Commentary: Changing the culture of out of hours care

The Department of Health and the GMSC have breathed collective, but possibly premature, sighs of relief following the settlement reached on out of hours care. The agreed package of structural and financial measures provides the opportunity for major changes in the way in which general practitioner services are delivered out of hours. However, the extent to which the potential for change is realised depends on a broad range of factors which either did not or could not form part of the negotiating agenda. Court and colleagues' findings on factors influencing decisions to visit out of hours are an example of the latter and should be considered in the light of the settlement that was agreed.

The rewording of clause 13 of general practitioners' terms and conditions of service1 has reinforced general practitioners' right to determine whether and where an out of hours consultation takes place. In conjunction with development funds and the payment of a fee for any face to face consultation at night, this is expected to encourage the establishment of primary care emergency centres as an alternative to home visiting. Development funds will also support the creation of cooperatives, a natural organisational focus for out of hours centres. The success of this strategy will depend on a major cultural change, not only among patients but also among general practitioners.

The idea inherent in clause 13, that the patient's medical condition is the sole factor governing the site of consultation, is manifestly too simplistic. As Court and colleagues report, general practitioners are influenced by social factors as well as clinical factors. The fear of missing an urgent condition or of being the subject of complaint reinforces negative, defensive practices. Patients also expect home visits on the basis of social factors.2 The advent of the market economy in health care, and the raised expectations created by this and patients' charters, make it more rather than less likely that they will insist on a home visit.

Efforts to introduce out of hours care based in surgeries to areas with little or no experience of the concept have not generally proved successful. In Cragg and colleagues' study of five primary care centres run by deputising services, the average attendance rate among patients requesting medical help was only 22%.2 Existing centres tend to function only at times of high demand—weekends and bank holidays, for instance—or to revert to traditional home visiting patterns during the night, when demand is low and problems are more likely to be clinically serious. The change in eligibility for a night visit fee is thus unlikely to have more than a marginal effect on the attraction of centre based care.

Before and during the dispute on out of hours care, an appreciable proportion of general practitioners voiced their opposition to the 24 hour contract3 and demanded that it be renegotiated.4 5 6 Despite the perception of many general practitioners, this issue was not on the negotiating agenda, though it is obliquely reflected in the agreement that one general practitioner may transfer to another the responsibility for his or her patients out of hours. The substantial development funds included in the package will be distributed to family health service authorities on an “equitable” basis, but they will be made available only to general practitioner bidders and restricted to the reimbursement of costs incurred by general practitioners. As Hurwitz has pointed out,7 their impact thus depends on general practitioners' willingness to retain a leading role in the provision of primary care services out of hours. Whether the package as a whole will be attractive enough to secure general practitioners' long term commitment to 24 hour care is uncertain.

Despite these reservations, valuable opportunities to improve the lot of general practitioners on call are contained within this settlement. Much will depend on the goodwill of general practitioners to create sustainable alternative patterns of organisation. It is difficult to predict to what extent they will be prepared and able to adapt their patterns of response, and whether the type of changes being encouraged will be acceptable to patients and their carers.