Dr Holden wrote this letter to the Times in response to an article. He has given permission for it to be reproduced.
Comments to Camilla Cavendish regarding article in the Sunday Times 29th of April 2013
"The GPs cushy deal means we are all left to suffer in casualty"
Camilla,
I read your article with interest and huge disappointment. I am a general practitioner of some 30 years standing, qualifying is a GP in 1983. Since 1985 I have been a principal in my practice in Matlock which has training status for both undergraduate and postgraduate doctors and for district nurses and health visitors. We also help run the local community hospital including its minor injuries unit. Until 2000 when the lawyers forced us out we used to do our own obstetrics as well.
From 1985 to 1996 I had to work every fourth night and every fourth weekend in addition to a full weeks work. If a partner went on holiday I had to cover my share of that absence – what used to be called one in four with prospective cover. Such a rota delivered an average working week of 80 hours with a peak of 114 hours and a trough of 56 hours with 32 hours and 80 hours at a stretch . From 1996 to 2004 I was part of our local general practice out of hours cooperative which meant that the population was covered in a local doctor who was not compelled to work all day and all following day, all week and all following week. Even then I had to do 1 in 12 on call for the community hospital in ADDITION to my shifts on the cooperative. Despite the contractual easements of 1996 and 2004 by the time I retire I will have worked 148,000+ hours at 60 years of age and 159,000 hours at 65 – that is twice the working career of the rest of society and typical of my generation of doctors who qualified in the late 70s or early 80’s
In understanding why general practitioners struggled with out of hours as organised before 2004 it is necessary to understand the changes that have occurred in society since the National Health Service began.
1. Nuclear families with no granny round the corner to offer advice to the new mother with a consequence that every child with a runny nose is brought to the GP.
2. Longer life expectancy and large numbers of elderly people with multiple pathology requiring significant input.
3. Modern medicine has moved a long way with much work that used to be done in hospitals and in outpatients now being performed in general practice.
4. Politicians keep on stoking up demand because it’s an easy vote winner
5. A society which is not prepared to tolerate risk of any sort
6. A consumerist society that simply views health services as a commodity when it comes to the organisation yet paradoxically wants highly personalised care when they come to being cared for. Patients want a bespoke service at mass-production prices.
Even in my own practice in a small town nobody can explain to me why with a static population with 100% child immunisation the out of hours call rate went from six or seven per week in 1985 when I joined the practice to over 10 times that number in some weeks in 2004. Such a rising workload coupled with massively increased complexity of daytime GP work is completely unsustainable on the model of out of hours care extant before 1996 and was very difficult between 1996 and 2004.
Compounding matters is the fact that despite the massive leftward shift of care into general practice of much former hospital work (UK general practice now deals with almost all people with hypertension, diabetes, thyroid disease, 90% of mental health problems, and most post-operative follow-ups all of which used to go back to hospital) with a workforce that is estimated to have increased from approximately 27,000 whole time equivalent GPs to about 34,000 whole time equivalent GPs. During this at a time hospital consultant numbers have doubled. To put things into perspective general practice delivers approximately 300,000,000 consultations per annum and does it with roughly 9% of the NHS budget.
I feel particularly aggrieved by your comments because even with my supposedly cushy number both myself and colleagues are finding ourselves with intensive 14 hour days and yet 40% of us still work on the out of hours service. Apart from 2000 to 2004 I have always worked on the out of hours service and have something around 40,000 out of hours calls under my belt. Here in Derbyshire the current out of hours provider Derbyshire Health United is the amalgamation of our two former cooperatives and over 97% of all our out of hour shifts are covered by Derbyshire GPs. It is wholly unrealistic to expect your own doctor or a doctor from your practice to attend you out of hours given the current demands on the service. Remember that when the NHS was set up it was envisaged that each patient would need 2 out of hours consultations per lifetime and one of those would be to certify the fact of death!
This is not just the rant of a country GP. I am one of only two survivors from the 2004 GP contract negotiating team and I was in the room when the out of hours deal was done so I have first-hand experience of exactly what was agreed. The only thing I’m likely to agree with you on is the fact that both Gordon Brown as Chancellor of the Exchequer and Tony Blair as Prime Minister were fully in the picture as to what was being negotiated at the time on a day to day basis. Representatives of number 10 and number 11 were in the room time.
For the avoidance of doubt what was agreed in 2004 was that general practitioners were relieved of the obligation to make the necessary arrangements for patients whose condition so warranted it to be seen out of hours.
Analysis of that obligation is crucial. The NHS was never set up to provide 24/7 routine general practice. Indeed even if we had the money we don’t have the workforce. The NHS was set up to provide 24/7 emergency care. From 1996 the GPs out of hours obligations which were hitherto implied were made explicit; namely that it was for the GP to decide whether when and where the consultation would take place if one was necessary. This was agreed because of rapidly escalating demand. By 2001 recruitment to general practice had collapsed (it is collapsing again) and this was largely because of the unacceptable working hours of general practice.
Although cooperatives were spreading, in 1996 when the cooperative deal was signed over 50% of GPs were condemned to doing their own on-call because they could not find anybody else or any company to cover the work. In 1997 the Doctors and Dentists Pay Review Body formally determined that the quantum of money paid to GPs for making arrangements for out of hours was approximately £6000. At the time I calculated that GPs were being paid much less than minimum wage to be on-call, cover their travelling and motoring costs, and any immediately necessary treatment drugs.
From 1996 cooperatives spread quickly in the urban areas where the was no out of hours deputising service and into the immediately neighbouring countryside, but the problems of getting cover in rural areas and especially remote areas whether urban or rural remained. Those doctors were working with 1947 resource to cope with 21st-century demand and the result was that even in the so-called plum practices - nice genteel rural attractive areas it was impossible to recruit new colleagues indeed, in my own practice it took almost 4 years.
In 2004/5 after we did the deal for out of hours the government expressed surprise that it had found it very complex operationally to organise out of hours care and that it had cost them almost 3 times as much to provide as they had recovered from the profession by withholding £6000 per doctor. That was not surprising to GPs because for many years the government and departmental officials had always denied our claims about the operational difficulties, burdens and, costs of delivering an out of hours service in the modern era.
From 2004 it fell to the primary care trusts to make arrangements to provide out of hours services. In many areas they stuck with the out of hours cooperative but insisted on paying less for purely financial reasons resulting in reduced staffing levels. Indeed this was a recipe for disaster - for example they tried to cover the whole of North Yorks Emergency Doctors area with only five doctors on the service. Call times became prolonged and lives were lost (I can prove that). The model was economically unsustainable and shortly afterwards North Yorkshire Emergency Doctors went under. I understand that re-provision cost far more.
In other areas the primary care trusts recognised the value of what they had and continued funding at economic levels. Quite properly PCTs sought to retender periodically and in some areas the existing contract holders lost out to commercial operations which that believed that they could save money. The only way to save money was to reduce staffing particularly call handling and medical staff. The consequences of this were delays in call handling and processing sometimes of a dangerous nature for the patients concerned. General Practitioners working for the services as employers often found that either their concerns were dismissed or they simply were not offered further work. As the financial pressures increased on the commercial firms they reduced the amounts they were willing to pay doctors and as a consequence the local GPs pulled out of working for the organisation particularly at the pay rates on offer. The result was the importation of general practitioners from Europe and we all know what happened with Dr Ubani.
In some areas the existing out of hours cooperatives made very robust contractual proposals to the PCT’s which were not the cheapest but were the best and the cards were played along the lines of we know this is not the cheapest but it is the best and we have minimal complaint rates and competition amongst local doctors to work for us. That type of approach worked in Derbyshire - the two cooperatives Derby Medical Services and North Derbyshire Doctors merged to form Derbyshire Health United a social enterprise NHS body fully and properly integrated paying appropriate rates of pay to all grades of staff with the result that over 97% of the GP shifts are staffed by Derbyshire GPs. DHU has gone on to secure the 111 contract for Derbyshire which was operating well as a pilot and still managed to stay afloat when the tsunami of transferred calls from other failing 111 services hit it in April 2013
The importation of GPs from Europe carries its own problems. The charge levelled at UK GPs being the best paid general practitioners in the world is true for the simple reason that we have the heaviest job weight of GPs in the world. For example we act as General Physicians in the Community (since there are no longer General Physicians in secondary care) we see all children, undertake considerable amounts of gynaecology and see pregnant or post natal patients and do baby checks, see 90% of mental health problems, undertake huge volumes of chronic disease management, and look after large numbers of elderly people in residential and nursing homes as well as ordinary reactive care.
Indeed the Commonwealth Fund report on primary care show UK general practice in a very good light indeed. I can send you a slide set!
Countries compared: Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, U.K., and U.S.
The UK has:
• Second lowest health spending per capita (slide 5)
• The lowest “cost related access problems” to primary care (slide 6)
• The joint best access to same/next day access to primary care physician (slide 8)
• The least difficulty I accessing out of hours care without needing to attend A&E (slide 9)
• The best access to out of hours care (slide 9)
• The highest access to online repeats and appointments (slide 10)
• The highest scores for management of chronic diseases (slide 17)
• Joint second in use of IT (slide 22)
• Highest in reviewing patient data and outcomes (slide 24)
• Highest level of practice comparative data (slide 26)
• Least physician satisfaction with time spent per patient (slide 37-we need longer consultations!)
• Access to GPs and OOH has improved in recent years (slide 40)
• Slide 45 summarises the UK well-a lot to be very proud about
European GPs do not see children less than four years of age and in some cases children under 16, many do not handle psychiatric problems at all, they do not provide in a systematic structured form the scope, quantity or depth of chronic disease management and in some countries elderly people in nursing and residential homes are looked after by community geriatricians. Colleagues report that when they are on shift out of hours with GPs who practice in Europe, delays are a nightmare because European colleagues avoid whole swathes of work and refer whole swathes into accident and emergency. The consequence of this is that UK-based GPs when they raise concerns find that they are at best ignored and at worst threatened. Under such circumstances the sensible UK-based GP resigns from the service in order to preserve their registration and that is what happens.
Our colleagues in accident and emergency do a hugely valuable job (I have held a part-time contract to run a minor injuries unit for 25 years) which I have been privileged to witness first hand. The current problems in Accident and Emergency (now properly known as the Emergency Department) are problems of outflow in that the hospital is often full because beds are being blocked by patients who need social support in order to be discharged safely. Social services are struggling because of cuts but also have a very different concept of urgent or emergency from those in the health professions. Those of us who work in the health professions have the perception that social services definition of emergency is this week and urgent is this month. Unless and until that changes government proposals to merge health and social care funds and puts the control of the health service into local authority hands is doomed to failure.
So why won’t GPs take back out of hours care? (OOH)
1. Bitter experience has taught GPs not to trust governments of either colour on this issue. Even if OOH was offered back on favourable terms within a year or so the government would reduce the funding and resources available
2. GPs already work a 52 ½ hour week
3. We have a whole generation of doctors who know nothing other than EWTD compliant working week
4. There are not enough GPs to provide the service AND maintain their own work life balance
Contrary to myth the GP working day is pretty much a sprint from start to finish. Morning surgery will be anything from 20 to 30 quite complex patients followed by three or four almost certainly complex visits usually to the elderly with multiple pathology, lunchtime will be a working affair with a sandwich about service operational matters followed by a surgery restarting in the late afternoon around 4 o’clock of another 20 patients at the end of which there will be repeat prescriptions to sign letters to read and laboratory reports to analyse and act upon. Gordon Brown insisted that we opened extended hours but what he failed to realise is that after 10 hours, 40 patients, 4 visits, a meeting, 30+ repeat prescriptions 55+ hospital letters and a couple of dozen laboratory reports; physically and mentally a GP cannot safely get their head around any more problems that day and will be going home at past 8pm at night.
During the 1990s a well-respected paper demonstrated that after the 17th patient the quality of consultation falls rapidly. If that is the case then the average practice is operating at 17% appointment overload all the time and 55% overload for almost half the year assuming that no member of staff is ill.
Is there any wonder that only 40% of GPs are involved in out of hours?
Most of us are too exhausted mentally at the end of the day to contemplate any further work.
If this is a cushy number then I’d like to know what constitutes a difficult road to hoe?
Peter JP Holden MB ChB FIMCRCSEd FRCGP
GMC reg no 2480804
Comments to Camilla Cavendish regarding article in the Sunday Times 29th of April 2013
"The GPs cushy deal means we are all left to suffer in casualty"
Camilla,
I read your article with interest and huge disappointment. I am a general practitioner of some 30 years standing, qualifying is a GP in 1983. Since 1985 I have been a principal in my practice in Matlock which has training status for both undergraduate and postgraduate doctors and for district nurses and health visitors. We also help run the local community hospital including its minor injuries unit. Until 2000 when the lawyers forced us out we used to do our own obstetrics as well.
From 1985 to 1996 I had to work every fourth night and every fourth weekend in addition to a full weeks work. If a partner went on holiday I had to cover my share of that absence – what used to be called one in four with prospective cover. Such a rota delivered an average working week of 80 hours with a peak of 114 hours and a trough of 56 hours with 32 hours and 80 hours at a stretch . From 1996 to 2004 I was part of our local general practice out of hours cooperative which meant that the population was covered in a local doctor who was not compelled to work all day and all following day, all week and all following week. Even then I had to do 1 in 12 on call for the community hospital in ADDITION to my shifts on the cooperative. Despite the contractual easements of 1996 and 2004 by the time I retire I will have worked 148,000+ hours at 60 years of age and 159,000 hours at 65 – that is twice the working career of the rest of society and typical of my generation of doctors who qualified in the late 70s or early 80’s
In understanding why general practitioners struggled with out of hours as organised before 2004 it is necessary to understand the changes that have occurred in society since the National Health Service began.
1. Nuclear families with no granny round the corner to offer advice to the new mother with a consequence that every child with a runny nose is brought to the GP.
2. Longer life expectancy and large numbers of elderly people with multiple pathology requiring significant input.
3. Modern medicine has moved a long way with much work that used to be done in hospitals and in outpatients now being performed in general practice.
4. Politicians keep on stoking up demand because it’s an easy vote winner
5. A society which is not prepared to tolerate risk of any sort
6. A consumerist society that simply views health services as a commodity when it comes to the organisation yet paradoxically wants highly personalised care when they come to being cared for. Patients want a bespoke service at mass-production prices.
Even in my own practice in a small town nobody can explain to me why with a static population with 100% child immunisation the out of hours call rate went from six or seven per week in 1985 when I joined the practice to over 10 times that number in some weeks in 2004. Such a rising workload coupled with massively increased complexity of daytime GP work is completely unsustainable on the model of out of hours care extant before 1996 and was very difficult between 1996 and 2004.
Compounding matters is the fact that despite the massive leftward shift of care into general practice of much former hospital work (UK general practice now deals with almost all people with hypertension, diabetes, thyroid disease, 90% of mental health problems, and most post-operative follow-ups all of which used to go back to hospital) with a workforce that is estimated to have increased from approximately 27,000 whole time equivalent GPs to about 34,000 whole time equivalent GPs. During this at a time hospital consultant numbers have doubled. To put things into perspective general practice delivers approximately 300,000,000 consultations per annum and does it with roughly 9% of the NHS budget.
I feel particularly aggrieved by your comments because even with my supposedly cushy number both myself and colleagues are finding ourselves with intensive 14 hour days and yet 40% of us still work on the out of hours service. Apart from 2000 to 2004 I have always worked on the out of hours service and have something around 40,000 out of hours calls under my belt. Here in Derbyshire the current out of hours provider Derbyshire Health United is the amalgamation of our two former cooperatives and over 97% of all our out of hour shifts are covered by Derbyshire GPs. It is wholly unrealistic to expect your own doctor or a doctor from your practice to attend you out of hours given the current demands on the service. Remember that when the NHS was set up it was envisaged that each patient would need 2 out of hours consultations per lifetime and one of those would be to certify the fact of death!
This is not just the rant of a country GP. I am one of only two survivors from the 2004 GP contract negotiating team and I was in the room when the out of hours deal was done so I have first-hand experience of exactly what was agreed. The only thing I’m likely to agree with you on is the fact that both Gordon Brown as Chancellor of the Exchequer and Tony Blair as Prime Minister were fully in the picture as to what was being negotiated at the time on a day to day basis. Representatives of number 10 and number 11 were in the room time.
For the avoidance of doubt what was agreed in 2004 was that general practitioners were relieved of the obligation to make the necessary arrangements for patients whose condition so warranted it to be seen out of hours.
Analysis of that obligation is crucial. The NHS was never set up to provide 24/7 routine general practice. Indeed even if we had the money we don’t have the workforce. The NHS was set up to provide 24/7 emergency care. From 1996 the GPs out of hours obligations which were hitherto implied were made explicit; namely that it was for the GP to decide whether when and where the consultation would take place if one was necessary. This was agreed because of rapidly escalating demand. By 2001 recruitment to general practice had collapsed (it is collapsing again) and this was largely because of the unacceptable working hours of general practice.
Although cooperatives were spreading, in 1996 when the cooperative deal was signed over 50% of GPs were condemned to doing their own on-call because they could not find anybody else or any company to cover the work. In 1997 the Doctors and Dentists Pay Review Body formally determined that the quantum of money paid to GPs for making arrangements for out of hours was approximately £6000. At the time I calculated that GPs were being paid much less than minimum wage to be on-call, cover their travelling and motoring costs, and any immediately necessary treatment drugs.
From 1996 cooperatives spread quickly in the urban areas where the was no out of hours deputising service and into the immediately neighbouring countryside, but the problems of getting cover in rural areas and especially remote areas whether urban or rural remained. Those doctors were working with 1947 resource to cope with 21st-century demand and the result was that even in the so-called plum practices - nice genteel rural attractive areas it was impossible to recruit new colleagues indeed, in my own practice it took almost 4 years.
In 2004/5 after we did the deal for out of hours the government expressed surprise that it had found it very complex operationally to organise out of hours care and that it had cost them almost 3 times as much to provide as they had recovered from the profession by withholding £6000 per doctor. That was not surprising to GPs because for many years the government and departmental officials had always denied our claims about the operational difficulties, burdens and, costs of delivering an out of hours service in the modern era.
From 2004 it fell to the primary care trusts to make arrangements to provide out of hours services. In many areas they stuck with the out of hours cooperative but insisted on paying less for purely financial reasons resulting in reduced staffing levels. Indeed this was a recipe for disaster - for example they tried to cover the whole of North Yorks Emergency Doctors area with only five doctors on the service. Call times became prolonged and lives were lost (I can prove that). The model was economically unsustainable and shortly afterwards North Yorkshire Emergency Doctors went under. I understand that re-provision cost far more.
In other areas the primary care trusts recognised the value of what they had and continued funding at economic levels. Quite properly PCTs sought to retender periodically and in some areas the existing contract holders lost out to commercial operations which that believed that they could save money. The only way to save money was to reduce staffing particularly call handling and medical staff. The consequences of this were delays in call handling and processing sometimes of a dangerous nature for the patients concerned. General Practitioners working for the services as employers often found that either their concerns were dismissed or they simply were not offered further work. As the financial pressures increased on the commercial firms they reduced the amounts they were willing to pay doctors and as a consequence the local GPs pulled out of working for the organisation particularly at the pay rates on offer. The result was the importation of general practitioners from Europe and we all know what happened with Dr Ubani.
In some areas the existing out of hours cooperatives made very robust contractual proposals to the PCT’s which were not the cheapest but were the best and the cards were played along the lines of we know this is not the cheapest but it is the best and we have minimal complaint rates and competition amongst local doctors to work for us. That type of approach worked in Derbyshire - the two cooperatives Derby Medical Services and North Derbyshire Doctors merged to form Derbyshire Health United a social enterprise NHS body fully and properly integrated paying appropriate rates of pay to all grades of staff with the result that over 97% of the GP shifts are staffed by Derbyshire GPs. DHU has gone on to secure the 111 contract for Derbyshire which was operating well as a pilot and still managed to stay afloat when the tsunami of transferred calls from other failing 111 services hit it in April 2013
The importation of GPs from Europe carries its own problems. The charge levelled at UK GPs being the best paid general practitioners in the world is true for the simple reason that we have the heaviest job weight of GPs in the world. For example we act as General Physicians in the Community (since there are no longer General Physicians in secondary care) we see all children, undertake considerable amounts of gynaecology and see pregnant or post natal patients and do baby checks, see 90% of mental health problems, undertake huge volumes of chronic disease management, and look after large numbers of elderly people in residential and nursing homes as well as ordinary reactive care.
Indeed the Commonwealth Fund report on primary care show UK general practice in a very good light indeed. I can send you a slide set!
Countries compared: Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, U.K., and U.S.
The UK has:
• Second lowest health spending per capita (slide 5)
• The lowest “cost related access problems” to primary care (slide 6)
• The joint best access to same/next day access to primary care physician (slide 8)
• The least difficulty I accessing out of hours care without needing to attend A&E (slide 9)
• The best access to out of hours care (slide 9)
• The highest access to online repeats and appointments (slide 10)
• The highest scores for management of chronic diseases (slide 17)
• Joint second in use of IT (slide 22)
• Highest in reviewing patient data and outcomes (slide 24)
• Highest level of practice comparative data (slide 26)
• Least physician satisfaction with time spent per patient (slide 37-we need longer consultations!)
• Access to GPs and OOH has improved in recent years (slide 40)
• Slide 45 summarises the UK well-a lot to be very proud about
European GPs do not see children less than four years of age and in some cases children under 16, many do not handle psychiatric problems at all, they do not provide in a systematic structured form the scope, quantity or depth of chronic disease management and in some countries elderly people in nursing and residential homes are looked after by community geriatricians. Colleagues report that when they are on shift out of hours with GPs who practice in Europe, delays are a nightmare because European colleagues avoid whole swathes of work and refer whole swathes into accident and emergency. The consequence of this is that UK-based GPs when they raise concerns find that they are at best ignored and at worst threatened. Under such circumstances the sensible UK-based GP resigns from the service in order to preserve their registration and that is what happens.
Our colleagues in accident and emergency do a hugely valuable job (I have held a part-time contract to run a minor injuries unit for 25 years) which I have been privileged to witness first hand. The current problems in Accident and Emergency (now properly known as the Emergency Department) are problems of outflow in that the hospital is often full because beds are being blocked by patients who need social support in order to be discharged safely. Social services are struggling because of cuts but also have a very different concept of urgent or emergency from those in the health professions. Those of us who work in the health professions have the perception that social services definition of emergency is this week and urgent is this month. Unless and until that changes government proposals to merge health and social care funds and puts the control of the health service into local authority hands is doomed to failure.
So why won’t GPs take back out of hours care? (OOH)
1. Bitter experience has taught GPs not to trust governments of either colour on this issue. Even if OOH was offered back on favourable terms within a year or so the government would reduce the funding and resources available
2. GPs already work a 52 ½ hour week
3. We have a whole generation of doctors who know nothing other than EWTD compliant working week
4. There are not enough GPs to provide the service AND maintain their own work life balance
Contrary to myth the GP working day is pretty much a sprint from start to finish. Morning surgery will be anything from 20 to 30 quite complex patients followed by three or four almost certainly complex visits usually to the elderly with multiple pathology, lunchtime will be a working affair with a sandwich about service operational matters followed by a surgery restarting in the late afternoon around 4 o’clock of another 20 patients at the end of which there will be repeat prescriptions to sign letters to read and laboratory reports to analyse and act upon. Gordon Brown insisted that we opened extended hours but what he failed to realise is that after 10 hours, 40 patients, 4 visits, a meeting, 30+ repeat prescriptions 55+ hospital letters and a couple of dozen laboratory reports; physically and mentally a GP cannot safely get their head around any more problems that day and will be going home at past 8pm at night.
During the 1990s a well-respected paper demonstrated that after the 17th patient the quality of consultation falls rapidly. If that is the case then the average practice is operating at 17% appointment overload all the time and 55% overload for almost half the year assuming that no member of staff is ill.
Is there any wonder that only 40% of GPs are involved in out of hours?
Most of us are too exhausted mentally at the end of the day to contemplate any further work.
If this is a cushy number then I’d like to know what constitutes a difficult road to hoe?
Peter JP Holden MB ChB FIMCRCSEd FRCGP
GMC reg no 2480804
