Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Superb overview
- Daryl J Mullen (17 February 2007)
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general response
- chris f quartly (17 February 2007)
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We had it sorted
- Mark A Vorster (18 February 2007)
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Out of hours primary care
- John P Toby (21 February 2007)
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Fragmantation and Farce
- Adrian Baker (21 February 2007)
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Expensive maybe, but not a shambles
- graeme mackenzie (22 February 2007)
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Daryl J Mullen, GP Tutor Parbold Surgery, The Green, Parbold WN8 7DN
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A masterly response to the fragmented thinkers that appear to be driving Government strategy. I do hope Patricia Hewitt (or should that be Gordon Brown and his Health Secretary) are listening. Competing interests: None declared |
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chris f quartly, general practioner West Street Surgery LU6 !SF
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Why on earth does Iona Heath think that the current cottage industry of GP practices want to enter into the responsibility of provision of OOH care ensuring that the current target standards are met. In hours doctors are struggling with ensuring that QOF targets are met, GP access targets are reached, as well as meeting all the other needs of patients and managing their practices. GP's voted over whelmingly for the new contract splitting in hours and out and hours citing they were too tired to undertake work in the out of hours period but too often complain about the pay rate offered by the OOH providers. Instead these posts are offered and taken by very willing, competent and able EEU doctors over and above the often ill informed OOH existing doctors concerned more for their income than anything else. General Practioners knew what they were voting for and if they didn't were naive. The current evolutionary development of OOH primary care should be welcomed which can give patients excellent care if managed by professional managers within the aggreement of the local primary care trust rather than doctors with a self interest of control. The goal posts should not be moved. Competing interests: 1, Previously responsible clinician to the Luton Primecare OOH Branch 2. Current deputising doctor for the OOH provider Care UK |
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Mark A Vorster, GP Principal Regal Chambers, Hitchin, Herts SG5 1LL
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I was delighted to read this perceptive piece by Iona Heath. Until now much has remained unsaid about the transition of the out of hours service from co-operatives, essentially GP led, to the present mish mash of ‘services’. These services do not have any underlying corporate understanding of what is required, other than jumping to attention to obey a constant stream of centralized directives. One such example is the proclamation to have ‘skill mix’, whether or not it is appropriate to the local circumstances. In my area we went through the exciting times in the 90’s when GP’s got together to set up local co-operatives. There was a real buzz, a real drive, a sense of creating something of quality which was good both for doctors and patients. We did it ourselves, essentially without real support from ‘management’, and in many cases, many, many hours of hard graft for no remuneration whatsoever. If this kernel of excellence had been fostered there would have been no need for any change with the opt out, because there would have been a viable mix of working and non working GP’s. Like many co-operatives the financial equations did not stack up once numbers of working GP’s leached away. GP’s would have known how best to blend their services with A+E departments, and how important it would have been to have robust electronic records to assist continuity of care (efficient working local systems that is, not the connecting for health debacle). Now we feel alienated from the ‘system’, although of course some of us do shifts (rather joylessly) while the money is there for the taking. It has taken many years, and much taxpayers money, for the politicians to appreciate what GP’s knew to be the hard realities of robust 24 hour care. Competing interests: None declared |
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John P Toby, Sessional GP Northamptonshire
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Iona Heath draws attention to some very important issues that merit urgent attention. However, the situation is more complex than she suggests in a number of ways and her diagnosis is incomplete. A number of areas other than SE London are still served by GP cooperatives or even by individual practices. One of these is Northampton where I have been a GP for many years and also chaired a PCT (Primary Care Trust) from 2002 to 2006. The suggestion that GPs were pushed out seems wrong since the ability to opt out was seen as an important demand of those negotiating the latest GMS Contract. The responsibility was widely regarded as a disadvantage of general practice and a deterrent to recruitment even though, as Heath points out, this may seem illogical as GPs were not required necessarily to provide the services themselves. However, I am sure that she is right that many PCTs have taken the opportunity to draw more professions into the provision of out of hours care. Some of these probably were motivated by a desire to reduce or even eliminate GPs but others were simply trying to ensure the provision of care for their patients. There may have been those in the NHS centrally who saw this as part of a policy of breaking the GP monopoly or used it opportunistically. However, to cast the GPs in the role of victims is not helpful even if there is an element of truth in the interpretation. Such an attitude tends to obscure the fact that the principal victims have been patients and confirm GPs in a passive role whereas an active response is required if patients are to continue to benefit from general practice. The victim mentality will also tend to alienate many supporters of general practice amongst patients and NHS managers. The principles set out by Heath are important. She highlights the need to have the most experienced personnel engaged in triage if patients are to be spared unnecessary referrals, investigations and treatment. She also emphasises the need for personal responsibility. The balance between need and convenience will require continuing dialogue with patients and the public but clearly sensible limits will continue to be needed. In essence, for many of us, it is time for general practice to set out its stall for patients and for this to include more comprehensive care. It is worth reminding readers that ‘out of hours’ care covers more than 2/3rds of the time and, if general practice is to have continuing credibility, it cannot afford to neglect this. It is interesting that Quigley, writing in the same issue of the BMJ of what patients want (BMJ2007;334:343), comes to the same conclusion. The new contractual options offer a variety of ways to make this possible but what is needed is an assertion of the values of general practice and its value for patients together with an open debate about how these can be sustained. Competing interests: None declared |
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Adrian Baker, GP Principal and Clinical Lead Nairn & Ardersier, Highland. IV12 4RF
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The OOH debris is currently being seen in patient care, with increasing numbers of elderly, terminal and infirm patients being admitted inappropriately to consultant beds. An integrated service offering local knowledge, retaining skills and multidisciplinary working, which resonates with General Practices core values is being maintained, in pockets, in the UK. The fragmentation of a once enthusiastic General Practice service and the obstruction of a return by GP's to the service by managers is detrimental to patient care and not cost effective. In our pocket we still operate personal lists, take responsibility and are accountable for our patients 24/7, providing A & E, OOH services and GP hospital beds. This results more patients being maintained in their own communities by their own GP's, nurses, AHP's, Home care teams and families The effect of this on the whole system for the wider population would produce higher quality care 24/7 and a net saving in the total budget. GP's opting back in, and being encouraged to do so, would improve the overall service. Competing interests: None declared |
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graeme mackenzie, GP OUT OF HOURS CUMBRIA
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I have recently become a full time salaried GP for an out of hours organisation, after 20 years as a principal. In my latter years as a GP principal, while working occasional shifts, I was struck as the higher quality of emergency care an out of hours organisation was able to provide. That ability is further enhanced by salaried out of hours specialists. While doing "emergency" visits during the day I was struck how inferior my equipment was, how much longer I often took to reach the patient, how difficult it was for patient to get through to request an urgent visit and how my frame of mind was not right for emergency care, especially in the home. That frame of mind was wrong because I was fitting in my urgent care and home visits, rather than it being my main responsibility. My remit as a principal had become too large. When out of hours co-operative started, I think in many areas there was a jump in quality. I remarked to many that if a patient requested a urgent visit before 8 am they got a fully equipped car supported by a signficant infrastructure. After 8 am they got a GP with a toothbrush hanging out his mouth, trying to fit in the work before surgery. The time has maybe come to separate urgent primary care from elective care. Out of hours is of course mostly urgent. GP practices could do it again but to achieve the standards of many co-operatives, they would need to invest (dedicated cars, fully equiped, care pathways within their practices for urgent care (no more constantly engaged tones) ) and even retrain. Of course that would be best done as groups of practices which of course brings us back to where we are. I will stick my neck out and say that the service I provided as a principal before co-operatives was signficantly inferior to what I provide as a salaried GP in an out of hours organisation. Competing interests: SALARIED OUT OF HOURS GP |
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