Saturday, April 6, 2013

Perceptions part 1: GPs & OOH

Dabbling in unscheduled care has been fun. So much of a learning curve but one regularly also sprinkled with bemusement as to how entrenched some myths and beliefs are. Thus, going through the history of the NHS over the last 10 years or so, has made for fascinating reading!

One of the enduring beliefs and spoken in sometimes hushed tones, is the impact on unscheduled care  when GPs renegotiated their contracts and pulled out of providing 24/7 care. In ethos such 24/7 activity was a noble one, but in practicality, one which got tested to the limits due to rising demands, expectations and burn out rates. Medicine being a holistic profession is an oft used term, but the reality of a burnt out, fed up doctor is that such a professional perhaps is of reduced use to any patients. So, negotiations took place and for a loss of 6K per year, each GP had the option to withdraw from out of hours care in 2004 ( do correct me if I am factually wrong, folks out there!)

I have two ways to test issues in healthcare..if it related to the patient, it's " what would I do if this was my relative?",while if related to business issues, "what would I do?" This being of the second type, the answer is resoundingly..Yes. Put it this way, I get paid approx 5-6K per year for being on call and if the option to stop being on call OOH or weekends were there, I would consider it too. And that's inspite of my physician on call being far less onerous than, say a surgeon or indeed a GP doing OOH under the previous system. Crucial difference? I am employed by an acute Trust who simply won't even put that on the negotiation table, while GPs, however you view it, were and are individual business units- and one may argue, better negotiators too.

And if one looks at it, then who wouldn't take up the offer? With the day job being stressful enough, for the loss of 6K from an already existing good salary package ( especially for GP partners) the option was to drop out of nights, or indeed weekends. So they did and the money taken from the GPs were to be used by PCTs to develop OOH care...and bang we walked ourselves into a monumental problem.

Problem 1: Gross underestimate of money. From a negotiation point of view, offering to take only 6K was ridiculous apart from the fact that it never estimated accurately the amount of work GPs actually did OOH. Result? GPs walked away from OOH "marvelling" at this negotiation "skills" of the other party while the money now released was woefully inadequate for PCTs to provide decent OOH care, a fact borne out time and again since 2004.
Problem 2: Fragmentation. we lost all form of continuity, multiple providers came into being, multiple options were thrown up, IT systems became fragmented and most alarmingly of all, the patient simply lost all clue trying to understand which avenue to explore OOH when ill.
Problem 3:  Rise of untested methods. telephone lines, virtual methods came into being. Some were successful, some were not, but in short, they were untried and untested and for about 10 years or so, the NHS has continued to experiment. I am a fan of Tele-health but only in the right setting. If you are going to use Tele-health to reduce emergency care,then frankly, that's going to be a losing battle. Example? If you are short of breath due to your asthma, do you want to play with a device or do you want to see someone who can assure you, give you the advice needed etc? On the other hand, would the patient like to use it when reasonably stable to consider tweaking their medications based on an algorithm- which in turn may reduce their chance of there's a possibility that may work. But as a tool for OOH care? Nope, unlikely to be that useful.

So that's my piece on the oft shared myth that GPs pulling out of OOH care has resulted in collapse of OOH probably has, but there are lots of caveats to it. 
Could the negotiations have been better? Possibly Could the money taken be ring fenced appropriately? Possibly. But we have now arrived where we have. 

Perhaps the silver lining is that hopefully with GPs in power, they will appreciate the lessons of history. The question is whether the family doctor will come back into play if all the fragmented money in play being used on so many providers is put in one pot. my view on that being devolved to acute trusts is known,...but whichever way you cut it, without the family doctor involved, whether it be on an individual basis or as a cooperative, the OOH system won't work. 

We as a system need them back in play and whatever we need to get them to bring them to the table, we should use it.The last 10 years have taught us most other untested systems have not worked to varying degrees. Why not consider bringing back the system which did work, but perhaps with a better recognition of what the work involved? Love them or hate them, GPs are the linchpins of the system. 
Back to the table then,please?


  1. Thanks Parthar,

    Some historical documents:

    1. The Department of Health commissions The Carson Report in 2000 which proposes taking OOH of GPs in order to 'raise standards'.

    2. And here is the 2004 report from the House of Commons Health Committee which looked to examine whether PCT were in a position to take over OOH care and stated
    "Although there were differences of opinion on many issues relating to GP out-of-hours
    services, our witnesses gave a clear and unanimous message that the handover of
    responsibility for GP out-of-hours services from GPs to PCTs represented an excellent
    opportunity to redesign out-of-hours provision for the better, designing services around
    patients and developing a new model of primary out-of-hours care that dovetailed with the
    wider economy of unscheduled care provision, including A&E departments, ambulance
    services, GP emergency clinics, Walk-In Centres, NHS Direct, and local authority social
    services provision."

    So I am not entirely sure that this agenda was driven by GPs.


  2. Thanks AM. I don't think this was "driven" by GPs either- but do believe that the negotiations undertaken from the other side was poor and undervalued GP contributions to OOH care.
    I have read the above reports- along with the one done by the National Audit Office in 2006, Public Accounts Committee 2007 and the DoH one in 2010. Pretty much same conclusion- poor recognition of GP work pre 2004, resulting in less money for existing system and fragmented multiple providers.

  3. What do you think of this view this view from the Jobbing Doctor?

    "The out-of-hours service remains criticised on a regular basis, because it is poor in my view. The Government offered GPs an incentive to drop doing out of hours (18.30 - 0800 Weekdays and weekends) so that their preferred service providers (the private sector companies) could get a foot into the NHS 'market'."

  4. Perhaps. However, in that case, I have 2 questions:

    1. Didn't the GPs know this at the time- given that they took up the offer at that time? Either they didn't realise and walked into it or they did and still signed up to it

    2. Would they have opted out if the money offered to be withdrawn was, say. 20K? It may have prevented majority of GPs walking away, while for those who did, the money available to fund OOH by PCTs would have been significantly high. I know I would walk away for a 6 K reduction in return for drop in OOH. Would seriously reconsider if money to be withdrawn was 20K.

    A situation of ifs and buts?

    1. 1. At the time I was working as a salaried GP ( I still am a salaried GP in the same practice) and voted against the change as I thought it would be bad for UK general practice. I should not that at that time all the GPs in my practice were salaried and we did OOH duties. The change in contract meant I didn't have to do OOH, but it made no difference to my salary on the clinical lecturer pay scale.
      I voted against the change as I thought that GPs having care of their patients for 24 hours was important.

      2. As I say I voted against this even though I would have no reduction income but would have a reduction in working hours. I don't know how other GPs made the decision.

  5. It was designed to make an offer we couldn't refuse. GP co-operatives were working well, but that was not the preference of the pro-marketeers who had taken over the Department of Health. So the offer was made to disadvantage co-operatives and allow in the private sector.

    It was all to do with ideology, and nothing to do with quality.

    1. Perhaps so, but surely GP leaders should have realised that or was that simply naivety? Either way, now its all down to conjecture and will never understand motives of parties involved (both sides I may stress) but makes for fascinating reading of history.