I tried to book tickets to travel on a European train last week. One telephone conversation soon became several phone conversations with different people, none of whom could sort it out. It became such a gloomy and time-consuming experience that I almost gave up.
This experience is similar to those that many patients have when trying to access out-of-hours services from their GPs. Or rather, whoever is contracted to provide these services. For the past three years, responsibility for out-of-hours care has rested with the primary care trust rather than your GP.
To date, the House of Commons public accounts committee has been unimpressed with the handover of care. It recently described preparations for the transfer in England as “shambolic” and said the annual cost was “£70m higher than foreseen”.
GPs either used to do their own “on call” work or share the out-of-hours burden with a nearby practice. There was no subsequent time off for a doctor who was out all night, and some patients were as likely to ring at 3am, whether they thought they were having a heart attack or had head lice. As demand for out-of-hours contact increased, providing the same service became untenable.
To tackle the issue, some GPs formed co-operatives. I have worked in excellent ones, with well-lit and well-equipped space to see patients and with drivers to get GPs to house calls efficiently. Doctors tended to work shorter shifts but more intensively. The tightly audited care was good. It was also highly organised.
GPs were responsible for providing evening and weekend medical care until 2004 when the Department of Health gave them the option to opt out and let the local primary care trust run the out-of-hours service. The vast majority of practices chose to give up out-of-hours care, for which GPs lost an average of £6,000 a year, according to the government’s own figures.
Since the opt-out, many hospital accident and emergency departments have complained that they have been inundated – either with referrals from NHS Direct, the telephone and internet advice service, or by people unwilling to wait for long call-back times from the new out-of-hours services. This can’t be good for patients. So why did it happen?
Dr Iona Heath, a GP writing recently in the British Medical Journal, notes that one co-operative in south-east London offered out-of-hours cover at less than the cost of opting out. As a result, most GPs in that area continued to offer 24-hour cover for their patients. “This suggests that the vast majority of GPs would have retained 24-hour responsibility if they had not been financially penalised for doing so. The opt-out is a one-way process: having opted out, practices are not allowed to opt backin again. Why should this be so? The only explanation that makes sense to me is that the government wished to break the GP monopoly and to open up GP services to commercial competition.”
It made sense for the government to encourage GPs to stop providing out-of-hours care; the premise was that it could be done cheaper by other means. Does this translate into better care for the populace? In terms of out-of-hours care, probably not. NHS Direct and its equivalents are great for getting information about the opening hours of the nearest pharmacy, or a list of recommended immunisations. Yet I remain unconvinced about their value in assessing acute emergencies.
For instance, most people following a flowchart can deal with scabies or athlete’s foot. The problem is that you need to have made the right diagnosis to start with. Does the sleepy, hot little child with a headache have a cold or meningitis? The cheaper version of handling triage, the system whereby the most urgent problems are dealt with first, is done by clerical staff and then healthcare workers using computer-aided protocols before details are – or are not – passed to a doctor.
If the right diagnosis is not made, there is, of course, a diminishing chance of getting the right treatment. It seems obvious that triage should be done by the most highly trained person but these days the reverse is true. Doctors are not perfect diagnosticians but it makes no sense to give the most important decision to those with less training and less experience.
Meanwhile, there is an expanding army of private-sector providers willing to provide competitive out-of-hours care at a cheaper price. Cost savings have to be made somewhere. I have seen no evidence, however, to say that cheaper providers are better for patients.
With my attempt to buy a train ticket, eventually spoke to someone – after five phone calls – who was willing to double-check my planned rail route and find tickets for it. No harm done, there? No, but then the NHS is not a call centre and these are not tickets for a train we are buying.
Margaret McCartney is a GP in Glasgow
More columns at www.ft.com/mccartney