It was last Christmas, with no surgeries open and a rota covering three practices for a rural population of about 8000 patients over 24 hours. In all there were six home visits and four calls to the minor injuries unit at the local community hospital, the first at 8.40am on Christmas morning, and the last at 5.30am on Boxing Day. The cases were oesophageal stricture, epilepsy, appendicitis, depression, asthma, tracheitis, chronic obstructive pulmonary disease, cervical spondolosis, suturing, and the ‘morning after’ pill. None were dramatic, and none unnecessary. Indeed in 40 years of ‘on call’ I have only had two really unnecessary calls.
It started in 1964 at Hyde Park Corner where the traffic noise in central London is constant for 24 hours a day — apart from a brief spell between 2am and 3am. As a junior hospital doctor at St. George's Hospital, before it became a hotel, we lived in for 6 months at a time, and were ‘on call’ five nights a fortnight. Consultants at the time said that was what they had to do in training, but this ignored the fact that even 40 years ago there were more investigations and greater patient throughput than in pre-war days. Today this is even more so, but such hours are now outlawed by the European Time Directive. It was stress training by sleep deprivation, rather like the army, but there was a camaraderie in the hospital mess, which is much less today. The only time we were officially allowed outside the hospital was to put up drips at private clinics for consultants who played the system for private patients. Partners were required to leave the hospital each morning clutching camp beds and sleeping bags, with no distinction made between wives and girlfriends; in those days junior hospital doctors were mainly male.
Hospital ‘on call’ became easier after the pre-registration year, although some involved house calls such as removing eyes from the recently deceased for corneal grafts … it sounds macabre, but the main impression was the gratefulness of relatives that someone else might benefit from their loss. After that, ‘on call’ meant house calls in primary care rather than hospital, with experience gained doing locums in the days before vocational training. During one summer in the north of Scotland the ‘on call’ system during the day depended on the lighthouse keeper who would send his son to the beach for the doctor when required.
This was followed by general practice in Glasgow, where a new health centre with six to eight practices covering some 40,000 patients established its own ‘on call’ system with an operator in the centre all night, a two-wave radio, and a back-up doctor if necessary. ‘On call’ was busy but the back-up was rarely required. One problem was getting someone to watch your car in case part of it disappeared while you were seeing the patient. Friends and neighbours were helpful at keeping an eye on the doctor's car, but even so a medical bag and a two-wave radio were taken during house calls.
Rural practice differs from inner-city practice depending on the distance from the nearest hospital with an accident and emergency department. In a city, all suturing, road traffic accidents, and most heart attacks go directly to a hospital; in rural areas ‘on call’ general practitioners (GPs) have to deal with all of these, which requires additional training if coming from an urban practice. This should be a requirement for rural practice together with, at least, annual refresher courses on emergency care, because the skills are not required often enough to remain competent through usage. Over a professional lifetime I have only used a defibrillator and CPR device twice, and a clot buster for myocardial infarction once. Rural GPs should be like airline pilots who are required to practice emergency landings regularly on simulators, which most will never have to use.
The 1990 GP contract brought in two-tier payments designed to make doctors more likely to see their own patients out of hours, but the unintended consequence was that larger rotas were formed which made this less likely.1 Although patients may prefer to see a practice doctor out of hours, there is no evidence that this results in more appropriate hospital referrals or better health outcomes.2,3 Other studies indicated a tendency to be more dissatisfied with telephone advice,4 which was more likely to be given by practice doctors who also gave fewer prescriptions than deputising doctors.5 During the 1990s the debate intensified regarding GPs opting out of out-of-hours care.6-9 This was partly due to the clumsy efforts of the 1990 Contract to encourage GPs to do more of out-of-hours care with financial incentives, together with an emphasis on capitation fees and competition. Other reasons were the rising demands of patients,10 and the growing number of female GPs who were not prepared for family life to be disrupted. Even so the Local Medical Committees conference in 1994 voted by a large majority to retain 24-hour responsibility in line with General Medical Services Committee policy at the time.11
As a result, additional money was allocated for out-of-hours care, with greater flexibility to form cooperatives or use deputising services.12-14 Many cooperatives were formed, which resulted in roughly 40% of calls being dealt with by telephone, 30% by visits to the primary care centre, and only 30% requiring a home visit.15 One study showed that cooperatives resulted in fewer patients being visited and fewer receiving prescriptions than a deputising service.16 Similar arrangements were set up in rural areas, such as more recently in Dumfries and Galloway where two call centres with nurse triage were delivering out-of-hours care with high patient satisfaction, by local GPs in conjunction with a good ambulance service and well trained paramedics.
Then came the new GMS contract with GPs being able to opt out of out-of-hours care. They could do this before through deputising services and cooperatives, but the sea change was ending the 24-hour, 365-day responsibility as part of general medical services. The local call centres were closed and calls were directed outside the region to Paisley, partly due to boost NHS 24, which in spite of millions of government money has not been shown to improve patient satisfaction or reduce demand on GPs. Because GPs are no longer responsible for out-of-hours care, the health board has prepared plans with minimal GP cover over a wide rural area backed up by nurse triage and an ambulance service that is already overstretched. This has caused increasing local concern, especially when patients may be 50 miles away from the nearest district general hospital. Petitions of over 3000 signatures from a sparsely populated rural area have been handed in to the health board, and local GPs have also written to say that the proposals are unsafe. Meanwhile the health board struggles to find GPs prepared to cover out-of-hours shifts, with a limited budget, which does not reflect the true cost of what used to be provided by GPs as part of their terms and conditions of service.
Clinically, there is now better control of chronic disease such as asthma, diabetes and, to a lesser extent, epilepsy, so that there are less likely to be calls for status asthmaticus or diabetic crises. There are also less childhood infectious diseases, but more older people are being cared for in the community, many with multiple pathology, and there are more problems with the mentally ill following closure of psychiatric hospitals. It is not clear why demand has increased, but one factor is the way in which patients are treated as consumers by successive governments, and used as pawns in a political game of one-up-manship. The result is that the relationship of personal trust between patients and family doctors is being replaced by demands from a service that has become increasingly impersonal. Even so, in my experience patients have usually been considerate about calling out of hours, but this may become less so when GPs no longer carry that responsibility themselves. Often the problem has been not calling sooner, and the iceberg of illness is larger than the trivia, even out of hours.17 One young doctor stopped complaining about unnecessary calls to children, when he started a family of his own. Publicity campaigns to stop troubling your doctor unnecessarily are as inappropriate as the suggestion to fine patients for not keeping surgery appointments. If patients don't miss scheduled appointments, how are GPs expected to catch up on full surgeries with only 10 minutes per patient?
There is no necessity for family doctors to do out-of-hours calls or, for that matter, to visit patients at home, but something has been lost from general practice. At a personal level there is the buzz of not knowing what to expect, although even experienced doctors can find this a source of anxiety. To counterbalance the telephone awakenings and loss of sleep, there are memories of dawn rising over Glasgow tenements and moonlight on the Solway Firth, and the satisfaction of feeling that perhaps sometimes one has made a difference.
In the world of the new contract, patients are no longer registered with a doctor but with a primary care team. It is ironic that while the numbers of medical students have increased, doctors may be less in demand in primary care when much of their job can be done by groups with less expensive training and expectations. The worth of GPs has now been diminished — in the eyes of government because there are less costly alternatives, and in the eyes of patients because they are no longer responsible for their care. It is as if those negotiating the new contract, were so busy redesigning the ship of general practice with bright new rigging for performance-related pay, that they inadvertently cast off the moorings, which secured the ship to the shore of responsibility for individual patients, so that the new rigged ship is now drifting away on a tide of political expedience.
- © British Journal of General Practice, 2004.