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Forget the spin – here’s what we know about the out-of-hours plan so far

From the Daily Mail front page on Tuesday to the high drama of an emergency debate at LMCs conference on Friday, there was only story in general practice last week – the health secretary’s bid to make GPs once again responsible for out-of-hours care.

It’s a suggestion which has predictably stirred up a powerful reaction from GPs. ‘Over my dead body’, one LMC representative declared, and that seems to be the consensus of the profession as a whole; the survey from Bedfordshire and Hertfordshire LMC which we report this morning found that more than 60% of grassroots GPs would consider quitting over the proposals.

But running amid all the anger, spin and hyperbole last week was a frustrating sense that GPs, patients and the Department of Health were arguing at cross purposes, confusing provision with responsibility, responsibility with commissioning and so forth.

So, as the dust settles on a frenetic week and GPs start to try and get their heads around how their jobs will actually change, if at all, here’s my attempt at a quick bullet-point summary - what we know so far, and what we don’t.

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1) First off, Jeremy Hunt is serious about making a real, significant change. There has been the suggestion from some quarters that the row over A&E attendances and out-of-hours has been blown out of all proportion and is simply an attempt to score some cheap headlines by blaming a capacity crisis on GPs.  That doesn’t seem to be the case. The careful build-up to Mr Hunt’s much-trailed speech at the King’s Fund – plus the meat of the speech itself – suggests the headlines are rooted in policy.

2) We’re not talking about provision. Much of GPs’ instinctive antipathy to the idea of having anything to do with out-of-hours is based on the muscle memory of weekends spent on call and peering at door numbers at 3am in the morning. This is explicitly not what is on the cards – NHS England are very clear that ‘no one is suggesting that GPs go back to personally being on call evenings and weekends’.

3) But we’re not just talking about GPs being responsible for out-of-hours care through CCGs, either. In the emergency debate on Friday, GPC chair Dr Laurence Buckman urged GPs to cut through the anti-GP spin and focus on what Jeremy Hunt had actually said. He then suggested that based on his speech at the King’s Fund, Mr Hunt could in fact plausibly be talking about GPs exercising their new-found commissioning power, through their existing membership of CCGs, and that would be that.

Based on Mr Hunt’s speech you could, if you were an optimistic sort, just about come to that conclusion. But in his response to the first question after his speech – asked by Pulse reporter Sofia Lind – Mr Hunt was explicit that the ‘contract needs to change’ to ensure GPs ‘sign off that they are happy with out-of-hours care’. Rewriting the contract seems to go much further than simply asking GPs to fulfil their existing CCG responsibilities.

4) Those contract changes are coming sooner rather than later. The Department of Health is keeping schtum and refusing to provide any details at all about how Mr Hunt’s lofty pronouncements will be engineered in practice, but NHS England was at least a little more forthcoming on the timing.

Dr Mike Bewick, deputy director for primary care at NHS England, told us today that the changes will ‘mean an opportunity for GPs to develop the more integrated care that we all know is central to ensuring balanced, sustainable NHS services’. And he added: ‘We look forward to working with the GPC during contract negotiations for 2014/15 which should bring us closer to this shared goal’.

5) The GPC will have plenty of discretion in how it handles those negotations, thanks to some careful framing of the emergency debate at the LMCs conference on Friday. Representatives had plenty of opportunity to vent, but little chance – despite spirited attempts from the floor – to actually shape how the GPC will respond. It remains the policy of the conference – and thus the GPC – that GPs do not accept out-of-hours responsibility. But beyond that negotatiors have not been tied to any specific negotiating position.

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Where does that leave us? Well, it seems likely, then, that there will be some significant change to GPs’ contractual responsibilities to make them more accountable for out-of-hours cover in their area, over and above their existing CCG commitments but stopping far short of actually providing that cover themselves.

Obviously GPs wanting to know how their job will change are currently left with more questions than answers. How will the contract change? What levers will GPs be given to improve out-of-hours care? How can a practice be held contractually responsible if care is commissioned at a CCG level? And will there be any more resource to cover the extra work involved?

Given that Jeremy Hunt has now signalled a change in policy, it’s to be hoped that someone at the Department of Health has an idea of the details, even if they’re keeping them secret for now. More will no doubt emerge in the coming months – and then hopefully we can start having a real debate about the changes which are actually proposed, and what they will mean for practices and patients.

Steve Nowottny is the editor of Pulse. You can follow him on Twitter @stevenowottny.