It’s Monday morning. The phone begins ringing incessantly when the appointment window opens at 8am sharp. In three minutes of whirling insanity, every appointment has gone and my receptionists are pulling their hair out as they reiterate ‘I’m sorry, we are fully booked. Is it an emergency for today? My computer screen fills up with the names and telephone numbers of the disappointed.
I pick the sheets of paper off the fax machine: messages from the out-of-hours service. Your patient Elspeth Humdinger was seen by a locum doctor out-of-hours, and was admitted to CDU by ambulance with a diagnosis of ‘unwell generally’. Her discharge summary is there as well. Overnight they made the diagnosis of tonsillitis and gave her some antibiotics.
We have made it so difficult for our patients to get to see us that they go to A&E, dial NHS Direct or 111 where (if they manage to get through at all) they are seen by inexperienced anxious doctors who over-treat them because of a fear of litigation, causing havoc in the emergency departments and dissatisfaction to many patients. All of this comes at a great cost to the taxpayer.
But the problem does not end there. Evidence is now emerging that outcomes are worse as well. The obstacles to treatment are causing people to present late with serious pathology and they are doing worse as a result.
The current out-of-hours service is not fit for purpose. This has caused a media backlash and an urgent political necessity to ‘do something about it’.
The pressure of being ‘on-call’
I have been a GP for over 30 years. In the early years I worked a four-in-five rota – yes, really. I worked our out of five nights and four out of five weekends: it was a nightmare.
I slept fitfully, ate my meals embarrassingly quickly, always aware that the phone might ring at any time. Socialising was a rare and somewhat intense experience. My moods varied from irritable to downright diabolical. My wife used to tell me about how the children were doing; I rarely saw them. My health was on a downward spiral along with my marriage and everything else that the modern GP values – never, never again.
The patients were happy, though. They got a doctor they knew at all times of the day or night, this gave them a confidence that made them paradoxically less demanding. I actually got very few calls. It was the pressure of being ‘on call’ that was draining me, as opposed to the work itself.
Any doctor who has even a hint of altruism cannot continue a system that is detrimental to the wellbeing of his/her patients. Two weeks ago at our practice we opened up the appointments system. We now let patients book exactly what they want, as far ahead as they want, although we keep a few appointments for emergencies each day.
My partners and I decided that we would cope with the occasional heavy day where we might need to fit in multiple extras. We had to remove the obstacles to care. It is going OK so far.
Let’s jump – before we’re pushed
How then are we to deal with the out-of-hours system? Going back to individual 24-hour contracts is impossible and I am sure would be illegal.
But I remember clearly a system that worked well. Before the 2004 contract took away our responsibility for out-of-hours care, many GP practices had organised into out-of-hours cooperatives, where the members provided the care on a sessional basis, paid the drivers and the receptionist, rented the building, and supplied the computer systems themselves.
All this was paid for by the GPs who were charged according to their usage of the service. The financial details would not be difficult to work out, and at CCG level it could be ensured that greater funds went to the more disadvantaged areas as these patients make greatest use of the out-of-hours service.
If the Government had valued the OOH service at more than £6,000 when they imposed the 2004 contract, none of us would have opted out.
We have never been in a stronger position to negotiate a realistic sum of money to renew our provision of the out-of-hours service to give the Government and the patients what they want in a way that we can control.
I think we would be wrong to lose this opportunity for it is likely, given the political imperatives detailed above, that something else might be imposed upon us.
Dr Martin Busk is a GP in Woodchurch, Kent