Fears over doctors' out-of-hours service

SCOTLAND'S out-of-hours health service is facing a staff crisis, as hundreds of GPs abandon evening and weekend working, a report has warned.

Audit Scotland, the public-spending watchdog, said the service was at "significant risk" of being unsustainable, particularly in rural areas, and advised health boards to come up with new ways to ensure the service could be maintained.

Since a controversial new contract allowed GPs to opt out of working out of normal hours, the number willing to do such shifts has dropped from almost 1,700 in 2004-5 to 1,440 in 2006-7.

The watchdog said at least five Scottish health boards were already struggling to fill their rotas to provide a full service. Some boards have had to bring in doctors from overseas to cover weekend shifts, at a cost of thousands of pounds.

Opposition politicians described the results as "alarming", while patients' groups demanded doctors be "more flexible" and cover the out-of-hours work.

The problems have been caused by the new GP contract introduced in 2004. It allowed family doctors to withdraw from providing out-of-hours care, forfeiting an average of £6,000 of their salary in the process. But under the new contract, which included performance-related elements, GPs' average incomes actually rose by 24.9 per cent to £82,696. However, salaries have been frozen for two years.

Audit Scotland said that, since 2004, 95 per cent of Scotland's GP practices had chosen to pass the responsibility for evening and weekend care to the health boards. Services are now provided by a mix of health professionals, such as nurses and paramedics, as well as individual GPs who have opted back in to out-of-hours shifts. For working such shifts, GPs can earn up to £80 an hour - rising to £150 at Christmas and New Year.

But the watchdog said the increase in GPs' income meant that the financial incentive to cover out-of-hours sessions was "less attractive". The number of GPs willing to work at weekends and evenings was dropping, particularly in rural areas.

Audit Scotland questioned six health boards and found Borders, Grampian, Lanarkshire, Highland and Shetland already had difficulties filling GP out-of-hours rotas. Only Greater Glasgow said it had no such problems.

It warned that if more GPs opted out of working out of hours, the future of the service could be at risk. Caroline Gardner, the deputy auditor general for Scotland, said: "Since the changes to out-of-hours services three years ago, NHS boards have worked hard to maintain the care patients have traditionally experienced, and most patients are satisfied.

"However, the way the service is currently delivered needs to change, as there is a significant risk that it is unsustainable in its current form, particularly in Scotland's rural and remote areas."

Ms Gardner said the boards and the Scottish Executive needed to look to other healthcare professionals to extend their roles to help cover out of hours.

Claire Sweeney, one of the authors of the Audit Scotland report, said: "What we have seen is that, over time, there is a reduction in GPs working out-of-hours sessions. This means that boards must look at how out-of-hours care is delivered.

"GPs are not the only ones who could be providing this care and they must look at extending the roles of other trained staff to fill the gaps and provide a joined-up service."

Margaret Watt, of the Scottish Patients Association, called for GPs to be more flexible in providing services in the evenings and at weekends.

"These doctors took an oath to look after the sick, the vulnerable and the elderly," she said. "They did not take an oath to look after patients between nine and one, and two and six. If you do not want to do these out-of-hours periods, then do not come into the profession.

"They need to be more willing to provide these services. What are we paying them for?"

The report found only 11 per cent of GPs believed patient care had improved as a result of the new arrangements for out-of-hours services.

But 88 per cent said they were relieved they no longer had 24-hour responsibility for patients, with 66 per cent saying it made a career as a GP more attractive.

Despite doctors' reservations, a separate survey of 600 patients by Audit Scotland found that 85 per cent were satisfied with the service they received during evenings and weekends.

The cost of providing out-of-hours care in Scotland was estimated at £67.93 million in 2006-7.

But only about 30 per cent of this came from the money clawed back from GPs opting out of the service, with boards having to find the extra money elsewhere in their budgets.

The Audit Scotland report found huge variations in the cost in different areas, with rural areas paying the most for cover. Costs ranged from £43.63 per registered patient in Argyll and Bute to only £7.61 in Greater Glasgow.

Audit Scotland said boards had successfully sustained out-of-hours services using contracts with the ambulance service and locum GP agencies. But it added that most of these contracts had not been reviewed to see if they were providing value for money.

The watchdog said there was also a lack of monitoring of out-of-hours services, so it was difficult to assess what impact they were having on patients.

Mary Scanlon, the Scottish Conservatives' health spokeswoman, said she was "deeply alarmed, but sadly not surprised" by the report.

"It is damning that only 11 per cent of GPs think that things have improved, and nearly one in five patients are dissatisfied with their experience of the new and potentially critical service," she said.

"There is now an impending crisis, as fewer and fewer GPs opt to provide their services to NHS 24, and the inherent danger that far less qualified medical staff will take over their responsibilities."

Dr Dean Marshall, the chairman of the British Medical Association's Scottish GPs committee, said he was aware of doctors wanting to work out of hours but not getting shifts.

He also defended the new contract, which he said was designed to combat a crisis in general practice and help with the recruitment and retention of GPs. "Before the new contract was introduced, morale was at an all-time low, GPs were planning to retire early and recruitment was becoming impossible," he said.

"Now, however, GPs have more control over their workload, and work-life balance and morale have improved. Importantly, more than two-thirds believe that a career in general practice has become attractive again."

Shona Robison, the public health minister, said it was important that the new government looked at the current operation of out-of-hours services and ensured their long-term sustainability and success.

"The health secretary has already made clear that she wants to see greater flexibility from GPs in delivering out-of-hours services and welcomes the positive attitude of the BMA in discussing this subject," she said.

"In order to maintain and improve the delivery of out-of-hours services, the Scottish government will work with boards to extend the roles of nurses, paramedics and others in delivering the service.

"It is important that, together with NHS Education, we continue to develop this skill-mix to complement the work of GPs in delivering the out-of-hours service."

'We welcome the fact that we have a choice'

AFTER many years of providing out-of-hours care for his patients, Dr John Garner welcomed the opportunity to opt out, writes Lyndsay Moss.

A GP for 28 years, he works at least ten hours every day at the busy Edinburgh practice he shares with five other full-time doctors.

He said the new contract had improved the lives of doctors across Scotland, as well as the care of patients.

"We all welcome the fact that we have a choice about working out of hours," he said.

"We talk about patient choice, but now we have a choice too. That is to either do out-of-hours [work] or to opt out. At my age, I have decided to opt out and not do it.

"People forget that our pay actually dropped quite significantly as a result, by thousands of pounds.

"But it was also obvious that we had been providing this service on the cheap. Health boards can't run out-of-hours [care] as cheaply as it was previously."

A day spent in Dr Garner's busy surgery reveals why many doctors may feel working a day shift is more than enough. He starts at 7:45am, seeing more than 20 patients in the surgery during the day as well as home visits. He ends the day with paperwork before leaving at around 6:30pm.

Dr Garner believes the new contract has created a work-life balance for doctors.

"Prior to the new contract and having to do out-of-hours as well, it was all-consuming. Now there is a life after work. We could not have sustained it as we were doing. It would have been difficult to recruit and there would have been more burn-out and dissatisfaction."

'24-hour cover is in best interests of our patients'

DONALD Cruickshank decided that opting out of providing out-of-hours cover when the new contract was introduced in 2004 was not in the best interests of his patients.

The GP said his location in the Aberdeenshire village of Braemar meant people faced a 60-mile trip to their nearest hospital and one of 30 miles to the out-of-hours health centre.

By choosing to cover out of hours for his patients, Dr Cruickshank is on call 24 hours a day for 244 days a year - the rest is covered by a part-time GP at his practice. The Braemar Health Clinic is the only practice in Grampian not to opt out of out-of-hours care.

"When deciding whether to opt out, we considered our geographical location and were just not happy with the service model which was being proposed to serve our patients," Dr Cruickshank said.

"We have many elderly patients and also a large number of tourists visiting the area. They could have difficulty travelling to the hospital or the out-of-hours centre. Many also do not have a car, which would make that difficult.

"In the end, we decided that patients could suffer unnecessary anxiety if we did not provide out-of-hours care."

Dr Cruickshank, a GP for 18 years, said they had some 600 patients but also cared for hundreds of tourists visiting the area.

He said being on call 24 hours a day for most of the year was a big responsibility. "It does limit what one can do. If you are off work, you can't go away for the day because you have to be nearby in case you get a call to a patient," he said.