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Analysis: What are the options for taking back out-of-hours care?

Whatever GPs think of health secretary Jeremy Hunt, he is a master at making what once was unthinkable look almost inevitable.

In a matter of weeks, the profession has seen a political row over the 2004 GP contract turn into a debate over how, rather than if, the profession will take back more responsibility for patients out of hours.

It has also seen a split emerge between the RCGP and the GPC over the college’s proposal that practices should take back 24-hour responsibility for the most vulnerable 5% of patients.

But as NHS England begins its consultation on improving urgent care – including ideas such as GPs providing 24/7 ‘decision support’ – what are the options and what will they mean for GPs?

The first concrete proposals have emerged in a menu of options published by NHS England last month as part of its review into urgent care.

The consultation admits the current pressure on emergency services is multifactorial – undermining Mr Hunt’s assertion that poor primary care provision is largely to blame – but many of its suggested solutions would involve a significant expansion in out-of-hours GP services.


Decision support

The NHS England consultation paper lists 12 objectives to improve round-the-clock care. One is for patients to be guaranteed seven-day ‘same-day’ access to a primary care team that is ‘integrated’ with the patient’s own GP practice. Among the possible ways to achieve these objectives, it includes GP phone consultations in and out of hours and GP-staffed urgent care centres.

But the most contentious proposal is for GP practices to provide 24/7 ‘decision support’ to out-of-hours medical staff to prevent their patients being hospitalised.

GPC chair Dr Laurence Buckman welcomes NHS England’s analysis of the problems – saying there is ‘very little’ he would disagree with – but says the proposed solution of 24/7 medical advice from the patient’s own practice is completely unrealistic. He says: ‘I can’t see how that is deliverable.’ 

He adds: ‘I think the idea of having a doctor on the front line or very near it, in any kind of urgent care situation, is essential. If it is a primary care thing then it should be a primary care physician and I think there are people who will do that, for money. For a suitable payment they’ll do it.’

He is similarly dismissive of the suggestion of providing same-day, every-day telephone, web or email contact with a primary care team.

He says: ‘If what they mean is on a Sunday, then I am sorry, you can’t deliver that kind of service, unless for urgent and emergency matters. I am not providing a routine service for things that are not so important.’

I’d defy you to find many GPs who look at Professor Gerada’s proposals with enthusiasm.

Dr Laurence Buckman

Dr Buckman says that some of the NHS England suggestions might be workable via GP co-operatives, but only with the requisite funding attached.

He says: ‘I think the GP co-ops would have been admirably suited to the task if they hadn’t been defunded to pay for 111. That was what we said all along, that GP out-of-hours services provide, largely, a very good level of service, and if you take their money away they won’t be able to provide a good service. That is what’s happened.’


Vulnerable patients

But the NHS England proposals are not the only ones on the table. The health secretary’s suggestion of GPs possibly ‘signing off’ out-of-hours arrangements for their patients does not appear in the consultation document. Mr Hunt made clear in his recent speech to the King’s Fund that he wants ‘the buck to stop’ with GPs by making them ‘the accountable clinician’ for all the care their patients receive outside hospital. Meanwhile, in an interview with the Guardian last month, RCGP chair Professor Clare Gerada raised another idea, proposing practices should resume out-of-hours responsibility for the most vulnerable patients.

Professor Gerada’s suggestion – also included in the college’s 10-year plan for the profession published last month – was that GPs should assume responsibility for 24/7 care for the most needy 5% of their patients, such as the elderly, those with complex medical problems and those needing palliative care or with mental health problems.

The GPC was enraged by the proposals. Dr Buckman said: ‘I’d defy you to find many GPs who look at Professor Gerada’s proposals with enthusiasm.’

This opposition was moderated somewhat after the college subsequently clarified that it would like to see federations and co-operatives of GPs and other healthcare professionals providing the care.

But the GPC still has reservations about an approach it fears could be seen as inequitable. Dr Buckman says: ‘We don’t think you can decide who the 5% are. It is the thin end of a very thick wedge.’ 

The RCGP’s suggestion was also not included in the list of ideas published by NHS England, but there are signs that it may be considered.

Dr David Geddes, NHS England’s head of primary care commissioning, says its consultation document is only a ‘first stab’ at solving the issue.

He says: ‘We work very closely with the RCGP. It is interesting information and evidence and we need to use that to inform the plan.’

Dr Geddes says any changes to the remit for 24-hour care could be included as soon as next year’s GP contract, even though the consultation runs into next year.

He adds: ‘We know there are a lot of concerns for the workforce of the profession so it is not something that we want to be taking unilateral action on.’

This is an over-my-dead-body issue.

Dr Mary Church

Grassroots opposition

NHS England may be keen to get started on negotiations, but GP leaders will struggle to sell any changes to a very sceptical profession.

A Pulse survey of almost 400 GPs last month found 69% would not take back out-of-hours responsibility ‘at any price’. Only 23% said they would do so for £20,000 per partner annually. Half of GPs said they would reject taking back responsibility for overseeing the quality of out-of-hours care for their patients even if there was a guarantee they did not have to do on-call shifts themselves – only 36% were in favour.

Some 62% said they would support the GPC in taking some form of industrial action if NHS England sought to change the GP contract to alter GPs’ remit for out-of-hours care, and 87% rejected the RCGP’s proposal for GPs to take back 24/7 responsibility for the 5% most vulnerable patients.

Responses to the survey were unequivocal. Dr Mark Beecham, a GP in Maldon, Essex, echoes Dr Buckman’s words: ‘Definitely not. It would be the thin end of the wedge.’

Another respondent, Dr Thomas Bloch, a GP in Broadway, Worcestershire, says: ‘This would be a recipe for disaster – we would get the blame for any shortcomings. This is the only reason the Government wants to be shot of it.’

Dr Mary Church, a GP in Blantyre, South Lanarkshire, simply says: ‘This is an over-my-dead-body issue.’

Preserving continuity

Those responses clearly show the depth of GP feeling, but experts insist that a way of improving continuity of care out of hours must be found.

Rick Stern, chief executive of the NHS Alliance and a director of the Primary Care Foundation, which benchmarks out-of-hours services, says:  ‘There is a balance to strike because certainly continuity of care is something we all want as patients and what most GPs want to provide.’

Mr Stern says many of the ideas presented so far are hard to see working in practice, but the solution may come from better use of technology, rather than GPs returning to 24-hour responsibility. He explains the need to develop systems ‘whereby whoever may be dealing with the patient in the middle of the night can access the best possible information’.

‘I don’t think anyone is seriously suggesting that all GPs should be on call all the time for their patients. We need doctors who work sensible hours and therefore are able to make decent decisions.’