Out of hours care : the cover up

Out of Hours medical care

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A year ago, during the first few weeks of NHS BLOG DOCTOR, I introduced you to Sue and Dave, who were tasked with presenting “Hospital at Night” to the NHS. To New Labour, a cut in health care is not a disaster, it is an opportunity. The decision to denude hospitals of medical staff outside normal working hours was thus presented as a “learning experience”. Although the Essence of Care came a close second, Sue and Dave’s “getting a picture of the night” remained my favourite example from 2006 of cringe-making fraudulent government healthcare psychobabble.

I am grateful to Dr Grumble for drawing my attention to another document, issued by the Department of Health in October, which explains the current Out of Hours (OOH) medical service in the community and may well get the "Sue and Dave" award for 2007.

Is it called “Why can I never get hold of a doctor?” or “Why is NHS Direct such a waste of time?” Don’t be silly. Of course not.

Hmmm. That sounds good, doesn’t it? It’s another health care journey. Maybe it will explain where Britain’s 30,000 family doctors are at nights and weekends. Maybe it will justify the annual £60 million pounds spent on NHS Redirect.

The document is forty six pages long, and glossy. It has, at great expense, been sent out to thousands of people. It gets down to business straight away with the government's latest health care strategy.

Dishonesty.

If you lie often enough, people will believe you.

Care services are being radically transformed: standards have gone up; waiting lists are the lowest since records began; deaths from the big killer diseases are falling; A&E services have been transformed; there are more new hospitals; there is more extra care housing and intensive home care. New services are being provided closer to or in people’s homes by GP practices, pharmacies, ambulance clinicians, community hospitals, Urgent Care Centres and rapid response teams; and through assistive technologies. (Lord Warner)

Thank you, My Lord.

Dr Crippen knows what patients want from an OOH service. He does not need forty-six glossy pages. He can summarise their needs in one sentence.

If patients are ill in the middle of the night, or at the weekend, they want to speak to or see a doctor.

That is all. That is clear. Unfortunately, that service is no longer available. The government scrapped it. The government does not trust doctors. Those nasty, idle, port-swilling, swan-eating consultants spent most of the working week playing golf. So the government put them “on the clock” with a new contract which said they were only going to get paid for work done. That resulted in an across the board 20% pay rise for most hospital doctors.

You would think the government might have learnt the lesson. It did not. In particular, it had no comprehension of the amount of work that GPs were doing, virtually for free, to provide an OOH service across the country. The government offered to take over the work themselves thinking it would be straight forward and cheap. It is not. The GPs said “thank you very much” and went home to bed for a good night’s sleep.

Is the government going to admit that it made a mistake? Certainly not. Is it going to admit that there is a now a desperate shortage of medical staff in the community, just as there is in the hospitals? Certainly not. As always, it is going to pretend that the new service is an improvement. Last year we had “hospital at night”; now, for the community, we have “Direction of Travel for urgent care.”

Patients would be forgiven for thinking that “urgent care” implies seeing a doctor. Not any more. The government has redefined "urgent care".

Urgent care is the range of responses that health and care services provide to people who require – or who perceive the need for – urgent advice, care, treatment or diagnosis. People using services and carers should expect 24/7 consistent and rigorous assessment of the urgency of their care need and an appropriate and prompt response to that need.

An appropriate response may include anything from telephone advice and the assurance to self-care, through to face-to-face consultation with a clinician or deployment of a crisis team or admission to hospital in an emergency requiring specialised facilities. Wherever clinically safe, care should be delivered as close to home as possible, within a community setting.

= There is no doctor available.

The assessment of an individual’s urgent needs will be delivered by a wide variety of different services. For many of those services the assessment can be either on the telephone or face to face. What matters is that wherever someone chooses to go, or whichever service they choose to telephone, the urgency of their care need is assessed consistently and rigorously and an appropriate response is given, ranging from advice for self-care to booking an appointment for face-to-face care or arranging an emergency response.

= There is no doctor available.

Acute/A&E services and urgent care services should be appropriately configured with the aim of caring for people in the community where it is clinically safe to do so. We will be working over the next few months with clinicians and others to identify more clearly what is clinically safe, building on the work of the National Leadership Network.

= No, you cannot come to the hospital

The emergency care centre is modelled around the walk-in centre concept and is largely nurse-led. It is managed by a partnership including the PCT, the local outof-hours provider, the acute trust and the ambulance service. The setting up and running of this service, which crosses a number of traditional provider boundaries, has been catalysed by an energetic board of four directors drawn equally from primary and secondary care.

Patients are seen in a GP-style consultation room (sic) rather than a curtained cubicle. This gives patients greater privacy and dignity. Diagnostic procedures are kept to a minimum. Emergency care practitioners also see patients and do home visits using the emergency care centre as a base.

= There is no doctor available. Fooled you!

Harrogate Fast Response Team
The Harrogate Fast Response Team aims to prevent avoidable hospital admissions, facilitate early discharge, and provide out-of-hours skilled nursing care. Service users are helped to be as independent as possible within their own home or care setting. The team consists of district nurses, community nurses, community care officers, occupational therapists, physiotherapists, and generic and healthcare support workers**, and provides health and social services. The team deals with:

• people in crisis in the community due to an acute illness, an exacerbation of a previous medical condition, deterioration in a chronic condition, or an accident which would be likely to lead to a hospital admission

• people who present in A&E with a condition or injury not requiring in-patient treatment and who with support could be safely looked after at home

• people who no longer require acute medical intervention within an acute hospital, and who, with a package of health, social or rehabilitation care, could be discharged

• people who have an identified nursing need that extends beyond the normal working day

= There are no doctors available.

Imagine it is the Christmas holidays. Your baby is coughing and, from time to time, choking. What direction of travel will you take? The Welch family are a sensible, intelligent middle-class family. See how they managed the system in “The Welch Family Christmas”.

“Direction of Travel for Urgent care” is 46 pages long. It is about providing out-of-hours medical care in the community. How better to sum it up than by saying that the expression “urgent care” occurs 154 times, whilst the word “doctor” occurs 8 times.


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**could anyone explain what "generic and healthcare support workers" means?