Can we improve doctors' out of hours service?

Written by David Heath MP and published in Western Gazette on Fri 19th Feb 2010

I had a miserable cold last week. I say that, not because I want or expect sympathy, but because when we are ill, we all want to ensure that we get the treatment we need, and sometimes that need doesn't fall conveniently into office hours. My cold was just that - a cold, and not something I'd dream of troubling a doctor with. If a toddler was running a high temperature, though, or someone with multiple health problems became sick, then you might very well want advice.

That's why the current concern over doctors' out-of-hours services is so important. People want to feel that, if they need help, it will be there. It used to be the local GP who would be woken from bed to go and visit an ailing patient. I'm sure it wasn't much fun, and they would rather sleep on undisturbed rather than pull on an overcoat and visit old Mrs Jones who felt a bit dippy, but do it they did, because it was part of the job. Incidentally, it also acted as an incentive to those who didn't want that sort of hassle to specialise in areas that wouldn't require such attention rather than general practice. I remember being told at medical school that the perfect job was one where the patients never die, never get entirely better, and don't call you out in the middle of the night. Perhaps that's why I chose eyes!

Anyway, the old system apparently wasn't sustainable. New GP contracts required a new arrangement, and the out of hours service was taken away from GP practices and vested in the local primary care trusts, who in turn contracted companies or organisations to provide cover in the evenings and at nights. It is that cover which is now attracting such criticism at national level, largely as a consequence of the very unfortunate case of the German doctor who administered a huge overdose of diamorphine to a patient who, tragically, died as a consequence.

The department of health is now trying to set new national guidelines. It will include what you might think are the elementary precautions of ensuring that any doctor employed by an out-of-hours service speaks English and is professionally competent. They will also want to ensure that the doctors used are not so tired as to be incapable of making sound clinical judgements. You would have thought that was basic.

But I think any review ought to go a little further. I have had a few complaints over the years about the out-of-hours service in Somerset, which is actually operated by the regional ambulance service. Normally it's because the patient feels, with justification, that their medical needs would be better met by the GP in their local practice who knows their history and better, as a result, in treating their symptoms. But the concern expressed to me by a partner in one of our local GP practices gave me real cause to worry about the present system.

This is not to question the ability or expertise of the doctors who provide the local service. I'm sure individually they do an excellent job on behalf of their patients. The doctor who spoke to me expressed concern that the role might in future be taken on by paramedics, and I agree that whatever their merits this is not a responsibility they should take on, but we are not at that point yet. The biggest concern is the sheer lack of numbers on duty at any one time, given the geography of the county. At a maximum, there are eight doctors covering the whole county and its 500,000 inhabitants. Of those, just four are in mobile units able to make house visits. And, as my doctor points out, there are many occasions when particular shifts are not filled.

What I raised with ministers last week was the fact that not a single out of hours doctor is based in my constituency, which extends over nine hundred square miles. That in itself isn't necessarily an issue, if the points of contact are very close by, but it does beg the question of why, for instance, there is no doctor based in Frome. But the geographical issue is further complicated by the fact that nowhere in my constituency is there an Accident and Emergency department either. Anyone with a trauma injury has to be taken up to Bath, Yeovil or Taunton. At any of those hospitals they will receive good treatment, but the time required to first get to the patient, and then take them to casualty, has to be factored into the response time. So someone in one of the villages in my constituency has no easy access to A & E, and no easy access to out-of-hours doctors' services either. That's hardly reassuring.

What is the answer? I think there is a strong case for going back to commissioning out of hours cover from local doctors surgeries. It wouldn't guarantee a consistent level of service, as previous experience showed, but at least it would provide continuity of care and ensure cover is localised. Failing that, I hope Somerset, when reviewing its arrangements, will look at whether extra evening treatment centres and at least one, perhaps two extra cars on duty might be required. And certainly, where we have community hospitals, does it not make sense for a GP to be contracted to be on duty during evening hours to ensure expert advice? I appreciate that systems like NHS direct do provide advice on demand, but sometimes you need to see a doctor, and in a place like Somerset, sometimes they need to come to you.