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As well as my salaried job, I’m also contracted by my local out-of-hours provider to work one day a week, every week. I like OOH, I find the acute, sharp edge of medicine stimulating and the change of scenery each week from my in-hours job surprisingly refreshing.
However, the job is stressful and risky. These are largely not my own patients, and even on the off chance one of my own patients does walk in, in my area I can’t see any of their previous notes apart from an electronic cocktail napkin possibly containing their medication list, if we’re lucky. The safety netting is therefore dialled all the way up to eleven, with clear instructions given on what to do if things get worse, or if things don’t get better. Once the patient walks out though, they’re gone – I never find out if they were OK, if they got better, if they were admitted.
Steps have been taken to try and mitigate this risk; in my local area they’re looking at increasing the appointment length to 15 minutes, in line with providers elsewhere in the country, but even this does little to truly address the risk. From personal experience, I find I see more of the acutely unwell patients in this setting. It’s more often that I use a nebuliser, or have to give IM Benzylpenicillin whilst on the phone to the ambulance service. Paediatric CPR has even been in the mix on one occasion.
This risk is reflected in our indemnity, the per-session rate for my OOH indemnity is almost four times more than my in-hours sessional rate. Because of these eye-watering rates, some GPs are actually unable to afford to work extra sessions. I see constant gaps in the rota of my local service. This is because when the rota team phone around the GPs to ask for a shift to be covered, it would mean that GP topping up their indemnity, which is unaffordable. As a salaried OOH GP, my indemnity is fortunately reimbursed by the provider, but this is done later on, as a monthly payment, meaning even I have reached my limit of what I can afford to work in terms of simple cash flow.
Measures like the Winter Indemnity Scheme – where NHS England promised to cover the indemnity costs for extra sessions worked in winter – are a welcome relief, and last year reported to have resulted in an extra 14,000 shifts worked. But there is no provision for such support any other time of year in out-of-hours.
As the overflow for a crippled, underfunded NHS, GP out-of-hours is at breaking point the Government needs to urgently address the rising risk, and rising cost of that risk to doctors, with a whole-year-round solution – because right now, in the NHS, it’s always winter.
Matthew Mayer is a salaried GP based in Aylesbury and a member of the sessional GP subcommittee.
As a GP Director and duty doctor for an Out of hours provider I quite agree with your concerns. Unfortunately despite the promises made in GPFV the issues re rising indemnity costs have not been resolved on the ground - NHSE have still not come out with a clear plan, and we found that not one of our duty doctors received any indemnity relief from last year's winter scheme. Our out of hour organisation (SELDOC covering 7 boroughs in south London) have therefore purchased indemnity for all our duty doctors so no one should be financially penalised by undertaking this work.
As you say the work can sometimes be more challenging, but actually we experience a very low complaint rate and patients generally are extremely grateful for the care they receive, so it can seem very worthwhile, and there is no admin! Having access to SCR is helpful - we are also working towards having access to views from the full GP record - and Medical defence associations recognise having the notes reduces the risk so shifts between 8am-8pm with notes access count as 'in hours' work.
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