enumerated) GPs now ?
it’s the money isn’t it ?
When our local GP Co-op started in 1996 it was easy to get local GP’s to fill sessions. As older doctors retired it became harder and harder to cover session. We eventually had to introduce an unpopular lottery system where if all else had failed member practice names would be drawn at random and asked to provide a doctor for a shift. We tried to limit this to only evening or daytime weekend sessions. The Co-op directors covered the overnights. When the 2004 reorganisation happened and our Co-op did not get the OOH contract it was a relief to not have the weekly stress of covering shifts. 20+ years later I do not think today’s GP’s will be rushing to take on the evenings, weekends and Bank Holidays.
I did my own on call for 10 years. It’s a completely different world now. It will never come back in the way you suggest. You correctly observe that GP services have been decimated over the past 14 years. That should be your focus.
Read “Politics on the edge” by Rory Stewart. That will give you an understanding of being a new MP. It will also explain why health professionals who become MPs are kept away from decision makings regarding the NHS.
Don’t dilly dally too long-Reform are coming.
Dear Simon – we would all be very grateful if you can highlight the severe GP unemployment crisis to all of your colleagues next time you are in Parliament
Many thanks in anticipation
https://www.pulsetoday.co.uk/news/workforce/bma-reveals-heartbreaking-stories-of-gp-unemployment/
Not
Going
to
Happen
Those of us still doing full time patient facing work all day every day have no time for this.
And the rest of our profession have even less appetite, hence their working arrangements seeming to skew towards spending as much time as far from patients as possible, especially where lurks greater volume of undifferentiated, unfamiliar and ungrateful.