Out of hours runs out of time

    Dr Finlay is dead, long live the emergency care practitioner.
    For the next time you call a doctor in the middle of the night, you
    will probably find things have changed. No more visits from a
    bleary-eyed GP who has already done a 16-hour day. You are as
    likely to receive a visit from a district nurse or specially
    trained paramedic. Or perhaps a GP who has flown over from Germany
    or Spain for a lucrative night’s work.

    The new contract for GPs, which came into effect in April, has
    potentially far-reaching ramifications. GPs can now choose to opt
    out of providing many services, including those for unpopular or
    challenging groups such as drug users, homeless people and
    alcoholics. But one of the most significant changes is yet to take
    place. By December this year most GPs will cease to be statutorily
    responsible for their patients out of hours.

    This makes history because since 1948 every registered patient in
    the UK has had a named GP who is personally and legally responsible
    for their care 24 hours a day. In reality, of course, this is not
    practical. Even the most dedicated GP does not want to be on duty
    all the time and, although some diehards still attempt to do their
    own out-of-hours work, most surgeries have bought in locum cover
    for nights and weekends, or formed co-operatives with other
    practices in the area, staffed on a rota.

    But faced with an increasingly demoralised profession and an
    accelerating recruitment crisis, doctors’ bodies and the
    departments of health in England, Wales, Scotland and Northern
    Ireland negotiated an end to this statutory duty, giving GPs the
    option to opt out of out-of-hours cover altogether. Most have done
    so, handing responsibility for primary care at nights, weekends and
    bank holidays to the local primary care trust. Each opted-out GP
    loses about £6,000 of their annual £60-80,000 salary but,
    in return, regains the use of their evenings and weekends. The
    £6,000 goes to the PCT to help fund the new out-of-hours
    service, though in most areas there will still be a significant
    shortfall.

    The upshot for patients who are likely to use out-of-hours services
    – predominantly older people, parents with young children, and
    people with mental health problems – is that their service will
    change provider. This in itself does not seem a big deal and, in
    fact, the PCTs and GPs hope that most patients will not notice the
    difference, at least in the short term. But there are concerns
    about the new arrangements.

    The first is about the way the new service will be accessed.
    Out-of-hours calls have always been routinely “triaged” – assessing
    the immediate medical need of a patient before sending a GP out.
    But many of the new PCT models use the nurse-led telephone helpline
    NHS Direct (NHS24 in Scotland) as the first port of call for anyone
    asking for emergency primary care. The government wants to have all
    out-of-hours work directed through the helpline within a few
    years.

    NHS Direct has been an undoubted success and four years since its
    launch now takes about 120,000 calls a week. Staff are to be given
    training in their new responsibilities, but it is an as-yet
    untested way of assessing whether a patient needs to see a doctor
    in the middle of the night. There is understandable concern that,
    under the new system, only the most seriously ill patients will
    receive a home visit.

    Philip Hurst, health policy officer for Age Concern England, is
    broadly supportive of the planned changes but says: “For older
    people I think the gateway to out-of-hours services is important.
    People shouldn’t have to go through an incredibly complex matrix of
    questions in order to see a doctor. It should be a simple,
    straightforward process. And it shouldn’t be about rationing or
    limiting access to GPs – people should get to see whoever it is
    they really need to see.”

    Hurst is also concerned about the location of out-of-hours services
    – as are many others. As PCTs take over, most are setting up a
    single out-of-hours service in one location. This means, in
    practice, that many patients will live miles away, and possibly
    tens of miles away, from the out-of-hours service. Many PCTs plan
    to include some sort of transport provision for patients unable to
    make their own way to the centre but how these will operate remains
    open to question. If an elderly man calls about his wife, who is
    confused and disoriented in the middle of the night, will he be
    expected to bring her to the out-of-hours centre? Does this
    constitute a “clinical need” for a home visit, or for transport to
    the centre? And who decides?

    As Hurst says: “The location of these centres is one thing we
    should be looking at carefully. PCTs need to specify how local is
    “local”. Primary care does not need to be based in hospitals – we
    should be looking at what else is open at night.”

    In common with many other professions, GPs are also becoming too
    rare and too expensive to do much of the out-of-hours work for
    which they were previously responsible. Most PCTs are setting up
    out-of-hours services which rely far more heavily on other health
    care workers, such as the new role of emergency care practitioner,
    as well as specially trained nurses and paramedics. In future the
    chances of a patient seeing a GP at 2am will be fairly slim.

    Alan Cohen, a GP and director of primary care at the Sainsbury
    Centre for Mental Health, says the strategy is a far better use of
    time. “I’ve been a GP for 25 years and I know that when I’ve been
    up at 5am for a child with earache the patients I saw the next day
    got a crap service. It’s not difficult to treat a sore throat, and
    actually it’s not what GPs are good at. We’re good at chronic
    disease management and spotting that someone complaining of
    backache is actually depressed. There’s no reason why many
    out-of-hours calls can’t be handled by people with appropriate
    training. And if someone does need a doctor, they will get a GP
    who’s awake, rather than exhausted.”

    But he has some concerns about the way the new arrangements will
    pan out in detail, particularly around information sharing between
    the agencies involved in a patient’s care.

    He points out that, at present, patient information stored on their
    local practice’s computers – for example the medicines they are
    taking or their medical history – is entirely confidential, so
    sharing of information between NHS, social services or out-of-hours
    teams is impossible. This is as it should be, says Cohen, because
    out-of-hours professionals should be talking to the patient rather
    than depending on electronic information.

    But he does feel that in some cases – such as when a patient with
    mental health problems is subject to a community treatment order
    (CTO) – out-of-hours professionals may need to be informed, even if
    they are simply visiting to deal with a cough. “If someone’s
    sufficiently unwell to be on a CTO, it’s possible that we’re
    sending people into a risky situation without enough information.
    There are a lot of issues around information sharing that are only
    just starting to crop up.”

    There are many other concerns about the way the new arrangements
    will pan out. Some warn that the changes will increase pressure on
    other services as confused patients give up on out of hours and
    call an ambulance or go to their local accident and emergency
    department instead.

    And there is anxiety that the UK’s shortage of GPs (who take 10
    years to train) will result in out-of-hours services struggling to
    maintain staffing levels. Already some PCTs are having to look to
    Spain and Germany to find GPs willing to do out-of-hours
    work.

    But, in general, most observers welcome the change. Hurst says:
    “It’s not as if we’re starting from a desirable situation – the
    quality of out-of-hours services is variable. I think it’s a
    sensible idea. It’s how that sensible idea is applied that
    matters.”

    – A health select committee report on out-of-hours services is
    published on 6 August. For details go to
    http://www.parliament.uk/parliamentary_committees/health_committee.cfm

    Durham prepares   

    Durham and Chester-le-Street PCT out-of-hours service is
    expected to go live on 1 October. The team will include GPs and
    specially trained nurses and paramedics employed as “emergency care
    practitioners”, all of whom will be available to see patients at
    the centre and do home visits. The team will also work closely with
    other agencies such as local social services duty teams. 

    The service is based in the nurse practitioner unit of the local
    general hospital. According to Lynne Preston, acting director of
    Primary and Community Care: “It would be nice to have our own
    dedicated accommodation but it’s always at a premium. This centre
    will be used by nurses during the day, and by the out-of-hours team
    overnight and at weekends.”  

    Preston admits that some patients will live “eight or nine miles
    away from the centre”. But she says: “We have arranged a transport
    service for patients who are unable to get here. If there’s a
    clinical need, they will receive a home visit.” 

    Posters have been sent to doctors’ surgeries to inform patients
    of the changes. All patients who call their GP out of hours will
    get a recorded message telling them to phone NHS Direct, which will
    assess them and put them through to the out-of-hours team if
    appropriate.  

    Preston says the PCT is confident that it will be able to find
    enough GPs to do out-of-hours work, but says increased reliance on
    other professionals should ease the burden.

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