Abstract
Complaints about the care provided by out of hours services in the UK are growing. Roger Jones thinks that general practitioners should take back the role, but Helen Herbert believes their efforts would be better focused on improving current systems
The question should not be whether general practitioners should take 24 hour contractual responsibility for their patients; rather we should be calling on primary care organisations to take creative and innovative action to engage providers, including general practices, to provide good local solutions. Several organisations have done this already so why not the rest? Access to good quality care should be the preserve of all, not just the lucky few.
Danger of long hours
The relinquishing of out of hours responsibility has led to accusations that general practitioners do not care about their patients. But it is precisely because we want the best care for patients that the change was made. Surely it cannot be in the interests of patients for doctors to work all day, be up most of the night on call, and then work through another full day in surgery. Sleep deprived people should not be making life threatening decisions. Lorry drivers and airline pilots would not be allowed to put others in such danger, so why should general practitioners?
The profession largely welcomed the new contract on the grounds of patient safety and improvements in their work-life balance. The newer generations of doctors have a more objective attitude to working hours, and recruitment to general practice was becoming a problem. The contract has been successful in its aim to improve quality of life for family doctors and thus help ensure the future of the profession.1
Those who criticise doctors for accepting the new contract fail to appreciate the stresses of the isolated and unsupported practitioner and the consequences of sleep deprivation on performance the next day.2 When I began in my practice 25 years ago, I worked a one in three rota, caring for 6000 patients covering an area of over 200 square miles. During the long periods on call, I worked alone without any team support. Often in a state of exhaustion, I would be called time and time again from my barely warm bed. Understandably, patients preferred the immediate contact with a known and trusted general practitioner, but many needed direction in the appropriate use of services and the system was open to abuse.
General practitioners are blamed unfairly for the state of out of hours services when the responsibility for commissioning and providing these services resides with primary care organisations. Although many do provide an excellent out of hours service, some services are confusing and fragmented and patients are often unable to determine the most appropriate service to access. The lack of clear signposting is a big problem, and we must urge primary care organisations to take action. As experts in providing out of hours care, general practitioners are the solution to improving urgent care services, not the problem.
Delegation not abdication
Recognising this, the Royal College of General Practitioners has published a position statement on urgent care, recommending that services are designed around the clinical needs of patients.3 It states that patients should expect to receive a consistent and rigorous assessment of their needs and an appropriate and prompt response to that need—regardless of who is administering their care. Crucially, the action plan calls for better signposting for access.
Where out of hours care is properly organised and resourced, it works well, and many studies have shown high satisfaction with the care provided.4 5 However, we must not be complacent when this care does not come up to the standards that our patients deserve. It is necessary to continually monitor not only the process but the outcome of the care, including patient satisfaction and effect on other services such as the ambulance service, accident and emergency departments, and social and secondary care.6 7
Nowhere is the need for good out of hours care better exemplified than for patients requiring end of life care. Being ill in the middle of the night can be a frightening and lonely experience for patients and carers alike. There are many excellent models facilitating systematic, anticipatory care in primary care and nursing homes8 with evidence of positive measurable outcomes such as the doubling of home death rates and reduction in hospital deaths. General practitioners continue to use their professionalism by identifying those patients likely to require out of hours care and anticipating their needs: providing drugs in the patients' home, communicating with the out of hours providers, possibly sharing personal telephone numbers, and following up relevant consultations the following morning.9
Continuity and accessibility remain important professional values of general practitioners. The profession made the difficult decision to withdraw provision of out of hours care to ensure the safety of our patients and recruitment of future generations of doctors, but we must maintain responsibility for these values by providing excellence in anticipatory care and by influencing the providers, commissioners, and policy makers to ensure provision of the high standards of care that we expect for our patients. Our advocacy role remains as important as ever, and we must champion optimal standards of out of hours care for our patients.
Competing interests: None declared.
References
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