Wat, it is all true, as far as it goes. But this is a hidden and larger bonfire than you think.
GPs contracted out because of the stresses and strains of the service (and yes, I know, to better concentrate on spending the £250,000...).
There is no other country in the world where you can pick a phone up at any time of the day or night and summon a doctor to your bedside for any condition, however trivial.
I used to dread the 11.15 pm peak of visits. Kylie, aged 8, has a temperature and is lying on the sofa. Mum is coping with this, and not worried. Then Dad gets home from the pub, worse for wear, and says to his dear lady, "What do you mean, she has a temperature...get the effing doctor out" and then he phones and tells you that "I want the doctor out, I pay your effing salary"
The cost of providing this luxurious service is high, and the service itself is absurd. 95% of the people who call could perfectly well come in to a call centre. In fact, for most, telephone advice would be enough, and that is what NHS Redirect pretends to provide at an annual cost of £70 million. Trouble is, for a conscientious doctor, a child with a temperature is always a possilbe meningitis. Once as the doctor you have spoken to the parent, the medico-legal responsiblity shifts onto you. It may be reasonable to say "give her some paracetamol and phone back if there are problems" - indeed it is reasable, but when, 3 hours, later Kylie gets meningitis and Dad rushes her off to hospital, the story he will give is "...and the effing doctor refused to come and see her" and probably also the inexperienced A/E doctor or, more likely these days, the nurse specialist will raise eyebrows and say, "Didn't the doctor come out? Oh! Dear." So, if you are a worrier like me, you always get up and go and see hot children. It is unnecessary mostly, but less stressful than lying awake thinking about it.
I could not cope with the strain of doing this any more, particularly as I have to work a full day, 8.00 to 7.00 after a night on call. There is no realistic amount of money that would make me go back to doing this. Which is why the OOH services are in trouble. They cannot find experienced family doctors prepared to do it. Some but not all of the doctors they do get are er...of a certain sort.
But the service is not necessary. It is fiscal nonesense.
If there were a charge of, say, £50 for calling a doctor out (safety netted and refundable to the poor) but no charge for attendance at a call centre or A/E department, the problem would be solved overnight.
The current service is a waste of money.
I am going to post on this on NHS BLOG DOCTOR this evening.
John
If the charges were "safety netted and refundable to the poor" what would be the anticipated drop in the demands on the call-out service? I'm not advocating that there should be charges, but given that any suggestion that charges should be introduced is always made with the caveat, "safety netted and refundable to the poor", what difference would introducing charges make? It's my understanding that around 50% of people are eligible for free prescriptions with 87% of prescription items dispensed free of charges (I assume this is due to the demographics of people who need prescriptions?).
If similar exemptions were to apply to charges for visits then would the cost-savings be worth the cost of collection? Or the debt-collection cost of failing to pay? What would be the penalty for failing to pay?
However, it does sound as if the main issue is whether or not the system of emergency home-vists should be maintained, and that is a completely different question.
Regards - Shinga
Hi Shinga
Perfectly good point; this is not an easy one; but the prescription business is not the best analagy, with respect. The exemption regs are ridiculous - often those who most need exemptions do not get it.
I would not necessarily refund ALL the £50. Maybe only £30 or something.
John
Anyone would think the health service is free. We are paying for the service and are customers. Basically those of us that do pay up and have never abused the system or disrespected our Doctor have been punished with the miscreants that should have been dealt with by the Primary Care Trusts!
If someone was regularly abusing the system then the Doctor and the PCT should have removed the service from just them, sending them to A&E and not the rest of the local health community.
That's like locking everyone up in a town because there were a few burglars causing problems for the police officers working the evening shift.
One of our Doctors used to do a noons shift (one week in about eight - shared with several practises) and saw patients at one of the local town clinics - this service from about 19:30 upto 21:30 pm, which ended last April without a buy your leave.
Well I'm sorry Dr. but I'm cross about that, my NHS bill hasn't reduced for this reduction in service, OK I may have only used it a couple of times in fifteen years but that's not the point it was there at times of need.
Why can't doctors take a day off in the week and work one Saturday on rota? Why can't we get an appointment after 5:00pm? Why can't we get an appointment before 08:30am?
When you work full time people are just putting off visiting their doctors at all - I'd like to check how many appointments less are made by full time workers now?
I agree you can't keep up clinic hours of 7am to 8pm but can't you work from 12 noon until 9pm occasionally on rota (less a lunch break of course)?
Any government that allows me to opt-out of the horerendous NHS will get my vote.
Why can't doctors take a day off in the week and work one Saturday on rota? Why can't we get an appointment after 5:00pm? Why can't we get an appointment before 08:30am?
++++
Tracy, why SHOULD you be able to have an appointment at those times for non-urgent matters?
You should be seen at any time if it is an emergency...but why should I work nights and weekends to see your verucca at a time of your choosing?
The reason the system is on its knees is the utterly unreasonable expectations of people like you who want a round the clock service for ROUTINE matters, not just for emergencies.
Try getting an appointment with your accountant at 8.00 at night. Try getting your car serviced on a Sunday.
People like you need to back off and allow the NHS to provide a proper out of hours service for emergencies, not for veruccas
John
Dr Crippen,
I provide a service 24/7 and have to pay the staff and organise rota's accordingly. I never suggested you work a Sunday without an alternative day off in the week. When you go out on your Sunday off where do you go? Or do you stay in. People work on Sundays to meet the needs of their customers. Why are Doctors different and should only be expected to work when you want?
I've never seen a Doctor for a verucca in my life. We've been self treating for those sort of problems for years. As I pointed out I'm not a serial user of Doctors services and I'm sick of being tarred with the same brush as the people who evidently caused many doctors problems with their abuse of the system. Deal with the abuse of the system by these people, don't remove the service altogether.
My husband needed to see a doctor at 3am one morning 18 months ago. We got through to NHS Direct who said he should go to A&E (Approx 16 miles away by car) he couldn't drive so explained that would mean getting 3 children up and dressed so that I could drive him there. They said there was no on-call doctor until 8am. So he refused to wake up the children and after suffering until 5am we got everyone up and went to A&E where he sat in agony for four hours to see a Doctor. That's the first time in eleven years he had seen a doctor.
Hi Tracey
I am not suggesting YOU would call a doctor on a Sunday for a verucca, but lots do.
Yes, I could work Sunday's - I did, for 20 years. But the "day of in lieu" that you describe is not available.
GPs were responsilbe for their patients 24/7. If I take a Wedneday off, I have to pay another doctor to see my patients.
I am not trying to be rude to you, but your complete lack of understanding of the problem is characteristic of most NHS users. They want access to medical care 24/7 for any condition, however trivial.
It is not economic to provide a walk in out side normal working hours medical service for non urgent problems.
What is happening to OOH services now is that they are being thrown open to market forces. The market forces that Wat so much admires. If you want a doctor to see your verucca on a Sunday, you now have to pay the economic rate for such a service.
The country cannot afford to provide this. In any case, it is not necessary.
John
Dear Doctor,
I didn't want to make this personal between you and I, however, you did say 'people like me' without knowing anything about how I have used the NHS in the past. I have a very good relationship with the Doctors at our surgery, and having a natural dislike of using their services at all we rarely see them, let alone put on them! I also like to reduce my children's dependence on antibiotics to get well.
I can assure you my family only ever see a Doctor when we have exhausted all self help treatment and only ever in an 'emergency' but these often aren't confined to 8:30 to 17:00 Monday to Friday, especially when the children were young, if I was alone at 8pm with three children and one was poorly - getting them all to the hospital walk in would be a nightmare.
You say it's not economic to provide local none emergency cover after 17:30 so why not change the hours of these super surgeries as I suggested it's the same economies then and it may suit some doctors work life balance issues, some of my staff prefer a later start and cover for others when asked to do so. You could then make regular appointments at 20 minute intervals keeping the 10 minute slot free for emergencies as they arose.
We were promised by the government that by paying an extra 1% both as an Employee and an extra 1% as an employer that they would hire extra doctors and nurses to treat us and improve the service. At the point that the promise was made we already had 'out of hours' cover. So weren't we to expect that this extra money was to be used to expand the services not contract them. At no time were we told vote for us and you'll have less local NHS cover than you've got now, they should have been honest with us. We now have no local out of hours cover and the impact on the ambulance service by some people not willing to wait like we did has caused problems as it did for Casualty staff.
We used to be able to go to the surgery when it opened at 08:30am and queue up, so we often waited until the surgery opened and took our turn. Now it's a case of arguing your need for an appointment that day over the telephone.
With regard to Market forces, there aren't any. The market that has been created is between the PCT and the Providers, there is no choice for the customer and therefore no competition. For example, if each PCT had four service providers all competing for our emergency there would be far more flexibility than there is at the moment. As the one that gets paid is the one that provides the service on the day we need (not want or demand, NEED) it. As any business person knows you won't be in business long if you don't provide the service that your customers need.
You say the Country can't afford to provide this service any longer. Yet there are other savings that have been made at the same time as putting up rates e.g. the health service now expects family to provide after care services in the home that were pr
How do you know the country cannot afford it?
Do you know how many working hours are lost because people have to take time off work to see doctors?
Do you know how much it would cost, net, if every GP practice were obliged to provide (say) one evening surgery and one weekend surgery per week, which OF COURSE would mean that GPs would probably have to be paid more for unsocial hours, or get double-time off during the week or whatever. INDIVIDUAL GPs aren't responsible for patients 24/7, are they; GP PRACTICES are.
Unless you do know the answers to these questions, you don't know whether the country could afford to pay for more OOH GP service for working people. Your comment above about "complete lack of understanding" IS rude; but it's also the pot calling the kettle black. You are completely ignoring the cost to the economy of lost working hours.
Potentilla
For once you are wrong. Completely wrong on several issues.
GPs have an individual contractual responsiblity to ensure that patients have 24/7 medical cover. Yes, they can delegate and share with partners, but those doctors would be jointly and severally liable if there were no cover.
Since the new contract there has been a big change. GPs may now - and as you know, most have - contract out of OOH services and hand that responsiblity to the PCT.
I am sorry if you find it "rude" but both you and Tracey fail to understand the realities of infinite health care demand. Your expectations are preposterous and it is expectations like this that are to some extent responsible for bringing the health service to its knees.
On a personal level - as i have said elsewhere - I do a late night surgery once a week so that people can come in after work, and I do four early morning surgeries, starting at 7.45 am so that people can some in before work.
I have no idea of the precise cost of hours at work lost by people having to take time off to see the doctor. Most people manage. I have no idea of the cost of hours lost at work by people visiting their accountants, stockbrokers and their tailors either.
OOH work should be for emergencies. It is absurd and ridiculous to expect the tax-payer to pay doctors and nurses to provide late night availability for routine medical problems for you, Tracy and thousand of others. It is daft beyond words, and a huge waste of resources driven by selfish people who have no idea of the real cost of health care.
The millions and millions wasted in this area would be so much better spend on cancer care, care of the mentally ill.
We cannot afford health care for all at a time of their choosing for any condition however trivial.
This is one of Wat's biggest bonfires.
John
I knew my comment would get you in a strop - and I realised after I posted it that I was using the abbreviation OOH inconsistently which didn't make my point clear.
Let's try it again. GPs have a contractual responsibility to provide 24/7 medical care UNLESS they have contracted out of OOH. In which case they have a contractual reponsibility to provide medical care for something less than 24/7 - not overnight, presumably - I would be interested to know exactly how OOH is defined for these purposes.
I agree that "real" OOH ie medical attention outside normal working hours ON AN UNBOOKED BASIS should be reserved for emergencies. (Yes, lots of problems about how you might achieve this).
HOWEVER I also think that it might be a good deal for the state to pay "whatever it takes" to provide some non-emergency medical care for people outside normal working hours - not in the middle of the night, just early evening/early moring/Saturday morning (the way your practice, being a well-run one attentive to the needs of its patients, provides already; but to borrow a phrase you used recently a propos of something else, "it's a postcode lottery").
You are entirely missing the economic point I am making. Ask your economics adviser about it as we are having this discussion on his blog. "Most people manage" is quite irrelevant (even ignoring the silly bit about stockbrokers). The majority of working people CANNOT be absent during the working day without someone else doing whatever it was they would have been doing were they at work; their EMPLOYERS have to organise this. There is a cost to organising it. It's not a problem for the person, it's a problem for the employer, and by extension the economy. It might well be that, across the entire economy, the cost would make it worth paying extra to GPs (or providing drop-in medical centres open late or whatever) to ensure that working people can be seen for non-emergency things outside normal working hours.
I don't KNOW whether this sum works out, but NEITHER DO YOU. It is NOT the same issue as unlimited demand for healthcare which, despite your strictures above, I understand very well.
Hi Wat, Tracy, Potentilla
I have tried to cover this in more detail at:
http://nhsblogdoc.blogspot.com/2...sonal-
view.html
John
No, I don't know the cost of hours lost by people attending the doctor.
Nor do you.
I suspect it is relatively trivial.
Remember, if people are acutally ill, they will be off work anyway, so that does not count.
Anyway, this is getting off piste for Wat and getting much more onto medical territory, so I have done a long post on it on NHS BLOG DOCTOR
I know you both disagree, and you both think I am a mean, lazy, overpaid shit....so be it.
I still cannot do OOH work catering for routine medical trivia.
Sorry
John
Oh for heaven's sake stop being a martyr. I have gone out of my way to mention that all I am suggesting is that other GPs ought to do what your practice does anyway.
I am not making a medical point, I am making an economic point, which is certainly not off-piste for Wat's blog.
I might do some research on the hours lost by medical appointments but I doubt it will be possible to separate "actually Ill" from other. (Maybe Wat knows of some data?)
"Remember, if people are acutally ill, they will be off work anyway, so that does not count". What proportion of your patient visits are taken up by people who are not ill enough to be off work but have a legitimate (in your eyes) reason to see a doctor? For instance, all the people on long-term medication (such as the pill) who need regular check-ups for repeat prescriptions? People who have a non-infectious non-self-limiting non-serious condition - they need their ears syringed or their ganglion diagnosed, for instance?
Compare the NHS GP "service" with something as trivial as blockbusters video hire.
Think in terms of cleanliness, opening hours, freindliness of staff(comnpare with those useless women at the front of the GPs), price, local availability and customer service.
No contest I'd rather be a member of blockbusters health service than the terrible NHS.
NHS GPs are overpaid blaggers.
As much as you think I'm ignorant, I do understand your point of view. I also understand your getting to a certain age and wanting to kick back.
Our original 'Out of Hours' work was contracted out, after 9pm and before 8am so my local GP’s didn’t provide the cover you did. You could still get a doctor to your home though. Since April 2004 this cover was cancelled.
I do understand that there are many more people now that are eligible for completely free drugs and therefore need a doctor in order to get them from the Pharmacist without any cost or inconvenience to themselves. This problem has been brought about through successive governments providing benefits such as the above to larger and larger numbers. You need, as I have said several times, to deal with the abuse properly, let them get their Calpol from the Pharmacist without needing a GP’s prescription.
As you’ve quite clearly now explained this is no longer anything to do with GP’s outside of 08:00 until 18:30 (I shall asking my GP’s surgery why they’re not available for appointments after 5pm if they’re responsible for my care until 18:30 as you say.) The clinic is locked up at 17:30 most nights, although they do have a woman’s clinic provided by the PCT once a month.
You are conflating two issues. I am not expecting any individual GP’s to be available for 24 hours, especially not for routine visits which is what you continue to imply, but like many other emergency cover organisations your contract, when it was completely re-written without a thought to the customer, could have allowed for surgery opening hours of say 7am until 7pm with the Doctors sharing the hours, e.g. one doing 7-3pm (which would have helped out those Doctors collecting children after school) and one 11am-7pm which would have helped with the doctors social life i.e. an early morning gym session before work. Especially when the PCT’s were expected to take over the responsibility of outside of surgery hours at the local hospitals, using hospital doctors for a longer stretch and putting more strain on the ambulance service, but as you say this is no-longer your problem. The government negotiators should have thought about this though.
You are handling this as a personal attack when our argument is with the masters of the health profession who were supposed to organise our care on our behalf and have botched it, they’ve charged us more and in my area reduced our local service to appointments between 08:30 and 17:00 Monday to Friday. You mentioned accountants my audit accountant was working doing our audit at 07:00am to miss the traffic, and worked one late start/late finish because she had an ante-natal clinic, she was able to because our offices are open 24 hours, she charges by the hour worked by the way, I've never asked for an appointment on a Saturday but you know what I'll ask if I could have one just to see next time, and the garage they are open on a Saturday, if they can't fit me in then, they collect my car for me and return it, they even fit windscreens now at the house or the office.
I do feel that when the contract was up for complete renegotiation and they took so much responsibility off your shoulders e.g. Weekends and Night cover they could have asked for longer surgery opening hours to fit in with the 21st Century workers needs, but obviously I understand why you would disagree with this.
I can see your point about the proletariat expecting too much from our professionals. Perhaps one day we’ll wake up, and all refuse to work outside of 08:00 to 18:30 Monday to Friday too, you know what I’m getting sick of it as well but unlike you if we don’t work after 18:30 people don’t pay us. You see in the private sector the one thing our customer have is the choice over where they spend their money, we can’t choose which work we want to do or tell them to try to get through tomorrow morning and expect them to phone back.
A colleague has diabetes she has to take regular time off to attend check ups, so other colleagues have to work overtime and stay late at the end of their shift to cover her work until she gets back. We don’t all work in the town we live in so a midday appointment means a half hour trip either way and half an hour to an hour in the clinic so we try to make appointments at the beginning or the end of the day because this time in the middle of a busy shift put an extra burden on other staff, my surgery and many of my colleagues surgeries no longer provide for this as you say you do. You usually can’t even get through on the phone for an hour! This 48 hour booking malarkey has ruined forward planning of appointments to assist business when needing to cover for staff who have routine doctors appointments too.
I'll stop twittering now.
Yours Mrs Unreasonable and Selfish, oh and naive (I hadn't realised I was held in so much contempt, but I do now).
Blimey- for various technical reasons (ie incompetence), I only just read this discussion.
A number of thoughts spring to mind...but I'm going to jump across to the Doc's post on this first and comment there.
Suffice it to say, I don't accept this mess is down to the failure of a market based system at all.
It's a failure of the Commissar's masterplan: we customers haven't been given the chance to vote with our wallets, choosing maybe different levels of hours cover, (like the AA's breakdown schemes).
I suppose a large part of the problem is the issue of what services ought to be available OOH. The medics think that OOH ought to be for emergencies only; others on here seem to feel there ought to be a provision for routine care OOH.
With current GP numbers, that is just not possible. If, as has been suggested, GPs do routine work at evenings and at weekends with days in lieu during the week, there will be even fewer appointments available during working hours, that work will spill over to weekends and evenings, and we'll be in a vicious circle.
We are working to full capacity as it is; there is no slack in the system to take up extra demand. The elephant in the corner of the room is that a system which is free at the point of demand will never be able to meet that demand; demand will simply increase to swallow up any extra capacity.
To the poster who asked why she could not be seen at half-six if the practice retains responsibility for her until then, the answer is that the practice is contracted to provide emergency health provision until 18.30, but it is not obliged to have surgeries running until then. The practice needs to have a means by which you can access emergency care up to 18.30. That's my understanding, at any rate.
A few comments from the US.
The way to rectify infinite demand is to make the consumer/patient pay. Don't make the consumer pay for his preventative care/cholesterol medication/heart surgery. Do make the consumer pay FULL cost for after hours visits. FULL cost is defined by what the physician charges. If someone called me and asked me to drive to their house at 3AM this would be difficult for me given I work 12 hours days. (my role is similar to Dr. Crippen). I would charge that person 10 times my regular charge. Some would pay, most won't. That is a true market. The rest is socialst bullshit. (no disrespect to your country)
We do not have after hours visits in the US so it is completely insane to hear people with their expectation that physician's should drive to their house in the middle of the night when they could drive themselves to the ER (A&E) or call 911(999).
You should be ashamed of yourself.
To the woman who explained that she is available 24/7 to her clients, it is interesting you didn't list any specifics--what do you do? I doubt being available means driving to their house, working 12 hours through lunch 7 days a week. You probably manage a staff that answers phones. That is light years away from what you are "demanding".
What both of our countries need is a basic floor of care for everyone and then tiers of higher urgency that come with higher marginal costs. You can figure out your own opportunity cost of missed time at work and calculate that against which doctor you'd like to see at what time. Visits between 7-9A are 3X the normal rate, 9p-midnight 5X the normal rate, midnight-7A 10X the normal rate, etc. Then you important people can call whenever you like and an enterprising physician will take your money. However, it goes against common sense that you never leave your highly important jobs between the hours of 7-5 during a weekwork EVER.
I don't usually read this blog and I only came here by way of Dr. Crippen's so I won't read your snide comments. But you should realize that nothing is free. To have people at your beck and call at all hours of the day will require either more tax money, or more personal funds. If you simply force doctors to do more, you will have fewer doctors in 10 years.
b
"The millions and millions wasted in this area would be so much better spend on cancer care, care of the mentally ill."
Where I live, you can forget a GP making a home visit for mental illness. My GP's practice has a list of what they will make a home visit for, and there are no mental illnesses on it. Heaven only knows what unknown doctor is going to do the assessment if someone needs to be sectioned. Oh, but I forgot, here the out of hours psychiatric care is effectively provided by the police, so the police surgeon can deal with the problem. That or the nurses.
Out of hours care is not an alternative to mental health care. Mental illness needs out of hours care, too.
I assume that any modification that involved charging fees for visits would wholesale adopt the exemption model that already exists (say, for prescriptions) rather than set-up a new one that might be at odds with it. If you were to propose a different model for prescriptions and charges, is there an overview of what it would look like?
I assume that there would have to be a taxi voucher provision to pay transport charges for 'the safety-netted and the poor' if they were to be referred to a walk-in centre. Judging by US medical blogs, a lot of time is taken up arranging transport or vouchering for it.
OOH house calls seem like an anachronism for all areas that have other resources available: I would imagine that rural and outlying places need to retain GP OOH but there is little justification for it to be retained elsewhere.
Regards - Shinga
I have read with interest the comments on this thread and would like to ask the Doctor that when his practice provided the out of hours cover prior to the change of contract was the practice compensated financially or was the cover provided gratis by the Doctors?
It is important to know who was providing the cover and also who was paying for it. If the Practice provided this service free of charge then you have every right to feel upset, however if the practice was compensated for this provision then surely you can see why we now feel upset at its demise since we are still paying for it.
Bella - the old GP contract made GPs responsible for patients 24/7 for x amount of money per annum. (So OOH was not 'provided gratis" it was a contractual requirement).
The new GP contract allows GPs to choose between the same as the old GP contract, or only to be responsible between 8am and 6.30pm, but to be paid a bit less than x.
The new contract also has lots of other changes unrelated to OOH, many of which pay the GP extra money if he does certain specific tests/checks on patients.
Shinga - for the chronically sick living at home and occasionally having acute episodes, it may well be more efficient for the state to fund home visits from their doctor who knows them, than to have them cluttering up A&E which is not only more expensive to run but won't have anyone who knows their history. Also it would probably be better for their health than a trip to A&E and a long wait. The home visits would probably not mostly be OOH, but sometimes they might need to be.
In fact, having the occasional OOH home visit may be the thing that actually enables people to go on living at home.
b, you seem to be suggesting that because you don't have OOH in the US, we are completely insane to have it in the UK. And then you go on to say you won't read the comments. Err...I suggest that if you want to participate in the discussion, you might actually bother to find out what points other people are making, which you demonstrably haven't done so far.
pontentilla
Thank you for answering my question. I have some more that you may be able to help me with.
From your comments it appears that though GPs had to give up a proportion of their pay in return for opting out of OOH cover they have been able to uplift their incomes from performing other tasks for the PCT/Government. Are these Task performed during the day or at home in their own time ( i.e. outside of their already contracted hours )?
Do these tasks provide a benefit to the patient to make up for the loss of OOH service in return for this extra income or are these tasks geared towards Government statistical requirements ?
If these tasks for which they receive this income are not directly patient realted ( care and diagnosis ) and completed during their contracted hours then have we as patients not been short changed again? If this is the case then the time a Doctor has to spend with us, their patients, will have been reduced further although the Doctor will be recieving more income from the PCT ( the taxpayers / patients ).
When I started reading this thread I was confused about who did what and how it was paid for, but the deeper you dig the more let down by the Government I feel.
I do not blame individual Doctors for wanting a better deal but no one asked us and since we both use the service and pay for it, its just not fair.
Umm....I'll do my best but if Dr Crippen comes back over here he will have much more detail. In order of your questions:-
- during the day; they get paid per capita for, for instance, getting women to have periodic cervical smears and asthma patients to have periodic spirometry - you can read about it here:
http://www.primarycarecontractin...g.nhs.uk/
16.php
and Dr Crippen has done a post about it which I can't find offhand (try searching his blog for QoF). They are all medical not administrative/statistical tasks, but not necessarily very useful ones for individual patients
- they do mostly provide a benefit to the patient, but not a new benefit, in that you the patient could always have had these things if you wanted. The point is mainly preventative medicine and consequent savings in the cost of hospital care, by encouraging people who otherwise wouldn't bother, or wouldn't have known, to have the tests/screens. Also probably to keep less good GPs up to the mark.
- I don't think anyone would disagree that the governement did a very bad deal purely commercially speaking on the new GP contract; that is, the state now gets less for its money, partly because of OOH and partly because lots of GPs were doing all the QoF things anyhow, they just get paid extra for them now. As you say, it's not the GPs' fault though.
It's also the case that the contract had to change somehow, because people's expectations have changed towards seeing medical care at any hour for any seriousness of condition as a right not a privilege, so demand has increased which has made GPs' jobs under the old contract much more onerous. If the contract hadn't changed, we would most likely have had a serious shortage of GPs in due course.
Actually, this is a slightly more user-friendly link
http://www.ic.nhs.uk/services/qof
and it shows its a bit more administrative than I said; but the admin is desgned to prove that you're doing the right things for your patients (like telling them not to smoke).
Also, I found Dr Crippen's post which expalins it more vividly:-
http://nhsblogdoc.blogspot.com/2...06-week-
10.html
(scroll down to Friday 10 March).
Policy-makers may tell us the NHS's trajectory is on an upward path, but those of us who rely on the NHS for after hours care or otherwise know better.
Perhaps the British public should consciously choose to elect a leadership at the next general election that itself is fully committed to the NHS as demonstrated by their own use of it without opt out?
I would argue that citizens should set their own targets by asking all policy-makers to voluntarily commit to always use the NHS without opt-out. Well, I’ve kick-started such an initiative... and to my surprise nineteen forward thinking members of Parliament who believe in leading by example have signed our health petition which asks that 'elected representatives of all UK political parties voluntarily refrain from self-paid or insurance-paid medical care treatment.'
Now it is up to ordinary citizens to ask their own MP if they too plan to sign the petition. To see which MP has already signed visit www.ourpetition.org, where you can also sign the petition itself.
Hi Potentilla, I've just seen your comment now, and, as you may have seen from the Crippen comments that I made earlier, we have some substantial area of agreement.
To reiterate, I do distinguish between home visits and emergency OOH care. I would like to think that special arrangements are feasible for some chronically ill patients to allow them to remain in their homes without the disruption of trips to A&E. I can not think that it is feasible to continue this level of coverage for all of the patients in a GPs practice.
End of life care or care for the chronically ill seems like a very different discussion to the provision of emergency GP OOH care for all. I know that there has been some earlier discussion of the power law theory of distribution on this blog (I can't find it because it was carried out in the comments which are not searchable). To use the example that was detailed by Gladwell, in 10 years, one particular homeless alcoholic cost the public purse around one million dollars in medical bills: Gladwell characterised this as the cost of doing nothing. In the light of those findings it was demonstrably cheaper to give the chronically homeless alcoholics a flat with supervision. This is a policy that has been adopted in various cities in the US, including Seattle.
I would imagine that power law would support your contention that it would be more effective and more desirable to have a team of medics (of a variety of skills) who are familiar with the case-histories of those who are most likely to need OOH care as part of their chronic illness history. I think that taking away universal GP OOH's emergency coverage and offering a range of options (phone, walk-in etc.) in combination with a service that is dedicated to the needs of the people most likely to derive real benefit from it would be an acceptable trade for most people.
Regards - Shinga
Dear Potentilla
Thanks for the information. I will read through the links before making any further comments in this thread.
One more thing, our American friend “b” made some comments about market forces and the like and how we should feel ashamed about our lament of the demise of the OOH service. He needs to remember that we pay not only to fund the NHS and our treatment but also too heavily subsidise the training of our Doctors and Consultants.
Having checked this out at two medical colleges here in the UK the cost to the taxpayer for a five year course runs to just under £100,000 or $ 170,000 and that does not cover specialisation. I wonder if he was subsidised to the same tune when he undertook his training in the States?
I feel badly let down by the negotiators of this new contract and want to understand better what we are paying for and what we have lost.
Dear Doctor,
Just finished reading your blog comments and for somebody who considers himself an intelligent academic, I find it hard to believe that you can draw up such a one-sided view of me as a person based on the limited comments made on this blog.
You maintain that I am selfish, by definition that means you believe that I am putting myself before others. If you are talking about wanting a return of a reasonable ooh service in the local community then I believe this to be the wish of the majority - so hardly a selfish opinion. Surely it's more selfish to deny it.
I reiterate I am not asking any Doctor to work more than nine hours per day but to provide some form of shift cover in association with the PCT. I am not asking for specialist treatment for me as an individual over everybody else in my community, just the same treatment as some people still enjoy depending on where they live - so again how does this make me selfish?
The last time I personally used the OOH emergency surgery (and in all the time it was there) after 5pm was ten years ago. I had tried to get in to see one of the GP's around 4pm in the afternoon but they couldn't see me and suggested I phoned back in the morning. It go so bad that I called the co-op clinic about 7pm and the doctor saw me at 9pm and referred me straight to hospital (I thought I had a migraine and went for a stronger painkiller than Solpadine) it was pretty serious (mri scan/lumber puncture/hospital stay). I certainly don't see myself as a selfish abuser of Doctors services whatever you want to imply to everyone who reads your blog.
continued..
Then you call me naive which implies that I'm too uneducated to understand such heady topics as the NHS and economics, however, what I do know is that pre-2004 we were paying considerably less for in your words considerably more. How is it then naive to expect at least a comparable service for all the extra billions.
Now that we are expected to self diagnose after 5pm weekdays and every hour of the weekend and decide for ourselves whether we're a serious enough case for A&E, I worry, in the same way that you say you used to, that because a wrong decision made as a parent, not to trouble A&E because you're not sure how bad it is, it could be serious. My first born picked up a staph infection in hospital when he was born, it was just a little blister on his thigh where his nappy was and grew to the size of a pea in a couple of hours and I had assumed it was a nappy rub and put on sudocreme. My mother visited after work and insisted I called the Doctor at 6pm because "it doesn't look right", we took him to the emergency co-op clinic that used to operate in the town, the family practitioner took one look and we were rushed into A&E and he was on a drip and in intensive care with me for a week being barrier nursed. The rate of spread over night on his whole thigh was terrifying and we thought we were going to lose him.
I agree there is much waste in the NHS and perhaps both Doctors and Patients should stop arguing between themselves and concentrate their efforts against the administrators in the NHS. I would add in closing that I’ve not made any personal remarks about you and in no way hold you personally responsible for the failings of the NHS. You have done what most people would do and that’s accept the best deal on the table.
Dear Friends,
Physicians in the US are not subsidized for their training. We go to college for 4 years ($40,000 for public school), then medical school for 4 years ($125,000 if you go to a cheaper state school) and then 3-7 years of residency during which time your salary is roughly $35,000. Currently I pay $1600/month for my student loans and will for the next 6 years.
I can't argue with your point that if you train the doctors, they should feel obliged to you. Personally I prefer this way in that I'm obliged to no one and do not therefore have to wear a collar of guilt for the public to pull whenever there is a discussion about "rich doctors".
No one is asking you to triage yourselves. Here if someone is sick and they wonder if they need to go to the ER or an after hours walk-in clinic (or good forbid wait 12 hours) they can call their physician and ask them. That is what my intelligent patients do. They call and ask about their symptoms and then I direct them appropriately. All this requires is a telephone.
In the end, you get what you pay for, but the majority of you are paying for something a minority of you use. The great majority probably uses OOH services once a decade. For that reason alone, you should consider re-allocating those resources.
b
"No one is asking you to triage yourselves"
B, you have no understanding of the UK system. If you are ill out-of-hours now, you have a choice between calling an ambulance, going to A&E (ER) or calling NHS Direct. At NHS Direct you will be triaged by a nurse from a protocol and quite likely told to go to A&E anyhow. Or she may put you through to the OOH medical (doctor) cover if it exists in your area. I don't know whether you can actually talk to a doctor in this case.
"Your physician" - ie someone who has your medical record and a clue who you are - in this country is your GP, unless you already have a medical condition which is being treated in hospital. You can't speak to GPs on the phone out of hours any longer. In some areas, you can't speak to ANY doctor on the phone out of hours, and in NO area can you speak to a doctor on the phone OOH without going through a nurse protocol first.
Potentilla - thank you.
Tracy, not at all. Dr Crippen says of himself in his comments recently "I combine a complete lack of patience with the diplomatic skills of Atilla the Hun" so I wouldn't take him losing his temper too seriously.
"Concentrate their efforts against the administrators in the NHS" is wildly off-base. "Against the politicians" perhaps? They're the ones who amndated the new GP contract. I could write you whole essays on the subject of the management of the NHS if you wanted!
Potentilla - I apologise for my misunderstanding (oh gosh you're not a Chief administrator are you? - upsetting two people in one blog *rolls eyes*).
I've done a fair few essays on management myself, but in the private sector not the NHS, so I'm happy to be educated or put right if you catch me making mistakes - that's what I love about blogs.
Since the weekend I have been doing a bit of bed time reading to gen up on the NHS, takes a lot of cross referencing on different websites but fascinating stuff 
No, I used to run fund management companies (retired early due to cancer) but am married to someone who used to be a director of various acute trusts. So I know a fair bit about NHS management, and can compare it with the private sector, which I find endlessly interesting. Doctors are a lot like fund managers!
(NHS admin is a nutshell is a bit like a large corporate, only much worse; lots of people in the centre with woolly job titles trying to get data from the far-flung subsidiaries, and adding apples and pears to get irrelevant strategic 5-year grapefruit; lots of people out in the subs trying to get on with running businesses, spending as little time and money as possible on collecting the data demanded by the centre, and generally hating the corporate office staff. The difference is that there is nobody who really has the power or understanding to bang all the heads together from time to time).
I'm afraid Dr Crippen just confirmed everything I thought about the decline of the GP service.
He seems to think the taxpayer expects EVERY doctor to be available all the time.
Wrong. What we expect is the VAST amount of money swallowed up by the NHS to be spent efficiently. Instead of expensive, useless and dangerous experiments like NHS Direct/24, the money should be used to employ enough GPs so that they can cover all hours BETWEEN them.
This means working shifts, Doctor. One week you might do days, one week nights, and one week back shifts. For the money we are paying you, that IS NOT too mch to ask.
Instead, you have managed to wangle a deal -- I'm sure it amazes you as much as it amazes us that -- where you do less and are paid infinitely more.
It is completely unsustainable and is fuelling inflation as more and more public-sector workers (lecturers, for example) look at what you lot are paid and demand a piece of the action.
It can't last.
now i realise why the nhs is in such a state. some moron compares OOH to blockbusters video!? durr, lets have free pizza/video delivery anytime anywhere(coz i pay effing taxes).
i once had to visit to see a flea bite on a sunday night. i agree with dr crippen; if the punters (patients) appreciate that there is a cost in providing medical services - which would be higher OOH - then they might not be so keen on wasting their tax contributions inappropriately.
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