Intended for healthcare professionals

Opinion Talking Point

John Launer: Out of hours—then and now

BMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p762 (Published 05 April 2023) Cite this as: BMJ 2023;381:p762
  1. John Launer, GP educator and writer
  1. London
  1. johnlauner{at}aol.com
    Follow John on Twitter @johnlauner

Over the course of my career, some things in primary care have become much better and others far worse. Among the improvements, I’d name the management of long term conditions such as diabetes and COPD. This used to be haphazard but is generally now more systematic. The main area of deterioration, by contrast, has been continuity of care. Possibly the worst effects have been in out-of-hours services.

A flashback. It’s 1985. I’ve been a full time GP partner for a couple of years, having started straight after vocational training, and I already know many of our patients quite well. Once or twice a week I cover the on-call shift for my practice. One evening, I’ve just sat down on my chair for supper when my bleep goes off (my wife and I call this the “bum-bleep reflex”). I phone the messaging service. They tell me that a mother has called in because her teenage son has a temperature and is out of sorts.

I phone the family. I know they may be disappointed that I’m not their usual doctor, but it turns out that they still know me: I’ve seen their youngest daughter for one of her vaccinations, and her grandmother works in a local shop. I spend a few minutes checking for alarm symptoms in their son and then offer reassurance and advice. I tell them that I’ll call back in a couple of hours. When I do so, all is well. The boy’s temperature has come down, and he’s sleeping peacefully. I get three other calls that evening, but none of them leads to a home visit.

Flash forward to 2023. I’m talking to a paramedic, and she’s telling me about a typical call from her last ambulance shift. By coincidence, it also concerned a teenage boy with fever. His parents had called NHS 111, where someone took them through an algorithm and ticked the box for “fever plus lethargy.” This triggered escalation to the ambulance service. They found a boy who was also out of sorts with a temperature but with nothing alarming. The paramedic did everything I’d done all those years ago, but it wasn’t in her job description to offer to call the parents back later—she expected that they’d take the boy to the emergency department if he didn’t pick up quickly. She does four or five visits like this on every shift.

You could draw several morals from this parable and think of many social and political factors that have brought us to this point. I have two overriding thoughts. One is that it’s all terribly sad, especially the fragmentation of services and the replacement of trust by technology. My other thought is that surely the NHS can do better than this.

I know we cannot and wouldn’t want to restore the working conditions that made it possible to have the conversation I did 40 years ago. But surely politicians and managers could devise better models of out-of-hours care than the confusing, clinically unsound, criminally wasteful mess we have now.

Footnotes

  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.