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.