John Launer: Out of hours—then and now

Dear Editor,
I have enjoyed Launer's earlier columns, but as an OOH GP leader, I wish to tell our story following his piece about OOH. I am Medical Director of BrisDoc Healthcare Services based in Bristol. BrisDoc grew from a GP co-op into a social enterprise which provides (in new money) Severnside Integrated Urgent Care Service, the 'marriage' of NHS 111 and (in old money) OOH. It serves around one million people. In my experience, understanding of OOH and 111 amongst the wider medical community is limited.

As Launer says, OOH is very different from almost forty years ago. But he goes on to conflate OOH and 111 - they are related but distinct services - and he offers slender anecdote. I have queasy memories of old-style OOH when I trained as a GP in the early nineties. Covering a large city-centre practice with a bleep, a landline and a map was relentless, stressful and exhausting. The GP profession readily, and for many good reasons, handed over responsibility for OOH in 2004. And then came NHS 111 a few years later. I have fired shots at 111 in the past, but have since gained insight into its scale, complexity and challenges. Inevitably it is risk-averse when it is taking literally millions of calls per year, and cases range from the trivial to the catastrophic. 111 is a simple number to remember, or to use online, anywhere in the country. Cases come straight from 111 (phone or online) to us. The plethora of urgent care services in some areas might be "confusing", as Launer says, but that is distinct from 111 and OOH.

Most of the 111 cases that generate an Emergency Department or ambulance disposition are sense-checked (validated) by a clinician. In the Clinical Assessment Service (CAS) of Severnside, we have enhanced this by creating a System CAS, which adds doctors, mental health workers and others who can use photo, video and prescribing to sort things out there and then. The results are impressive. And in the OOH part of Severnside, we take around 400 calls per month from paramedics (whether originally from 111 or not). We keep around 85% of such patients out of hospital; the boy in Launer's second anecdote would likely be one such example. Yes, there are cases which slip the net, but the accusation of a "criminally wasteful mess" is, in my view, unfair and inaccurate.

Launer asserts that OOH is "clinically unsound". I invite him, and anyone else, to come and visit. We were pioneers of clinical audit software called Clinical Guardian, which provides near-time feedback, support and advice to all our clinicians. It is now used by multiple OOH providers, has been described as "outstanding" by CQC, and was the subject of a BJGP paper looking at how it could be transposed into general practice. BrisDoc won the HSJ patient safety culture award in 2022. As well as concrete measures such as Guardian, we enable an open, supportive learning environment. And we have a Severnside queue called "Consult and Hold", in which we hold cases (such as the boy in Launer's first anecdote) whom we have assessed and plan to call back to check again (where possible by the same clinician), or for whom we're awaiting results, or complex cases for the designated senior GP to review.

In addition to the above, we work hand-in-hand with the local GP federation, to do our collective best to keep general practice joined-up 24/7.

The clock only moves forward. Both 111 and OOH providers work hard to serve patients well. And BrisDoc is not alone; we are members of Urgent Health UK, an umbrella organisation for around twenty-six social enterprise OOH providers, who offer mutual support, insight and intelligence.

I encourage Launer to pause, reflect and enquire in future, before making sweepingly negative statements about entire sectors.

Good wishes,

Kathy

Dr Kathy Ryan