I’m ill. It’s 6.30pm – where do I go?!

James Gubb, 9 August 2007

The BBC reported yesterday ‘that the number of serious complaints made against GPs over out-of-hours care has soared in recent years’. Complaints received by the Medical Defence Union (MDU) increased from 30 new cases in 2003 to 100 in 2006, and by the Medical Protection Society (MPS) from 120 in 2002, to 182 last year.
This may seem relatively insignificant, but when one considers that they only get involved in the most complex cases, ‘such as those that involve deaths, compensation claims, or issues involving the GMC’ (simpler complaints are dealt with by GP practices or PCTs), it is anything but so. Laurence Buckman, chairman of the BMA’s GP committee, tried to gloss over this rise by offering the following remark: “It is a fact that patients are annoyed when they cannot see their normal doctor and I think it is more likely to make them complain”. But, for one, you would then expect the overall number of complaints to the MDU and MPS to have increased, which has not been the case – the total number of complaints they have received each year has remained steady at around 3,500 p.a. And, more poignantly, the statistic on serious complaints is just the latest worry in a whole string of concerns over out-of-hours care since the GP contract caused 90% of GP practices to opt-out of provision.

Prior to the introduction of this new contract in April 2004, it was GPs’ responsibility to provide out-of-hours care between 6.30-8.00pm on weekdays and over the weekend. But the new contract allowed them to opt-out, in return for giving up c.£6,000 a year – relatively small-change in comparison to the overall salary hike received by many GPs of as much as 69% since 2001. For the 90% that unsurprisingly did opt-out, responsibility for the provision of out-of-hours care transferred to PCTs.
Since then public dissatisfaction with out-of-hours care has steadily risen. Surveys carried out by the Picker Institute of local health services show how the number of patients surveyed who reported ‘being put off from going to their GP practice because they found its opening hours inconvenient for them ‘ stood at 25% in 2006, compared with 20% in 2003 (although, interestingly, when the question was rephrased with a positive slant by the DH to ‘satisfied with opening hours?’, only 16% said they were dissatisfied in a national GP patient survey this year). Sixty percent of respondents in the Picker survey for 2006 also said they would want extra opening hours two or three days a week. And there is also a massive economic cost of the lack of out-of-hours care in GP practices – the CBI has estimated the cost to the business in terms of lost hours through employees being forced to go to see their doctor during working hours to be as much as £1 billion a year.
But more damaging is the overall effect that transferring responsibility for providing out-of-hours care away from GP practices to PCTs has had. This was the subject of vehement criticism in a report by the House of Commons Public Accounts Committee released in March this year, that found the government had ‘thoroughly mishandled’ the transition, which had been ‘good news for doctors, but no-one else’. The NAO reached similar conclusions a year earlier: ‘PCTs who took over responsibility for organising out-of-hours services from GPs lacked knowledge and expertise in this area’, [and] ‘the actual costs [of provision] under the new system some 22% more than the specific DH allocations’. It did find that services were improving and beginning to reach a satisfactory standard, but ‘no providers [were] meeting all the requirements and few [were] reaching requirements for speed of response’. Some reassurance is found in the fact that the NAO found ‘no evidence patient safety is being compromised’, but this is somewhat hard to believe when we find stories such as that of ‘Urgent Care 24’ (UC24), introduced in the Merseyside area for call handling since the changes, which included a doctor being sent to a dead person’s house and a patient being sent to a supermarket to look for a walk-in centre that didn’t exist. These are extreme examples, but systematic inefficiency failings were also reported with most calls (60%) being over-prioritised. This obviously has severe knock-on risks for genuine emergencies.
The root of the problem, in a sense, is that with the new system many patients simply don’t have a clue where to go for non-emergency, but possibly urgent, out-of-hours care. In an article for the HSJ, David Barker, CEO of Clinical Solutions, pithily makes this point:

‘Imagine this scenario: a patient living in the centre of a city falls and injures their wrist. While this isn’t life-threatening enough to demand an ambulance, it is causing a great deal of discomfort and needs to be looked at. But where should they go? What factors determine which treatment centre is best for patient care? Which is the most effective means of treating the patient using the most appropriate NHS resources at minimum cost? The patient may be in walking distance of an accident and emergency department but the injury could be one that is treatable more quickly (and more cost-effectively) at their local walk-in centre.
The patient is not at fault for selecting an inappropriate service, nor is A&E to blame for treating the patient with the resources available. The job has been done – but it could be done better. The challenge is how to get the most appropriate care for the patient, with the least impact on NHS resources and budgets.’
Too true – I wouldn’t really know where to go. Is it to my GP (if I’m lucky enough to be at one of the 10% who still provide some out-of-hours care), is it to A&E, is it to a walk-in centre, an urgent care centre, or do I ring NHS Direct, or whatever other helpline has been set up for out-of-hours care? Many no doubt think the same. And it’s having massively perverse effects, most particularly on A&E, where attendances have rocketed in recent years. This was graphically revealed by Dr Patricia Hamilton, head of the Royal Colleges of Paediatrics and Child Health, in an exclusive interview with the Daily Telegraph yesterday, who revealed that parents are increasingly taking their child to A&E with minor problems, such as a cold or fever. In her opinion it’s the result of “a combination of things [but], particularly the change in the provision of out-of-hours care”. This is both massively inefficient, with the unit cost of treatment being considerably higher in A&E than in primary care, and massively distortionary in terms of treating patients by clinical priority.
So what’s the solution? One option is that posited by the Telegraph leader article, which is to introduce charging for A&E attendees: ‘Reimburse the needy by all means, but charge all of us, if only modestly, for emergency treatment. Then we might think twice before getting our sneezing child in the queue ahead of the mugging victim’. A possibility, but it would seem unbelievably harsh to charge the homeless mugging victim, or the person who’s just arrived in an ambulance after suffering a heart attack. And, a wider point, charging can have somewhat perverse unintended consequences. People tend to value things more when they have to pay for them. Unless you’re going to charge some exorbitant amount, it’s unlikely to deter people from going; instead they’ll just demand more when they’re there. This wouldn’t necessarily be a bad thing in the general scheme of things – perhaps it would help drive up standards and the responsiveness of services – but the point is those with ‘sneezing children’ shouldn’t be in A&E in the first place.
Charging will not tackle the underlying problem, which is the wider inadequacy of out-of-hours care and the fact that people genuinely aren’t sure of where they’re supposed to be going in the system. I’m sure people would rather speak to their GP out-of-hours than sit in A&E for 4 hours at a time.
A better idea, at least in the short-term, would be for PCTs and GP practices to at least relay a clear roadmap for out-of-hours care and the myriad of options patients now have for ‘urgent’ care.
In the longer-term, however, the government itself could, for once, have the answer: the APMS contract. Last month, Alan Johnson, the new Secretary of State for Health asked PCTs to use independent providers to fill gaps in GP services, highlighted in the 2007 GP Patient Survey, as part of a drive to ensure better access for patients. Indeed, as was reported in the HSJ, the DH has already been working with nine PCTs to put GP services out to tender as part of the ‘Fairness in Primary Care’ procurement to get GPs into under-doctored areas. Using the APMS contract is important; not only does it increase independent provision, but it also enables PCTs to lay down specifications – including longer opening hours and that GP practices organise out-of-hours care. GP practices signing-up to practice-based commissioning will also have this responsibility. Other GP practices will then be forced to compete, drive up their own standards and, with PCTs, commission (or provide) decent out-of-hours care, with real cost-based incentives to relay the best pathways to their patients. If they don’t, patients can vote with their feet and go elsewhere to another GP practice.