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Out-of-hours needs a plan for the whole of general practice

Out-of-hours care is the embarrassing relative of general practice. It's rarely discussed out in the open because it makes the profession feel slightly awkward about itself. There's no question the 2004 opt-out was a necessary step for the recuperation of a profession that had become exhausted and demoralised, but equally many GPs would probably admit that the standard of out-of-hours services slipped as a result. Our investigation this week finds there are still some unresolved issues.

It is four years since German locum Daniel Ubani gave a patient a fatal overdose of diamorphine during his first on-call shift and sparked the latest round of handwringing over out-of-hours services. The intervening period has seen a high-profile inquest and MPs' report, a Pulse investigation – nominated this month for an award – into the lack of checks on EU doctors, and moves in some parts of the country to restrict out-of-hours shifts to local GPs. But has any of this – or the earlier outrage generated by the death of Penny Campbell after an out-of-hours mix-up in 2005 – made a real difference to the quality and consistency of services?

Our findings suggest there's still some way to go, with evidence that the well-intentioned response to the Ubani case could have made the process of recruiting GPs to work out of hours even harder. We found it is now so difficult in some areas to find willing doctors to work shifts that up to a quarter of slots on rotas are going unfilled. The search for on-call doctors appears toughest, perhaps predictably, where its parameters have been narrowed to local doctors only.

Certain problems have dogged out-of-hours care ever since the 2004 opt-out. Ministers grossly underestimated the money required to plug the gap left by GPs, while few PCTs were equipped for the complex task of planning and regulating out-of-hours care. Trusts sought cheap options to fill rotas, and so up grew a reliance on fly-by-night doctors from outside the UK – sometimes without the clinical or language skills to do the job.

But simply banning foreign doctors is to treat the symptoms while leaving the cause – a lack of money for well-qualified local staff – untouched. The problem has also been exacerbated by a broader GP jobs crisis, as doctors are sucked up by commissioning or extended hours, or lost to the jobs market through retirement or reduced hours. Out-of-hours providers have been forced to compete for the remaining doctors with practices, walk-in centres and Darzi centres. Given the popularity of red-eye shifts, they haven't stood a chance.

Ministers have spent eight years trying to find a specific solution for the out-of-hours problem, yet any resolution must surely be tied to a wider plan for the whole of general practice. For too long, governments have behaved as though their decisions to cut GP funding, slash pensions and force the profession into commissioning would have no consequences, appearing unmoved even as applications for GP training crashed.

But unless ministers develop a proper plan for the recruitment and retention of GPs, they are going to find the consequences are disturbingly real. They will involve an acute shortage of GPs, unfilled positions on on-call shifts and perhaps a new slew of unwanted attention for out-of-hours services.