GPs in the UK relinquished responsibility for managing out-of-hours care in 2004, and since then there has been a rumbling undertone about the quality provided. Years ago, when I was completing my training as a junior, the responsibility for night work was pretty clear. The GPs covered their own practices at night, and most of the work in hospitals was done by the junior doctors — some of them with several years' experience, and many of them of excellent judgement, but juniors nevertheless. Then the whole role of juniors changed, with fewer of them around, and their hours of work more tightly controlled. At the same time the plan was that consultants, the doctors with most expertise, should be more personally involved out-of-hours, as has happened. But look: in the same period exactly the opposite change has taken place in primary care. Now those with most experience sleep soundly in their beds while those with rather less experience do the work. The editorial on page 3 points out why this is difficult work: the doctors are more isolated, with less team support, and are less likely to know the patients. You would predict that the less experienced doctors will refer more patients to hospital, so that changes in out-of-hours arrangements for primary care will be reflected not in primary care, but in secondary care data. The study on page 24 didn't report on extent of experience, but did find an association between GPs ability to tolerate risk and lower referral rates, confirming findings from the same authors' study published in 2007.1 One quirky finding in this study was that only 5% of the participating doctors considered themselves ‘high referrers’. Out-of-hours work is demanding enough, but patients' expectations about the ideal speed of response is now at a level where delivering a service perceived as ‘excellent’ is going to be very difficult (page 18). A paper a few years ago suggested that one of the attractions of general practice as a career option is the prospect of a quiet life.2 (That motive may go some way to explaining the ‘shy GP factor’ postulated by Matthew Burkes on page 53). So it's a pleasant surprise to learn that, in Scotland at least, 40% of GPs are volunteering for out-of-hours work — the authors report that such willingness is at least partly linked to a desire to boost income (page 12).
Elsewhere in the Back Pages, John Middleton has paid homage to his father's contribution to general practice (page 62), and the ICER training model developed in the Midlands. For once we've been able to present empirical evidence to support such personal opinions. The paper on page 29 reports an association between reporting more ICE (ideas, concerns, and expectations) components and lower levels of prescribing new medication. The overall conclusion is in line with the notion, I think first reported by Ann Cartwright many years ago, that doctors often overestimate their patients' desire to receive a prescription. The study also, rather depressingly, reports that there was no exploration of ICE in one-fifth of all consultations. But then doctors cannot be expected to do the right thing all the time, any more than their patients can. A striking illustration is given on page 37, where patients with type 2 diabetes were aware of the increased risk to their offspring and felt they should be giving them advice, but were not succeeding in doing so. Application of the ICE approach sounds like one of the formulae that we could all apply to try to emulate the ‘good doctors’ described in history and literature (page 58); interesting that the author is unsure whether Dr Gachet, the doctor immortalised in Van Gogh's portraits, belongs in this category or not.
Also in the Back Pages there is a small outbreak of classical allusions. Spot the conscious one on page 57 (it's Virgil). But on page 63, the reference to a monster with many eyes reminded me of the mythological Argos, who was killed by Hermes and then turned into a peacock with the eyes becoming his tail. Then I was reminded of the parody, whose provenance I have been unable to trace (answers in an email please):
‘The night has a thousand eyes
And the poet might surmise
How lucky the night is
Not to have conjunctivitis.’
- © British Journal of General Practice, 2009.
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