More controversy has erupted about GP services and the new contract.
The responsibility for Out of Hours (OOH) services was removed from GPs and given to Primary Care Trusts [PCTs Perfectly Crap Treatments? - Ed.] when the new GMS2 contract came in April 2004. For many GPs this was the best part of the deal. GPs are no longer responsible for the standards or provision of OOH services.
Indeed any current complaints about OOH services cannot be laid at the GP’s door. They must go to the PCTs charged with providing them. The fact that PCTs are struggling to do this, as demonstrated by SERCO vs KERNOWDOC in Cornwall is a problem for the PCTs [and the patients - Ed.], not GPs.
The DH and PCTs thought they could provide doctor lite services - doctors are so expensive, overpaid, and over-rated they felt. They thought Red Adair was wrong - “If you think professional advice is expensive, try taking advice from an amateur”. They thought advice from non-doctors would do just as well for colds and sniffles.
This policy is crashing down around the DH and its PCT lackeys today. Yet another great piece of New Labour management.
Why were GPs so keen to give OOH work up?
We’ll start with the obvious fact that unsocial hours are unsocial. Having evenings and nights disrupted by calls is disruptive. When you have to do this and work the day after then it starts to take a toll on you.
But this wasn’t the biggest problem.
There were other underlying dynamics that combined to really make many GPs detest OOH work. Any job is a combination of satisfaction, salary and support.
The Department of Health valued OOH work at around £6000 per year per GP in the new GMS contract. Before this, GPs essentially did the work for free. If they wanted to offload this work say to a deputising service or OOH co-operative then they had to pay, and ended up losing money. So the service started from poor pay.
Then the support element was minimal. OOH services were supposed to be for emergencies only. Sadly the definition of emergency proved elastic and having answered calls about head lice at 3am and spoken to sad, drunken alcoholics at 1.30 a.m. my tolerance wore thin. If the OOH service had been kept to genuine emergencies then GPs would have had to lump it and do it. But it wasn’t. The call rate rose steadily throughout the 1980s and 1990s.
And politicians kept on encouraging people to call whenever and whatever they wanted. No politician can utter the R word:
and so no one had the courage to back GPs in their attempt to keep demand down. Added to this the increasingly jittery public, that want everything checked just to be sure, and who think all rashes are meningitis, then the support for GPs was minimal at a time when demand was rising. Also society was becoming more violent and the risk of attacks on lone, especially female GPs operating in rough areas was growing. Who wants to save lives by putting their own in danger routinely?
This led to the development of GP OOH co-operatives which proved successful organisations pooling GP resources, providing drivers, and security. They provided good service and got most calls sorted within an hour. Phone advice, OOH centre appointments, or visits, were provided according to need.
Needless to say the Government couldn’t give these organisations any credit, and so set about duplicating these services with the dire NHS direct (or NHS Re-Direct as it is known in the trade). Rather than having experienced doctors, nurses who are inexperienced at diagnosis were given algorithms to follow. And of course, algorithims are so much better at diagnosing things than doctors.
Fundamentally there was no support for GPs doing OOH work in terms of income, appreciation or safety.
The third nail in the coffin of GPs and OOH work was lack of satisfaction. The demand were rising, the support dropping, and then the risk of complaints got ever higher. OOH was only a small fraction of GP workload but by far the most dangerous in terms of medico-legal risk. Strange as it may seem, doctors hate medico-legal risks. They will do their best to avoid situations likely to expose them to these risks. In OOH work it was easy to make mistakes, and patients complained and sued us frequently. Local papers loved stories of “bungling doctors” and, with their duty of confidentiality, GPs have no chance of defending themselves against lurid allegations splashed across newspapers. The fact most complaints are answered satisfactorily or dropped never gets a mention in the papers. We were tired and stressed enough at the end of a full day’s work (0830 to 1830 approx, 35-50 patients seen). To then go and see patients was a recipe for trouble, grumpy doctors, and stressed out patients. It was a combustible combination and bad for doctors and patients alike.
Can you see why doctors were keen to avoid work that is poorly paid, unappreciated, physically risky and medico-legally risky?
These are the reasons why GPs cheered the OOH opt out in the new contract.
Any attempt to make us go back to it is unlikely to be successful. GPs were resigning and retiring to get away from OOH work. Partnerships were having internal rows about OOH work. Partnerships were unable to recruit new partners as they would not take on OOH commitment.
The new contract has bolstered GP partnerships, and made GP again an attractive job. Any attempt to foist OOH back onto GPs could see a rush of GPs either to the barricades or the exit.
The responsibility for Out of Hours (OOH) services was removed from GPs and given to Primary Care Trusts [PCTs Perfectly Crap Treatments? - Ed.] when the new GMS2 contract came in April 2004. For many GPs this was the best part of the deal. GPs are no longer responsible for the standards or provision of OOH services.
Indeed any current complaints about OOH services cannot be laid at the GP’s door. They must go to the PCTs charged with providing them. The fact that PCTs are struggling to do this, as demonstrated by SERCO vs KERNOWDOC in Cornwall is a problem for the PCTs [and the patients - Ed.], not GPs.
The DH and PCTs thought they could provide doctor lite services - doctors are so expensive, overpaid, and over-rated they felt. They thought Red Adair was wrong - “If you think professional advice is expensive, try taking advice from an amateur”. They thought advice from non-doctors would do just as well for colds and sniffles.
This policy is crashing down around the DH and its PCT lackeys today. Yet another great piece of New Labour management.
Why were GPs so keen to give OOH work up?
We’ll start with the obvious fact that unsocial hours are unsocial. Having evenings and nights disrupted by calls is disruptive. When you have to do this and work the day after then it starts to take a toll on you.
But this wasn’t the biggest problem.
There were other underlying dynamics that combined to really make many GPs detest OOH work. Any job is a combination of satisfaction, salary and support.
The Department of Health valued OOH work at around £6000 per year per GP in the new GMS contract. Before this, GPs essentially did the work for free. If they wanted to offload this work say to a deputising service or OOH co-operative then they had to pay, and ended up losing money. So the service started from poor pay.
Then the support element was minimal. OOH services were supposed to be for emergencies only. Sadly the definition of emergency proved elastic and having answered calls about head lice at 3am and spoken to sad, drunken alcoholics at 1.30 a.m. my tolerance wore thin. If the OOH service had been kept to genuine emergencies then GPs would have had to lump it and do it. But it wasn’t. The call rate rose steadily throughout the 1980s and 1990s.
And politicians kept on encouraging people to call whenever and whatever they wanted. No politician can utter the R word:
RATIONING
and so no one had the courage to back GPs in their attempt to keep demand down. Added to this the increasingly jittery public, that want everything checked just to be sure, and who think all rashes are meningitis, then the support for GPs was minimal at a time when demand was rising. Also society was becoming more violent and the risk of attacks on lone, especially female GPs operating in rough areas was growing. Who wants to save lives by putting their own in danger routinely?
This led to the development of GP OOH co-operatives which proved successful organisations pooling GP resources, providing drivers, and security. They provided good service and got most calls sorted within an hour. Phone advice, OOH centre appointments, or visits, were provided according to need.
Needless to say the Government couldn’t give these organisations any credit, and so set about duplicating these services with the dire NHS direct (or NHS Re-Direct as it is known in the trade). Rather than having experienced doctors, nurses who are inexperienced at diagnosis were given algorithms to follow. And of course, algorithims are so much better at diagnosing things than doctors.
Fundamentally there was no support for GPs doing OOH work in terms of income, appreciation or safety.
The third nail in the coffin of GPs and OOH work was lack of satisfaction. The demand were rising, the support dropping, and then the risk of complaints got ever higher. OOH was only a small fraction of GP workload but by far the most dangerous in terms of medico-legal risk. Strange as it may seem, doctors hate medico-legal risks. They will do their best to avoid situations likely to expose them to these risks. In OOH work it was easy to make mistakes, and patients complained and sued us frequently. Local papers loved stories of “bungling doctors” and, with their duty of confidentiality, GPs have no chance of defending themselves against lurid allegations splashed across newspapers. The fact most complaints are answered satisfactorily or dropped never gets a mention in the papers. We were tired and stressed enough at the end of a full day’s work (0830 to 1830 approx, 35-50 patients seen). To then go and see patients was a recipe for trouble, grumpy doctors, and stressed out patients. It was a combustible combination and bad for doctors and patients alike.
Can you see why doctors were keen to avoid work that is poorly paid, unappreciated, physically risky and medico-legally risky?
These are the reasons why GPs cheered the OOH opt out in the new contract.
Any attempt to make us go back to it is unlikely to be successful. GPs were resigning and retiring to get away from OOH work. Partnerships were having internal rows about OOH work. Partnerships were unable to recruit new partners as they would not take on OOH commitment.
The new contract has bolstered GP partnerships, and made GP again an attractive job. Any attempt to foist OOH back onto GPs could see a rush of GPs either to the barricades or the exit.
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13 comments:
I do all my own OOH work because there is no alternative. Patients in my area know the EXACT difference between 24-hour medical care and Emergency cover.In one case they will be advised to FOAD and in the other, they might unfortunately die. They may occasionally get it wrong but, surprisingly rarely. That is all that makes it possible.
If ONE of you bastards take back OOH in the state it's in now, after what this contract has cost me in blood sweat and tears, then "I" will opt.
I read Iona Heath on this subject in the BMJ and wept.
In my rantier moments, I blame the number of medical dramas on TV in which all of the staff tolerate an extraordinary amount of abuse and are endlessly understanding of people who are not ill/wasting resources. It also seems as if they are educating people to expect an IV for a mild case of food-poisoning.
However, I've also been known to blame many other sources for an epidemic of diagnoses and over-anxious parents/patients. If you put together a poor understanding of risk v. danger with public education that tells you to consult your doctor about vague symptoms along with a feeling of entitlement, then there may well be an over-use by some patients.
By the by, I must thank you for your introduction to krappocephalos and incidentalomas in your linked post. Entertaining and useful - who could ask for anything more.
Regards - Shinga
All you say is true and well argued. The consequences however have not been covered. Initially, PCTs tried to use the very same GPs to do the out of hours work. At £70-£100 per hour the difficulties GPs had with OOH did not prove insurmountable but it did cost too much to be a long term fix. Now I hear that numpeys (Nurse Practitioners or NPs) are being recruited to provide the OOH service. Now, I am prepared to accept that dealing with OOH work is the most difficult, stressful and risky part of the GPs work. If this can be done by a numpey (or more like, the public can be convinced it can be done by a numpey) what is the point of having proper doctors doing the easier work during the day for 3-4 times the numpeys wage. Do you see where this is going? GPs are being suckered into becoming dispensable and in a generation or so the specialty will cease to exist. GPs are the architects of their own destruction. It is beginning already. In Hereford, American trained physicians assistants have been recruited instead of GPs when posts became vacant in the last year in, at least, two practices that I know of.
2Y8HXm write more, thanks.
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