BMJ  2007;335:696 (6 October), doi:10.1136/bmj.39350.506991.AD

Feature

Head to head

Should general practitioners resume 24 hour responsibility for their patients? Yes

Department of General Practice and Primary Care, King's College London, London SE11 6SP

Complaints about the care provided by out of hours services in the UK are growing. Roger Jones thinks that general practitioners should take back the role, but Helen Herbert believes their efforts would be better focused on improving current systems

New contractual arrangements to encourage practices to opt back in to 24 hour responsibility and to support general practitioners who choose to discharge this responsibility personally would have many benefits. The change would begin to redress the increasing separation of daytime, surgery based care from out of hours care provided by deputising services. These arrangements would also improve general practice training; greatly increase the quality and appropriateness of out of hours care, particularly in terms of hospital admissions and appropriate use of services by patients; and enhance patient safety by improving the communication of important clinical information. They would be widely welcomed not only by patients but also by other sectors of the medical profession, and are also likely to be cost effective.

Sick system

The background to this debate is the new contract for general practitioners introduced in 2004, which allowed practitioners to opt out of 24 hour responsibility. In a recent article suggesting that out of hours primary care in the UK was becoming a shambles, Heath pointed out that the new contract provided little money for practices that wanted to continue to cover out of hours care, effectively forcing them to opt out.¹ This has led to a situation in which the best trained general practitioners concentrate their efforts on daytime care, while patients who become ill at night risk being seen by less experienced doctors without the depth of background knowledge needed to make the most appropriate decisions about management, including hospital admission. Not only does a parallel out of hours service lead to fragmentation of care and potentially dangerous communication errors, it is likely to be more expensive, in terms of both running costs and unnecessary inpatient costs.

Complaints about out of hours general practice care have risen sharply in the past two years. The Medical Protection Society opened 30 cases related to out of hours care in 2003 and 100 in 2006 (personal communication). Many of these complaints relate to poor doctor-patient communication (including rudeness) and to diagnostic delay and error.² The second Wanless report has linked a recent steep rise in accident and emergency attendances to changes in general practice out of hours arrangements.³ Audit Scotland has recently declared the out of hours services in that country to be financially unsustainable.⁴

International experience

These difficulties are not restricted to the UK. Six years ago Dutch general practitioners gave up personal responsibility for out of hours services, many with mixed feelings, and now a subgroup of patients is emerging who use the service for semi-routine primary care consultations. Patients are often seen by recently trained doctors with little experience and no personal connection to their general practitioner. In Australia and New Zealand general practitioners are still responsible for 24 hour cover, which is usually contracted to out of hours services of varying quality. Some cover is provided by doctors who have made career decisions to work in out of hours services, avoiding the responsibilities of practice management and long term patient care. The Royal Australian College of General Practitioners has set out detailed requirements for the arrangements that practices are required to make when delegating their 24 hour responsibility, including stringent guidelines for the communication of essential clinical information. There is evidence that in the UK quality assurance arrangements of this kind do not always work well, and that patient satisfaction is often not assessed.⁵

I am not suggesting that all general practitioners resume out of hours responsibility for their entire professional life. And I am certainly not supporting the view that surgeries should be open at all hours for routine care—this entirely misses the point. However, during vocational training and in the early years of practice, seeing patients in their homes, assessing acute medical problems—particularly in areas where paramedical services are not readily available—and making appropriate decisions about treatment and hospital referral should be regarded as core aspects of training and professional development, just as they are in hospital medicine. Younger doctors, more able to tolerate broken sleep, may also be more interested in earning additional income by taking part in out of hours rotas for their practices, and more senior doctors may also wish to maintain patient contact.

In parts of Canada, regional health authorities help general practitioners to form networks in which out of hours care is shared between practices, and in which trainees in family medicine, supervised by experienced primary care doctors, are first on call. Heath suggested that the NHS should be able to devise and fund a system of out of hours care based on smaller rotas of general practitioners covering smaller populations,¹ so that the possibility of some sort of continuity—of hearing a familiar voice or seeing a familiar face—is enhanced.

I have covered my practice at night in the rural south of England and in inner city areas of Southampton, Newcastle, and London. I have sometimes been concerned for my safety. I do not underestimate the difficulties of re-engaging with personal out of hours care but am convinced that for many doctors and patients a return to a more personal approach to 24 hour responsibility would reap enormous benefits.

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Competing interests: None declared.

References

1. Heath I. Out of hours primary care—a shambles? BMJ 2007;334:341.[Free Full Text]
2. Price J, Haslam J, Cowan J. Emerging risks in out-of-hours primary care services. Clin Governance 2006;11:289-98.[CrossRef]
3. Wanless D, Appleby J, Morrison A, Patel D. Our future health secured? A review of NHS funding and performance. London: King's Fund, 2007. www.kingsfund.org.uk/publications/kings_fund_publications/our_future.html
4. Audit Scotland. Primary care out-of-hours services. Edinburgh: Audit Scotland, 2007.
5. Hurst K. British out-of-hours primary and community care: a review of the literature. Int J Health Care Qual Assur Inc Leadersh Health Serv 2006;19:42-59.[Medline]

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