Julie Hoskin: Problems in practice for ‘open-all-hours’ GP surgeries

Many will have some sympathy with the Government position and feel that if the rest of 
the NHS is opening seven 
days a week why shouldn’t GP surgeries?

One of the main reasons is to do with the fact that GPs and their staff are not part of the NHS in the way that consultants, registrars and hospital nurses are. The Government cannot force the GPs to “open all hours” any more than Tesco and Sainsbury’s can force independent shops to close at 4pm on Sundays.

To put this into context, when the NHS opened its doors to patients, health care professionals (hospital doctors, nurses, pharmacists, dentists and opticians) were united under the NHS umbrella. It was originally intended that GPs should be employed directly by the NHS but this was unaffordable, so they remained as independent contractors. When given the choice of joining in the early 1950s, GPs voted overwhelmingly against the idea.

This situation exists today as GPs are contracted to provide services for patients by the Department of Health. These services are for people who are ill, or believe that they are, with conditions from which recovery is expected. They also provide care for patients with long-term, chronic illnesses and for those who are terminally ill. This is the core contract, with additional services added on or removed as successive governments change.

Until 2004, part of this provision of services included out-of-hours cover, which would include night visits. GPs would make several night visits but would still have to provide a daytime service.

They were also responsible for providing 24-hour weekend care as well as cover on bank holidays.

The contract established in 2004 offered GPs the chance to opt out of providing out-of-hours care and transferred this responsibility to the Primary Care Trusts. The GPs lost income for this, on average £6,000 per year, but many chose to accept it and the PCTs had to devolve the service to a mixture of GP co-operatives, private providers and nurse triage services.

The question of who should provide out-of-hours care is one that seems unlikely to go away. The development of walk-in centres and out-of-hours services set up in the grounds of hospitals have no more solved the problem than surgeries set up in Sainsbury’s stores.

But the reported demand for 8am to 8pm opening by the working population may not even exist. Many GPs took advantage of an incentive payment scheme to provide extended opening hours in 2008, only to find it was under-used and funding was subsequently cut by the Government and the scheme was dropped.

As a practice nurse, I took a role in primary care to get away from a shift work pattern but I have always worked Saturdays as part of a rota. If surgeries are to open Saturdays, Sundays and Bank Holidays, GPs will have to pay their staff too.

An off-peak hours system might be an answer. It would mean patients who were working could only have an appointment before 9am and after 5pm.

Appointments between these times could then be given to those who are not at work, the elderly, or parents whose children are too ill to attend school. Scheduled appointments for patients with long-term conditions could be offered in the under-used slots with nurses who already support many of these patients and would be better placed to assist them with self-managed care plans.

It’s important that people remember that there are also pharmacies with consultation rooms with qualified prescribers who are keen to help. There also need to be stronger messages from A&E departments in terms of providing more advice on the conditions that can and cannot be treated by A&E staff.

The crux of the problem seems to be that the GP model of locally-based family care that provides a continuity of care and the familiarity of the family GP is what patients want from the service. If we are ill or our loved ones are ill, we want the reassurance of a familiar face telling us good or bad news in surroundings that we have come to know, regardless of the hour of the day or night.

How to make GPs agree to provide these services in an affordable way, as patients require it, is a dilemma that’s going to be difficult for both GPs and the Government to solve.

*Julie Hoskin is Senior lecturer in the Centre for Postgraduate Medical and Dental Education at Sheffield Hallam University.