Out of Hours work - a personal view

Family doctor on-call

There has been a lot of comment in the press recently about the deterioration of “out of hours” (OOH) medical cover since GPs went onto the new contract. Over 90% of the profession accepted the government’s offer to opt out of providing this cover. GPs have had significant pay rises over the last two years. Not as high as the media would have you believe, but nonetheless significant. For the large part these pay rises have been achieved by chasing government designed health care targets which, though not totally without merit, have not impacted on the day to day health care received by patients.

Most patients would prefer to be able to see their own doctor on a Saturday afternoon than know that he has entered their height, weight and cholesterol levels onto his computer. So the deterioration in OOH service has not been mitigated by successful target chasing.

I want to give a personal account of what my partners and I have done with OOH care over the last twenty years. I will describe as best I can what has happened, and why it has happened.

I will describe honestly how we feel about it. I make no judgement as to rights and wrongs. That is for others.

I did five years of hospital medicine before becoming a family doctor. During those five years I worked 1 in 2s, 1 in 3s and, for one job, a luxurious 1 in 4. Working a “1 in 2” means that, as well as the ordinary working week, you work every other night and every other weekend. During those years, I saw little of friends in other careers and, indeed, lost touch with some of them. On nights off I was too tired to do much. I usually ended up drinking too much beer and falling asleep in an arm chair. My partner was also a doctor. If we got onto rotas that did not fit properly, we might go a month without seeing each other.

The general practice I joined, and am still in, had seven partners (now nine) but five of them were over sixty and two of them were over seventy. They did not do OOH work themselves. They farmed it out to a commercial deputising service, commonly known in the trade as the “dangerous doctor service”. I was committed to family medicine, and to providing a personal service to patients, as was the other young partner.

We started doing our own on call. As the older partners retired, the whole practice followed suit. We put a clause in the partnership agreement banning the use of deputising services. We were on a mission. We hated deputising services. We were totally committed to personal availability.

The on-call commitment was one weekday night a week, and one weekend in six. I usually did Tuesday night. From seven in the evening, when the practice closed until eight in the morning when it opened, I was available for the patients. At the weekend, we would be on call from eight o’ clock on Saturday morning through until Monday at 8.00 a.m. There was no time off in lieu. I worked solidly from Tuesday morning through until Wednesday evening. It was hard.

The weekends were worse.

I felt strongly that a family doctor should be available for his patients. That is why I went into the job. I did not fall off a hospital ladder. I was always going to be a GP.

I did not resent being called out for medical emergencies. I remember going to see an old lady in LVF at four o’ clock in the morning. Neither she nor her husband wanted hospital. So I gave her a small dose of morphine and a large dose of frusemide and went back to see her at half seven on the way into work. And she was better. Treating LVF – when it works – is gratifying. I remember nebulising the asthmatics. I remember the pneumonias, the chest pains, and the serious problems.

How often was I called out at night? We kept figures. It was not that often at first. On average, I would expect two visits before midnight and one after. Occasionally, they could be dealt with on the phone, but I was never very good at telephone advice, particularly for hot children. I never got back to sleep. Less stressful to go to see them.

It was always stressful. The stress was not doing the visits. It was waiting for them. The only time you relaxed slightly was when you were actually doing the visit. Even if you had a lucky night with no calls, you rarely slept.

Weekends were worse, particularly Sundays. The house-calls would start coming in at about seven o’clock in the morning, and the whole of Sunday would be spent driving from house to house. And always the frustrations: a couple of calls, drive home, and the phone goes again just as you got out of the car.

Telephone medicine is bad medicine as the failure of NHS DIRECT shows. For a conscientious doctor, a child with a temperature is always a possible meningitis. As a doctor, once you have spoken to the parent, the medico-legal responsibility shifts onto you. It may be reasonable to say "give her some paracetamol and phone back if there are problems" - indeed it is reasonable but when, three hours later, the child gets meningitis and Dad rushes her off to hospital, the story he will give is "...and the effing doctor refused to come and see her" and probably also the inexperienced A/E doctor or, more likely these days, the nurse specialist will raise eyebrows and say, "Didn't the doctor come out? Oh! Dear."

So, if you are a worrier like me, you always get up and go and see hot children. It is less stressful than lying awake thinking about it.

I did this for twelve years.

Things evolve with time. Things change. I got older. I had been doing OOH on-call work of one sort or another for seventeen years. I still did not resent the calls to urgent medical problems. That is the job. But the nature of the calls changed too. People no longer viewed the OOH service as something for emergencies. They started using it for routine medical problems.

I really was called out on a Sunday to look at a verucca. I had a call at 3.00 am for a couple who had just had intercourse and burst a condom. Could I bring them the morning after pill? Parents were no longer prepared to deal with minor childhood illness. I had to visit children with coughs, colds and sneezes at all times of the day and night. For some reason, OOH problems are always regarded as more urgent. A parent who phones at 8.00 am for an appointment on a Monday seems happy when given a slot at 2.00 p.m. At the weekend, however, there is an expectation, fuelled by the government, that such visits should be done within two hours. Why?

Some patients give less thought to calling out the doctor than they would to ordering a late-night take-away pizza.

I used to dread the 11.15 pm peak of visits. Kylie, aged 8, has a temperature and is lying on the sofa. Mum is coping with this, and not worried. Dad gets home from the pub, worse for wear, and says to his dear lady, "What do you mean, she has a temperature...get the effing doctor out" and then he phones and tells you that "I want the doctor out, I pay your effing salary"

In the late nineties, when the strain of providing this OOH service was becoming too much, I co-founded a doctors' co-operative with fifty colleagues in the area. This grew very quickly and within two years was one of the largest co-operatives in the country. We still did the OOH work ourselves, but we shared it. We set up OOH visiting centres so that patients could come in during the evening and the weekend.

We were a victim of our own success. Co-operatives did take the strain off but, by providing walk-in centres, fuelled the demand and the expectation for routine medical care at any time of the day or night.

Co-operatives sprung up all over the country. The government saw them as a mechanism for centralising and controlling OOH services and, with the new contract, took most of them over.

They made one mistake. They had not realised that the co-operatives only survived financially because the doctors worked either for free or for a token payment only.

The government underestimated the amount of work that GPs were doing out-of-hours. They offered to allow GPs to contract out of the work in return for a pay cut of £6000 per year. They thought there would be few takers. In fact, the whole profession took the option.

So now the government had to run the co-operatives themselves and had to pay an economic rate to attract doctors to the job. The source of free labour dried up. The co-operatives began to fail. A great shame. They had been an excellent compromise. Now it was back to our friends The Dangerous Doctor Service. This is an example of “the market place” in medicine. Much lauded by the right wingers as the answer to all the problems of the NHS. In reality, the market place serves only to demonstrate the real cost of medical care.

Dangerous Doctor Service

Neither I nor my partners work for the PCT out of hours service. Nor will we. There is no amount of money that could realistically be paid that would make any of us go back to this work. It is too onerous. It is too stressful.

The crowning irony of all this controversy is that, for the most part, the OOH service the government is attempting to provide is completely unnecessary. Most people who call a doctor out do so for reasons of their own convenience and could perfectly well come in to a call centre. NHS Direct tries to deal with it with a user friendly website and telephone advice, but it does not work. Nearly seventy per cent of calls to NHS Direct are passed on to the doctors. The aptly renamed NHS Redirect costs £70 million a year.

The cost of providing this unnecessary OOH service is enormous. It is a luxury we can ill afford.

I lost many years of my young adult life to OOH work. I could not cope with the strain of it anymore. I have to work a full day, 8.00 a.m. to 7.00 p.m.. There is no realistic amount of money that would make me go back to doing OOH work. If the government legislates to put the responsibility for modern OOH work back onto GPs I shall resign, as will thousands of other GPs. I could not do it anymore. It is not meanness or laziness. I could not do it.

This is why the government is in trouble with OOH services. They cannot find experienced family doctors prepared to do it. Some but not all of the doctors they do find are er...of a certain sort.

The most irritating thing about the demand for OOH routine medical services is that it is driven by the twittering middle classes who ought to know better. They ramble on about how hard they work, and the hours they do in their jobs, and therefore they think it reasonable that they should be able to see a doctor at the weekend. They do not expect to see their accountant or their stock-broker at the weekend, but that is different. What they do not realise is that having seen the doctor, there will be investigations and treatment. They will want to have their X-Rays and their blood tests and their physiotherapy and their out-patient appointments at weekends as well. And so it goes on. Unreasonable demand predicated by naivety and selfishness.

As Wat Tyler has demonstrated in Sex, Violence and Healthcare, the cost of health care is on track to consume the whole of the British GDP. We need to cut back on expenditure. We should concentrate on having a good service for medical emergencies at all times. We are failing in that area at the moment. It is not safe to be in hospital out side the ordinary working week as we saw in Hospital at Night with Sue & Dave and their protocol to cover up for the absence of OOH within hospitals.

Resources are thus being diverted from real medical care so that we can pander to Sebastian and Samantha who want their in-growing toe-nail cut on Sunday afternoon.

On a personal level, I regret that I will no longer be available to see the old lady in LVF. Now she will be sent straight into hospital. But I cannot provide a round the clock service for Sebastian and Samantha, however much money you offer me. I did it for seventeen years, and I have had enough. Someone else will have to cut their toenails.



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