Tom Goodfellow

Shared responsibility needed for OOH cover

As the entirely predictable (and in my view avoidable) A&E crisis rumbles on it is equally predictable that the “name, blame and shame” game will continue. The press, spurred on by the Secretary of State himself, are targeting the poor GPs and their 2004 BMA negotiated contract which allowed them to opt out of Out of Hours (OoH) care.

We now have a procession of GP leaders on TV and radio banging on about how it is not fair to blame them and that the problem is far more complex and multifactoral. Indeed my fellow blogger and colleague, Bob Bury, has posted recently on this theme.

I listened to Dr Laurence Buckman, the BMA GP chairman speaking on the Radio4 Today programme stating that the health secretary Jeremy Hunt is spouting “rubbish” (no great surprise there). The work load of GPs, he claims, has risen hugely since 2004 much of it related to the huge amount of box-ticking they are required to do. The real problem, he states, is the massive disinvestment in social care with frail old folk trapped in hospital beds. He obviously has a point!

However, and I am about to make a lot of doctors very cross, I am getting pretty fed up with listening to GP leaders, including Dr Buckman, bleating on about how hard they have to work during the day and that is quite impossible to expect them to work all night as well.

Well Dr Buckman may I point out that as a hospital consultant I have to work bloody hard too, as do my colleagues. Over the years we also have seen our work load rise inexorably and many of us feel that we are like rats on a treadmill, never managing to keep up but goaded on by endless “targets”. It is the hospital doctors who are bearing the brunt of the A&E crisis – my own trust seems to be on “black alert” almost continually.

But in addition to this there is the EWTD, strongly supported by the BMA, which has resulted in a marked reduction in the hours which juniors are allowed to work. Many consultants report that the post-take ward round frequently takes place with no juniors and no one who knows the patient. Consultants are now regularly being required to “act down” to cover absent juniors. Wearing my HCSA hat I have occasionally been involved with consultants who have been through a disciplinary process by their Trust because they refused to be compliant with such requests.

Also there are the reports showing that patient outcomes are much poorer at weekends when there is reduced senior cover; consequently there is now pressure for the 24 hour “consultant present” model of working (which is already happening in some specialities) with additional pressure for full seven day working.

Many consultants now work heavy on-call rotas with increasingly frequent call-outs and in most cases still have to work normally the next day. This is especially true in smaller hospitals with fewer junior staff to help cover rotas.

My point is that if it is inappropriate for GPs to work a full busy day and then work at night it is equally inappropriate for consultants. But since 60% of the profession (GPs) have opted out of unsocial hours working this simply dumps the load on the rest of us. Add to this the prospect of working to the age of 68 and we have what is, in my view, a very damaging toxic mix.

So I am sorry Dr Buckman, but although the A&E crisis is clearly multifactoral your wretched 2004 contract is a significant factor and to whine that you are all too busy to contribute to OoH working is simply to close your eyes and hope that the problem will go away (or that the hospital consultants will sort it for you). But then we all know that the BMA is largely regarded as the GPs’ union!

My rant is nearly over. But to try to be positive I think the solution must be that the profession as a whole should take responsibility for OoH cover. There should be models of care which allow for combined working and shared responsibility. No one wants to go back to the days when the GP alone had to be available day and night to treat a case of acute dandruff because the patient had no time during the day to make an appointment. Clearly there must be contractual arrangements for GPs and consultants which allow proper scheduling of OoH shifts with appropriate rest periods. This will inevitably require investment and new ways of working.

Sadly the Health & Social Care Act has simply increased the divide between primary and secondary care. The GPs are now in the driving seat as health “commissioners” while the consultants are increasingly demoted to merely one group of “providers” among many. The BMA are clearly becoming entrenched in their view that the 2004 contract is irrelevant to the issue and I doubt will show any leeway to support hospital staff.

Interesting times…

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5 Responses to “Shared responsibility needed for OOH cover”

  1. Dr D A Kilroy says:

    Arguably the 1948 contract got us all off onto a bad footing. Time I think for us to put the rants away and play healthcare with the ultimate straight bat – data, lots of it, used properly, and nuanced by a collaborative clinical context. Let’s put all the HSMR, SHMI, C Diff, MRSA, 95% and any other data you can think of into a big computer alongside all the stats for postcode, hospital, age, GP, waiting time to be seen by a specialist, and any other variable anyone is measuring. Then take a deep breath….pause….and press “analyse”.

    And computer says……

  2. HeartDr says:

    CCGs run mainly by GPs holding the purse string, what a joke. At one stage the PCT were stopping consultant to consultant referral. So we write to GPs to suggest that they refer to my fellow consultant colleague. Another time wasting exercise. To date I have not seen any of my referral being refused by GPs. So why waste time?

  3. Dr M D says:

    I think we need to be cautious here in avoiding a clear attempt at ‘Divide and rule’ by the government. This week it’s general practice’s turn to be chastised but hospital consultants will be back as the culprits next week.
    I think we in hospitals would value some commitment by general practitioners to share the problems and to have more clinical (rather than managerial) ownership of OOH, and perhaps some contribution to the OOH, whether by some evening surgeries or by gps doing some sessions in the evenings or weekend daytime so that there is some return to ownership of patients. Of course in the end this comes back to there being sufficient general practitioners to cover this in addition to their busy daytime workload, and to funding as ever.
    I think it’s important that we remember how many other things have changed clinically in the 9 years since 2004 – management of many acute medical conditions which might have been community-based then now require immediate admission and protocol driven acute care. Many more options are available for many medical conditions. The co-incidence of this with the expansion of the number of elderly people surviving longer and developing acute medical conditions which do warrant acute care in a hospital setting is creating this crisis.
    We need more hospital beds not less, as well as more community based care, and if we are truly going to offer a 7 day consultant based service, we need more consultants, middle grade doctors and F1/2 doctors in all specialties.

  4. DocHuw says:

    Couldn’t agree more; as a GP I accept that we are actually a major part of the problem. When we were respected (by our patients, politicians and fellow professionals) we were able to act as gatekeeper. We were also allowed to do more that was practical to keep patients out of A+E. The role of GP has become progressively more proscribed so that I no longer recognise it as the job for which I trained all those years ago. Many of the minor accident work that we used to do gratis we are no longer allowed to do if it distracts from the “bums on seats” approach that our masters have allocated us.

    Furthermore, when we were offered a financial inducement to stop providing out of hours care, GPs shot themselves in the foot and altered the relationship between patient and GP to its detriment. When we looked haggard at morning surgery it was assumed that we had had a bad night on call; now the assumption is that we have been on the piss!

    Over the years the patient perception of what a GP does has changed and we are seen as less qualified than our hospital colleagues. We don’t have exciting machinery in our offices, immediate x-rays and blood tests that will measure serum sausage and plasma potato.

    As many of the problems in A+E are GP related, is not the solution to have a 24h GP presence in A+E?

  5. […] at University Hospitals Coventry and Warwickshire NHS Trust. His blog in Hospital Dr (add link to highlights a divide between providers of primary and secondary care as well as a lack of sympathy […]

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