The out-of-hours debate - my view

I write my blog in my spare time. It takes up a lot of my spare time, but I have to do it then because I have a proper job. I have been a partner in a GP practice for over 22 years, and have trained other GPs for nearly 18 years. In that time, I have seen a lot of changes - but perhaps never as many concerns as I have in recent months about out-of-hours.

The endless stream of headlines about GPs being to blame for the current 'crisis' in A&E departments seems, to me and my fellow doctors, to be something of a bad dream. Far from slacking, we all feel we're working harder than ever - and the evidence backs this up.

So what are the facts? The Department of Health's own figures show that attendances at A&E have only increased in recent years in line with the population - by about 1% a year. The increase in the number of GP appointments has gone up three times as fast, by about 3% a year between 1995 and 2006. When I became a GP, most of my work consisted of helping people who were ill.

I still do just as much of that, but I also spend a huge amount of my time helping people to stay healthy, by recognising and treating conditions like high blood pressure and raised cholesterol, which may not cause symptoms in the short term but which hugely increase your risk of heart attack and stroke. It's a lot of hard work, but it is making a huge difference to death rates - in the UK, death rates from heart disease have been falling since the 1970s, and in under-75s have dropped by 44% in the last decade alone. Some of this is down to improved treatment and survival rates, but much of the downward trend is thanks to preventive medicine.

You might think that if we doctors claim we're so good at preventing disease, we should be seeing fewer sick people. In fact, people are living for longer, but they do have to die some time. The tragic stories of young people cut off in their prime are less common, but as a population we're living for longer than ever. That means that I spend another large proportion of my time helping people who have long-term conditions like Parkinson's or dementia, which become more common with increasing age.

When I became a GP, my partners and I provided out of hours cover for all our patients. That meant that we would regularly work in the practice from 8am-7pm, take calls and visit patients all through the night, and be back in our surgeries for another eleven-hour working day the next morning. I know there were times I was far too tired to be at the top of my game - and as a GP, if you miss a diagnosis, the results can be disastrous. These days, the government claims we have all 'given up' providing out of hours care. In fact, over 80% of all consultations with patients, both in and out of hours, are still provided by GPs. In 2008, GPs carried out 300 million consultations, compared to 20 million in A&E departments. Many patients seen in A&E departments are actually seen by GPs who work there to provide emergency care. A year of care by a GP (to run the practice and pay all attached staff) is around £100-£150 per year - equivalent to one or two attendances at the local emergency department and less than one 999 ambulance call out.

There are undoubtedly problems getting medical care out of hours, and of course we need to do something about that. But not everyone has a bad experience. In a recent survey, 79% of patients surveyed rated the "ease of contacting the out-of-hours GP service by telephone" as "very easy" or "fairly easy" (2). The recently introduced 111 service has worked in some areas, but been a disaster in others - just today my colleagues and I discussed a 'significant adverse event' caused when one of my partners (who was still trying to get a terminally ill patient the help they needed at 9pm, when the papers claim we all 'clock off' at 5pm) couldn't get through to 111 to access the 24-hour nursing service. The theory is sound - 111 is supposed to be able to direct you to whichever service you need, including nursing services. When it works, my patients tell me it works well - but when it's bad, as they say, it's horrid. I am, sadly, not surprised to discover that in a poll, almost ¾ of respondents didn't have faith in the service.

So what is the solution? A fully functioning 111 service would make a huge difference - my personal experience is that far more patients are being told by 111 to go to A&E 'just in case' than they were under the old system. Patients need a single point of contact, with safe, sensible advice about what to do when they're concerned and access to a doctor if they need it.

We all need to be responsible about using the NHS - every day I get reports from A&E departments about patients who have walked in complaining of a sore knee they've had for two weeks but haven't taken a painkiller for, or to get their dressing changed.

We need to keep working to make it easier for patients to access the help they need during working hours (in 'standard' surgery hours, patients are seen from 8.30-6.30pm and many see patients from 7am-8pm). This is harder than it seems - at my practice we analyse our patient satisfaction questionnaire every year and change our appointment bookings in reply to demand, but we can never keep everyone happy. Patients often believe we're sitting twiddling our thumbs when we're not seeing patients. In fact, we spend several hours every day interpreting and acting on blood test results; acting on recommendations from hospital or social services letters; doing joint visits for dying patients; having meetings to discuss the latest restrictions on our referrals or prescribing; trying to save money for the NHS by analysing our prescribing, so we can afford more physiotherapy appointments or the latest cancer treatment for our patients - the list is endless.

Is the solution to get GPs to go back to covering care for their own patients 24 hours a day? My working day is officially 11 hours long with no break, and I come home physically and mentally drained. Would you want to be treated by me when I'd been working for 24 hours straight?



2) GPPS survey

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