Abstract
Far from turning their backs on 24 hour responsibility, it seems that GPs may have been pushed out
Until 2004, general practitioners were responsible for the care of their registered patients 24 hours a day and seven days a week. They did not have to provide that care themselves but remained responsible for arranging and coordinating it. As a result of the new GP contract, most general practitioners have now opted out of this responsibility and are contracted to work for the NHS from 8 am to 6 30 pm and for only five days a week. Since these changes, out of hours care has become more expensive and less efficient, with a profusion of different arrangements across the country. Attempts are being made to replace GPs with a multitude of people from different disciplines, and care is being fragmented proportionately.
How did we get into this mess? There is no doubt that GPs were becoming overwhelmed by an increasing out of hours workload, with people being encouraged to expect that medical care should be as convenient and accessible as a supermarket. However, the government is seeking to portray GPs as having turned their back on out of hours care to the detriment of patients, and this is a dishonourable attempt to rewrite history.
At the time of the new contract, most GPs had already organised themselves into larger cooperatives of groups of practices, which reduced the burden on single practices. Perversely, the new contract awarded little money for continuing to cover out of hours care. As some GPs began to opt out, cooperatives were obliged to pay much more realistic rates to doctors undertaking shifts so that, for those practices remaining opted in, the cost became unsustainable and they too were obliged to opt out in turn. The exception was SELDOC, the co-op for the GPs of Lambeth, Southwark, and Lewisham. SELDOC set out to provide an all inclusive out of hours service for its members for an annual payment of less than the cost of opting out. Remarkably, they have succeeded and, as a direct result, more than 90% of GPs in these three London boroughs remain opted in for 24 hour responsibility. This suggests that the vast majority of GPs would have retained 24 hour responsibility if they had not been financially penalised for doing so. The opt-out is a one way process: having opted out, practices are not allowed to opt back in again. Why should this be so? The only explanation that makes sense to me is that the government wished to break the GP monopoly and to open up GP services to commercial competition. This is why the individual doctor's name has been taken off the medical card and it is why the opt-out is one way. Far from turning their backs, it seems that GPs may in fact have been pushed out.
What can be done? What are the principles on which a sustainable out of hours service should be based? Firstly, a service funded through general taxation should be predicated on need rather than convenience. I cannot be alone in my willingness to pay tax to ensure that someone taken acutely ill at night gets immediate and appropriate care and my unwillingness to pay for someone to discuss their problems of ear wax at 10 pm. Secondly, as many people as possible should be asleep at night. We know that working at night undermines health and, as far as possible, the NHS has a responsibility to protect the health of those who work for it. The bulk of out of hours work is triage and immediately necessary treatment. We know that triage is most effective when it is undertaken by the most highly trained personnel and, in the out of hours context, this means GPs. There is no need for the full panoply of health professionals to be available out of hours and there are both personal and financial costs to attempting it. Thirdly, the concept of personal responsibility should be reintroduced into out of hours care so there is someone taking a personal interest in the quality and outcome of each episode of care. It is becoming increasingly difficult to coordinate the care of a practice's registered patients when responsibility is limited to 10.5 hours a day. Finally, we should acknowledge that if continuity of care is important during the day it is also important at night.
The out of hours problem seems to me to be symptomatic of a wider malaise in the health service that has developed as responsibility vested in individuals has been replaced by elaborate bureaucratic structures. Current systems fail to acknowledge the central transaction of medical care, which occurs when one named individual takes responsibility for the care of another. This is a personal as well as a contractual undertaking.
When people are ill, the fear, loneliness, and suffering are always much more overwhelming at night when there are inevitably fewer distractions and less human company and when, as Philip Larkin put it, “the dread of dying, and being dead, flashes afresh to hold and horrify.” It cannot be beyond the capacity of the NHS to devise and fund a system of out of hours care based on smaller rotas of GPs covering smaller populations so that the possibility of some sort of continuity, of seeing a familiar face, is enhanced. A first essential step would be to allow GPs to opt back in to 24 hour responsibility without financial penalty.
The out of hours problem seems to me to be symptomatic of a wider malaise in the health service that has developed as responsibility vested in individuals has been replaced by elaborate bureaucratic structures