Twenty-four hour responsibility for a registered patient list was one of the cardinal features of NHS general practice for many years. In the almost unimaginable days before mobile telephones, a relatively untrained spouse often had the unenviable task of triaging phone calls from worried patients and trying to track down the GP who was out on calls, perhaps with a cumbersome radio-telephone with unreliable reception. These unsatisfactory and potentially unsafe arrangements were gradually superseded by a more structured approach to out-of-hours care, but for many years practices or groups of practices not only retained personal responsibility for their patients but were also personally involved in doing house calls at night. The Monday morning team meeting was a good opportunity to review the illest, most vulnerable, and most problematic patients on the list. Changes in the GP contract over more recent years have resulted in a retreat from these responsibilities and a growing division between those GPs doing in-hours care and those providing emergency care at night and weekends. The professional, clinical, educational, ethical, and political ramifications of these changes have been discussed endlessly, and there are real concerns about the erosion of continuity, the safety of handovers from sessional doctors about patients seen at weekends, the training opportunities that have been lost when trainees see so little emergency primary care medicine, and the impact on public trust and esteem of the apparent increasing unavailability of GPs. The topic has most recently reappeared in the spotlight because of a perception that accident and emergency departments are now reeling under a greatly-increased patient load which, it is claimed, is at least in part caused by poor provision of out-of-hours services in primary care.
How should urgent primary care be provided? Who are the key players and how should they form an effective out-of-hours team? Is it worth trying to re-connect with some of the values and commitments that set British general practice apart — the jewel in the crown of the NHS — or should we give up the idea of a lost, golden age and get real about the aspirations and working lives of medical professionals in the 21st century? We asked four well-placed colleagues for their views.
- © British Journal of General Practice 2013
