Out of Hours

Posted on July 22, 2009. Filed under: News stories | Tags: |

BMJ Careers | Authors: Kathy Oxtoby | freelance journalist London | Publication date:  22 Jul 2009

There are increasing mutterings that the experiment of taking out of hours work away from GPs may have failed. Kathy Oxtoby investigates 

For some general practitioners, out of hours work was the bane of their lives. Often it meant getting up in the middle of the night to see a patient and then having to face a busy surgery the following day. Being expected to visit patients any time of day or night meant general practitioners often felt exhausted, not to mention worried that they might make mistakes. Working regular weekends also made it hard to have a family life.

In 2004 all that changed. The new general practitioner contract allowed practices to hand over responsibility for providing out of hours (OOH) coverage to their local primary care organisation in return for giving up an average of £6000 (€7000; $9700) per year. And many were only too happy to do so.

But some patients were less than pleased. Research carried out among more than 3000 patients on behalf of Pulse magazine by the online market research company Opinion Health in 2007 showed that patients were increasingly unhappy with the quality of OOH coverage and many feared for their safety.

Poor provision

That same year a public accounts committee report found preparations to introduce the new system of OOH coverage were “shambolic” and that only general practitioners had benefited from the arrangements.

In April this year, the standard of OOH provision was again called into question after an analysis of more than 70 primary care trusts in England by the Primary Care Foundation found the proportion of OOH cases classified as in need of urgent attention varies by as much as 30-fold across primary care trusts.

Then there are the individual stories, such as that of David Gray, a Cambridgeshire man and father of a general practitioner who died last year after a diamorphine prescribing error by German locum Daniel Ubani. In response to the case, the Care Quality Commission is conducting an inquiry into the OOH provider involved, Take Care Now, and is also looking at the way in which the services were commissioned by local primary care trusts.

So once again OOH coverage is under scrutiny, with some ministers calling for a review of the way the system works. The case of David Gray has also caused many to question whether private providers should be using foreign doctors to treat patients.

“Problems can occur when these providers use doctors who don’t have the same qualifications as general practitioners in this country and who aren’t well acquainted with our systems,” says Mike Dixon, chairman of the NHS Alliance. Critics of OOH coverage post-2004 are concerned about how much the cost and quality of services vary in different parts of the country.

“It is clear that provision is extremely patchy in terms of quality of service,” says shadow health minister Mark Simmonds. “People also tell me there are enormous disparities in terms of cost per person.”

Accident and emergency

Since the change to OOH provision, accident and emergency services have been under extra pressure. Don MacKechnie, vice president of the College of Emergency Medicine, says there has been a “steady increase” in the number of patients attending accident and emergency departments.

General practitioners made a “big mistake” when they voted to give away the responsibility for OOH coverage, believes Roger Chapman, a general practitioner in Bedfordshire. “I thought it was wrong to stop being responsible for OOH, but I respected that was where majority opinion lay. It was not in our interest because it undermined our claim to offer continuity of care. It was bad for patients, and it undermined our negotiating position.”

Although the current system has its problems, Chaand Nagpaul, General Practitioners Committee negotiator with responsibility for OOH coverage, stresses these are “more to do with the failings in PCT [primary care trust] commissioning and PCT behaviour—not the contract.

“PCTs in many areas have developed OOH policies without adequate input of clinicians, who are best placed to understand patients’ needs.

“The funding of OOH care varies considerably between PCTs, and we are concerned that decisions may be influenced by financial drivers, rather than ensuring the best quality OOH provision,” Dr Nagpaul says.

Relieving general practitioners of the responsibility of providing OOH coverage has been “a successful move” he believes. “It has transformed the professional lives of many general practitioners, allowing them to control their work load and maintain a work-life balance.”

Dr Dixon believes that on the whole, current OOH services are probably “clinically safer” because they are manned by clinicians employed to give their time and attention specifically to providing such care.

Career choice

Many general practitioners are choosing to make OOH provision a career choice, combining it with part time care. For Lancashire general practitioner Zahir Mohammed, who does a session a week for Bury and Rochdale Doctors on Call, a not for profit organisation, OOH work “is a way to keep up with developments and there is also the monetary reward.”

Current OOH services are in keeping with a society where people will search the internet or pick up a phone for health information or advice. Where once patients wouldn’t dream of calling their general practitioner outside surgery hours unless they had a serious illness, now they phone private providers, such as Harmoni, to get advice on all manner of ailments.

“Roughly 45 per cent of calls to Harmoni are completed over the phone,” says the organisation’s marketing director Mike Barradell-Smith. Such services can increase access to health advice and ease pressure on day time surgeries.

As these services are well established and general practitioners are now used to working without the responsibility of providing OOH services, it is hard to imagine a return to the old days of being on call, or indeed that the profession would even consider it.

That said, many feel there is room for improvement. The David Gray tragedy has prompted calls for primary care trusts to be more vigorous in the way they vet potential providers of OOH services and for those providers to be more rigorous in their recruitment methods. And some believe that OOH services should only employ local general practitioners.

Others question the use of private providers, suggesting their focus is profit not quality. But Mr Barradell-Smith, who stresses that Harmoni recruits its clinicians using a “rigorous assessment process,” believes the issue is “not about whether you’re an NHS provider or a private provider. It’s about being a quality provider.”

Monitoring quality

In the future, monitoring the quality of all OOH providers will be the task of the Care Quality Commission. Later this year, general practitioner practices and other primary care services, including OOH services, will be under the direct scope of independent regulation for the first time. These services will need to register with the organisation and must meet a set of essential standards of quality and safety in order to maintain registration.

One way of raising the quality of services would be for general practitioners to be involved in commissioning, says Professor Steve Field, chairman of the Royal College of General Practitioners.

“OOH should be led by those who really understand the system, so we should be putting the emphasis back on the general practitioners to commission OOH care,” he says.

General practitioners could well be back in the driving seat for OOH care come a change of government. “GPs should be responsible for commissioning—though not necessarily providing—OOH care,” says Mark Simmonds. “They are the best people to do this because they are much closer to patients’ requirements and needs. GPs should also be given control of hard budgets so they can commission on behalf of patients,” he says.

A new government

The likelihood of a change of government prompted general practitioners at this year’s local medical committee conference to pass the motion that in the event that the profession takes back responsibility for the commissioning of OOH cover, the General Practitioners Committee would agree and publish a minimum set of criteria. Attendees at the conference also passed the motion that primary care organisations would allocate reasonable funding levels to OOH providers to enable them to provide good quality care.

Dr Nagpaul says that although the BMA welcomes general practitioners being more closely involved in commissioning OOH services, “We don’t want to go back to general practitioners being responsible for its provision.”

Making general practitioners responsible for real commissioning budgets is another concern he says. “If these services are underfunded and budgets are inadequate, and general practitioners are responsible for providing them, this could open up a whole can of worms,” he says. “We must keep OOH budgets separate from GMS [general medical services] budgets.”

For Dr Dixon, the future of OOH coverage lies with practice based commissioning, with more primary care trusts handing groups of general practitioners “the reins” to drive services. Dr Chapman urges general practitioners to “grab” any chance to get back in the driving seat and take back responsibility for OOH coverage to safeguard the future of OOH care.

“That doesn’t mean going back to doing on call. It means taking control over what is happening with OOH. It’s in the interest of patients and the NHS. And it’s in the interest of the profession, for without that responsibility we’re undermining our ability to offer patients continuity of care, which is selling ourselves short.”

Competing interests: None declared.

Case study

Tony Davies is a general practitioner at the Lodge Surgery, St Albans and clinical director of Herts Urgent Care, a general practitioner led out of hours provider. He says: “When PCTs [primary care trusts] in Hertfordshire decided they wanted one OOH provider for the area, local general practitioners felt strongly that they didn’t want it to be a private one. They were keen to control the quality of services and for money for OOH to go to ensuring quality of patient care, not to shareholders’ pockets. It was also important to have local general practitioners who know the area and understand how services work.

“Herts Urgent Care was awarded the contract. The company was set up on social enterprise principles and is an amalgamation of some of the organisations that were part of St Albans and Region Doctors On-call (STARDOC), a general practitioner coop that had previously provided OOH to the community.

“The service went live in September 2008 and covers around 1.2 million patients across the county. Since then we’ve had positive feedback about the standard of care we offer. We tend to use only local GPs and there are more than 250 on our books.

“Many do shifts not just for the money, but so they can make sure the quality of care they provide continues through the night as well as the day time.

“I believe those GPs who don’t do OOH miss out on something very special to general practice.”



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