General practitioners - out-of-hours cover
May 2006
Note: the out-of-hours period is from 6.30pm to 8.00am on weekdays, the whole of weekends, bank holidays and public holidays.
Since implementation of a new general practitioners’ contract in April 2004, GP practices have been able to exercise their right to change their responsibility for out-of-hours work. Between April and 31 December 2004, it was with the consent of the local primary care organisation (PCO).{1} Since January 2005, practices can continue to retain their of out-of-hours responsibility if they want to, but PCOs now have full responsibility for out-of-hours care.
At all times, patients will continue to have access to an out-of-hours primary health service.
There is a critical shortage of GPs in many areas that threatens not just out-of-hours care but also in-hours care and it is essential that the best use is made of limited resources in ways that protect patients whilst giving doctors the rest and recreation time to which they are entitled.
The changing demographics of the profession together with the increasing intensity of daytime work and the added demands of out-of-hours have necessitated these changes. They derive as much from the need to ensure a comprehensive twenty-four hour service to patients as from the desire to give doctors a more reasonable balance between their professional and family lives.
Patients should be reassured that they will see a health professional, if they need one, who is fit and alert and that this will include access to a GP where this is clinically appropriate.
While it is true that the majority of GP practices in the UK have exercised their right to transfer their responsibility, this does not mean that patients will be without a service out of hours Many individual GPs are still willing to work during the out-of-hours period for a fair reward.
There is a Patient Services Guarantee in the GP contract that should ensure that patients are provided with at least the level and range of services they previously received. Patients should not have noticed any sudden change in the out-of-hours service they receive as, even before the new arrangements, few patients saw their own doctor on a home visit at night. The majority of GPs already used co-operatives, deputising services or a shared rota with other practices to provide cover.
The changes have been made so that urgent care outside normal working hours can be provided more effectively and efficiently while continuing to ensure that all patients get the best quality care. Innovative new schemes involve a better use of the skills of a variety of healthcare professionals including nurses, pharmacists and paramedics, as well as doctors.
The BMA believes that the changes are beneficial for patients as well as improving the quality of life for GPs. Patients will be seen by a health professional who is fresh and alert and will make the appropriate response in the circumstances. This may not always be initially doctor-based, but when patients do need a trained GP, they will have access to one.
GPs providing out-of-hours services
Practices providing out-of-hours services can continue if they wish to do so. The right to transfer their responsibility was on a practice basis only and not on an individual doctor basis. Where GPs no longer provide out-of-hours cover, their income is reduced. For the average GP in an average practice, this was by around £6,000 per annum.
Some GPs offer surgeries or consultations during the out-of-hours periods (for example, an evening commuter surgery) and these can continue, even where the GPs have transferred responsibility out of hours.
PCOs are required to have a contingency plan in place which can be put into immediate operation should an out-of-hours provider fail. The default option will lie with the PCOs, not individual GPs, as was the case before the GP contract.
Alternative provision
How out-of-hours services are delivered will vary from area to area. Urgent care outside normal hours can be provided in more flexible, clinically appropriate and modern ways. The money released by those practices that transfer responsibility are available to the PCO to provide out-of-hours services. The English health department has also provided Primary Care Trusts (PCTs) with some additional money.
PCOs are able to consider a range of alternative provision for out of hours, for example, NHS Direct/24, NHS walk-in centres where available, GP co-operatives, partnerships between practices, paramedics, GPs and primary care nurses in A&E departments, community nursing teams and commercial deputising services.
Remote and isolated areas
Practices in particularly remote and isolated areas may not be able to transfer the responsibility for out-of-hours cover. This should only happen in exceptional circumstances. Practices that cannot transfer responsibility are supported in a variety of ways and given additional resources to help compensate them for their increased burden.
Accident and Emergency Departments
While some PCOs have chosen to involve A&E department in their plans for out-of-hours care, it is not intended that primary care work will be passed to A&E inappropriately. There is no evidence that this has happened so far, though there have been some press reports confusing the rise in attendance at A&E (which has been going on for some years) with a change of responsibility for out-of-hours care. The two do not correlate. In some areas, there may be an perceived increase in frequent users of OOH services using A&E more regularly but that this is likely to be dependent on the quality of OOH services available locally.
The National Audit Office report on the provision of out-of-hours care in England, published in May 2006, contained a survey of the public's views and experiences of OOH services. A large percentage surveyed who were using OOH services for the first time said they would ring their local GP and only a small percentage would go to Accident & Emergency.
Note: there are approximately 36,000 GP principals (partners in practice) in around 11,000 practices (UK) and a further 7,000 qualified GPs who work as locums or in other positions in general practice. Over two-thirds of practices used GP co-operatives to provide out-of-hours cover, while around a quarter use commercial deputising services. (National Survey of GP Opinion, October 2001).
For further information, please contact the parliamentary unit.
- Primary care organisation (PCO) is the generic UK term used to cover primary care trusts (PCTs) in England, local health boards (LHBs) in health in Wales, health and social service boards (HSSBs) in Northern Ireland, and in Scotland it is the primary care trust, unified health board or Island health board.