In his desperate quest to find some distinctive policy to distinguish his ascent to prime ministerial office, Gordon Brown has latched on to the notion of extending access to GP services outside conventional working hours. He seems to be committed to the principle of ‘unscheduled’ care, offering unrestricted access to patients, irrespective of whether their complaints are serious or trivial, acute or chronic. While the media extol the virtues of primary health care on the Tesco model, there appears to be little public objection to the emergence of surgeries staffed by security guards and the healthcare equivalent of the minimum-wage shelf-stacker — or the call-centre shift-worker — providing instant advice and treatment according to the dictates of a computer algorithm.
As Iona Heath has argued, the reorganisation of out-of-hours care following the introduction of the new contract in 2004 has resulted in the fragmentation of services and in a further erosion of the personal relationship between doctor and patient that has been the bedrock of the NHS (and, as it happens, the secret of both its effectiveness and its efficiency).1 Although there has been some recent discussion of the problems of access to records within out-of-hours services, these pale into insignificance before the problems that are likely to result from the lack of availability of patients' routine medical records in out-of-hours consultations. If, as Gordon Brown demands and others approve, the role of out-of-hours services is to be shifted away from providing urgent, ‘immediately-necessary’, care pending a return to the patient's regular GP, towards the provision of universal ‘unscheduled’ care 24/7, then these problems are likely to be exacerbated. They will be particularly serious for patients with complex medical problems, for those whose command of English is poor, for those with mental health or learning difficulties.
In the early 1990s, when we first installed a practice computer and the word ‘modem’ entered our vocabulary, I recall setting up a system that enabled us to hack into our surgery records when we were on call on evenings and weekends. It was always useful, sometimes essential, to get basic information about medical history, recent encounters, and current medication before returning a call to a patient or doing a home visit. When, in the late 1990s, we joined up in a local out-of-hours coop, it was no longer possible to do this, even for our own patients, although it was easy enough to ask the driver to stop off at the surgery en route to visits to pick up records. Although it was the familiar NHS IT experience of ‘two steps forward, one step back’, continuity of care was preserved to some degree through close personal contacts among a small number of GPs, so that it was easy to pass on details of particular cases, informally and efficiently.
Since our entry into the primary care millennium inaugurated by the 2004 contract, our local coop has become incorporated into a vast consortium. All out-of-hours contacts between patients and doctors now have a random, atomised, character: the default assumption is of no previous relationship, no mutual knowledge, or understanding. Furthermore, not only is the doctor in contact with the patient out of hours very unlikely to be the patient's regular GP, the out-of-hours doctor is also unlikely even to know this GP, or to have any familiarity with the practice at which the patient is registered. Thus, although some form of call sheet may be faxed or e-mailed, it is likely to have a formal and perfunctory character. The result is a system that is unsatisfactory for patients and for doctors, and increasingly risky for both.
Given that anxieties about confidentiality are likely to make any readily-accessible national database of patient records unfeasible, it is difficult to see how the current out-of-hours system can be made safe without some system of patient-held records. In the absence of a reliable system for making key medical information available, the promotion under the slogan of access of a more comprehensive system of unscheduled care is likely to compromise the quality and continuity of care and, inevitably, patient safety.
- © British Journal of General Practice, 2007.
