Out of Hours Medical cover in Bristol in 2004
Michael Whitfield.
When their temperature goes too high its worrying, you worry about brain damage and things, and they could die, or there might be something more deeply worrying than I could imagine Quote from mother in a recent study.
A single phone call to NHS Direct will provide a one-stop gateway to healthcare, to give patients more choice about accessing the NHS. Depending on the problem, NHS Direct nurses will advise on care at home, going to the local pharmacist, making a routine appointment, arranging for an emergency consultation, calling an ambulance or social services support. If the problem is routine, NHS Direct will offer the option of ordering the prescription and arrange for delivery to the patients door. Round the clock medical care for minor ailments and accidents will be available for all within convenient travelling distanceAs services are modernised long waits in accident and emergency departments will become a thing of the past. The NHS Plan D of H 2000
Three years after the launching of the NHS Plan what do people do in the UK when they require out-of-hours (OOH) medical attention? A number of studies have indicated that just under two thirds of contacts are still with general practitioners and just over a third with Accident and Emergency departments. Over the last few years the development of electronic call management systems, the development of co-operatives that take all OOH calls for most general practices and the new walk-in primary care centres have created a new challenge to those seeking out-of-hours care.
Currently, Bristol patients and carers have a choice when they require out-of-hours medical advice. Although they can still attend one of the three Accident and Emergency Departments and the two NHS Walk-in services, they are now encouraged to contact NHS Direct by telephone as an option before trying to contact their general practitioner or seeking any other medical care. NHS Direct was established as a nurse-run national telephone help-line in November 2000 and a National Audit Office report a year later found that it operated safely and advice to callers erred on the side of safety. It reported that one in five callers had to wait more than 30 minutes for a nurse to call back with advice. The cost of NHS Direct was £78million in 2000-1 and was expected to increase to £99m in the next year. Like all telephone help-line services, the key problem centres on their ability to cope with surges in demand. The local call centre Avon, Gloucester and Wiltshire NHS Direct
(AGW NHS Direct) based at Almondsbury, has to use other centres when it is under pressure and calls may be taken by nurses in other parts of the country who are able to use an intranet to ensure that they have details of all local services. Patients, though, are unaware where their call is being answered. Currently, OOH calls for over 10 million patients go directly to NHS Direct and by 2006 it is expected that the whole of England will be covered. By then it is expected that the telephone number 0845 4647 will be as well known as 999. About a third of patients who call NHS Direct are advised on how to care for themselves and where GP Co-operatives calls are taken, initially by NHS Direct, between 30% and 50% of the calls are handled without reference to a GP. From April 2004 NHS Direct will be delivered by a Special Health Authority and all funding will be routed via Primary Care Trusts (PCTs) who will commission the services.
NHS Direct was designed to ensure that callers receive the right care quickly and efficiently by making the best use of health professionals skills and redirecting callers appropriately. The plan was that this should be an appropriate service, as many calls from patients can be dealt with by well-trained nurses. Nationally, NHS Direct takes in excess of 500,000 calls each month from the public and is now the largest telephone based provider of health care in the world. NHS Direct currently does not triage requests for ambulance calls and do not normally access dentistry and community nursing services directly. However, the AGW NHS Direct is currently involved in work with ambulance services to assess Category C (non-urgent) calls, and it seems that about 250 blue-light ambulances are being released for more urgent tasks every month.
Contacting a general practitioner out of hours used to be straightforward, a phone call to the surgery was re-directed to the doctor on call and he or she dealt with the request. Over the last 15 years or so there have been some significant changes. There have been a number of factors involved. Patient demand is certainly one of these, with the number of night visits done by doctors more than doubling during the 1990s. One reason for this is simply rising patient expectation for a 24 hour service, but others might be the willingness of deputising services to visit rather than give advice over the telephone and individuals lack of family support. With the continuing difficulty in recruiting to general practice, the falling proportion of full-time general practitioners and the proportion of female general practitioners rising-- recent surveys have indicated that the great majority of general practitioners would prefer not to continue to provide OOH services for their patients. Last years General Medical Services (GMS) contract finally stated that the 24-hour service, that had been expected from general practitioners since the beginning of the NHS, was no longer obligatory. By opting out of providing this service, an individual general practitioner would forgo about £6000 per year. The Primary Care Trust has been given the responsibility of ensuring that OOH cover continues and, when the practice declines to provide it, the Trust has to do this, usually by contracting with a deputising service or a general practice cooperative. The new contractual arrangements about GP OOH work are expected to be finalised in the latter part of 2004 and the PCTs have indicated that the preferred providers are the current providers of care.
There are three GP cooperatives in Bristol, NORDoc, based in the outpatient department at Southmead Hospital, FRENDoc based in outpatients at Frenchay hospital and BRISDoc based in the walk-in centre at the Knowle Health Park. Each of these is a not for profit organisation that is entirely owned by, and mostly medically staffed by, the GP principals in the area in which it operates. Each one is organised differently. Since 2000, NORDoc has its calls routed via NHSDirect for call handling and initial nurse assessment as part of the DoH Exemplar Project. Calls from the NORDoc number are given priority. Each cooperatives employed staff include administrators, nurses and drivers. Each runs a primary care centre where patients can be examined and treated and is open from 1900hours to 0700 or 0800hours each day and at weekends from 0700 hours on Saturday to 0700 or 0800 hours on Monday. Approved GPs staff the centre and can visit patients in their homes when clinically appropriate. It is extremely rare nowadays for a patient under the age of 12 years to be visited at home by a doctor working for a cooperative. Each duty session lasts between 4-6 hours and a few choose to do over-night sessions. Each doctor contracts to do about one session every 15 days, much less onerous than in the old days. The cost of the cooperative is met mostly by subscriptions from GP member practices based on list size with some funding coming directly from the Department of Health and PCTs. The cooperatives provide OOH care to at least two thirds of the Bristol practices and there is some evidence that more GPs are using them. Providing OOH care for patients just outside Bristol can be a problem. The Weston GP cooperative is currently in discussion about providing OOH cover for patients in the Woodspring area with a possible primary care centre in Clevedon.
Individual GPs and practices and the PCT can also choose to employ the local commercial deputising agency, Primecare, to do their OOH work. This is expensive for the individual doctor, but has the advantage that the doctor can use the telephone answering and OOH cover as much or as little as desired. Both the deputising service and the cooperatives have to conform to certain standards set down centrally and managed by the local PCT. Some of these standards are more stringent than those expected of normal GP services!
The final part of the out-of-hours cover is provided by the walk-in centres. There are two of these in Bristol, one in the centre and the other on the Knowle Health Park. These have proved to be extremely popular with patients and are open from 0800 hours to 2000 hours on most days. They are staffed by nurses who consult using electronic systems for care protocols. They are of particular benefit to those who are not registered with a general practitioner in the city. However many general practitioners view the walk-in centres as a waste of money and expensive nurse resources, particularly when patients have to be referred to general practitioners when they may have further waits and may well be seen by another nurse before reaching a doctor! This is particularly the case in the Knowle area, where general practitioner services and walk-in service exist next to each other.
There are a number of important questions that need to be answered during 2004:
What do you think about the present state of out-of-hours work in Bristol. If you are a GP is this the sort of service you want to support? If you work in the hospital service is the current service causing you particular problems? If you, as a patient, have had good or bad experiences that you would like to share with us, please tell us about it via the Bristol Med-Chi Your Say web page (e-mail address: janet@bristolmedchi.co.uk).
Michael Whitfield
January 2004