Bill Hart: Dr Finlay is history, but we can find a prescription for out-of-hours care

I still feel that GPs greatly lost public respect and goodwill when we abdicated responsibility for out-of-hours care under the 2004 new contract. Nowadays, between 6pm and 8am, the local Primary Care Trust takes over the provision of emergency calls – so, strictly, accountability for the standard of care no longer lies with the doctor.

Patients, however, will see that differently, as most people relate to their GP as the first port of call in times of distress. When you are ill or frightened, having to go through your symptoms to a call centre operator, who is obviously using an on-screen template, can seem to be a waste of time.

Nevertheless, the old image of the familiar GP turning out in the small hours to dispense wisdom and antibiotics has to be consigned to history and may, anyway, have owed more to the imagination of AJ Cronin's Dr Finlay than to reality.

Many GPs were good when on call, others less so and many grumpy.

And who manned the telephone when the doctor was out on the road?

Often, it was an answering machine but usually a spouse carried the can.

My wife is a brilliant music teacher but not so hot on the diagnosis of meningitis over the phone. In truth, the service could be a bit amateurish, especially before we had mobile phones, and it badly needed updating.

Now, in theory, we should have a much safer system of out-of hours care, with modern communications, recording of calls and a rapid

response by appropriate professionals. The downside has to be the loss of continuity, but then sometimes you might rather not see that tired old GP you saw earlier in the week.

But herein lies the rub: without that continuity, the system becomes overwhelmed, unless the PCT invests more and more money in it,

neglecting other local priorities.

Lack of continuity means that patients are less likely to trust the advice given, and just turn up at A&E or call an ambulance.

It also means that those manning the out-of-hours service will play safe, as they don't have either the local knowledge or access to the medical records, tending to have people admitted to hospital when they do not want to go or their condition may not warrant it. This inevitably puts even more pressure on the ambulances and the hospital casualty unit.

From the GP's point of view, being on call, as well as doing the day job, has become almost impossible. We now do so much more in surgery than we used to. The management of chronic conditions, and their complex treatments, of which any one patient may have several, form the bulk of our work.

It's also about helping patients to navigate the increasingly bizarre and tortuous hospital services, fragmented as they are by super specialisation and the daft internal market. The paperwork forms mountains.

GPs have changed, too; nowadays they are much more likely to be part-time and want a life outside the profession. They are much less likely to be partners in the practice; rather they are salaried and work

fixed hours. All of this means that the idea of working out-of-hours, as well as during the day, is no longer seen as feasible or safe.

The knock-on effect of this is that GPs are fast becoming de-skilled in out-of-hours work.

So what is the solution?

If the Conservative Party is returned at the forthcoming election, it intends to give back responsibility for commissioning of out-of-hours services to GPs.

In practice, this is likely to mean that not much will change. The same organisations will continue to provide the service, but will be

directly accountable to GPs rather than the PCT, although there is a chance that this might drive up standards, provided someone is willing to spend money on it.

What it will not imply is a return to the continuity of old. My

suggestions are two-fold. Firstly, the National Electronic Heath Record

scheme, with appropriate safeguards for confidentiality, combining GP, hospital and social care records, must be brought in as a matter of urgency, at least ensuring continuity of information, if not of

practitioner.

Secondly, I would propose a new type of health professional to work out-of-hours. They would be a combination of paramedic and district nurse, working both on the road and in large health centres, being overseen

by doctors qualified in emergency medicine.

They would be able to prescribe or arrange hospital admission, having access to the electronic record, thus making the out-of-hours service safer and more responsive.

Faith could then be restored in the system and pressure taken off the hospitals.

Dr Bill Hart is a GP in East Yorkshire.