MP guest blog: ‘GPs should take back control of out-of-hours services’

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