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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 8 - Out of Hours
RADIO 4
THURSDAY 28/02/06 2100-2130
PRESENTER:
MARK PORTER
REPORTER: LESLEY HILTON
CONTRIBUTORS:
LAURENCE BUCKMAN
STEPHEN WIBBERLEY
MARTIN O'CONNOR
HELEN ALPIN
SIMON CARLEY
PRODUCER:
ERIKA WRIGHT
NOT CHECKED AS BROADCAST
PORTER
Hello. In today's programme I'll be looking at out-hours-cover in the NHS.
Now that GPs no longer have to provide 24 hour cover for their patients, who do you call, and where do you go when your local surgery is shut?
I meet the staff of an NHS Direct call centre in South London that handles a thousand enquiries a day.
We join a GP working an evening shift for an insider's view of the out-of-hours service in Leeds
And I'll be talking to a consultant from accident and emergency to find out what effect recent changes have had on his department's workload, and how hospital based "emergency villages" could one day be a one-stop venue for people who develop a medical problem outside of normal working hours.
But first a bit of history to explain how we ended up with the current system. My guest today is Laurence Buckman - a GP in North London.
Laurence, talk us through the changes from the old Dr Finlay system where if you rang the surgery out-of-hours you got the doctor, his wife or his housekeeper in those days, to today's system where you might not even get to speak to a doctor, let alone one that you know - or one that knows you?
BUCKMAN
We used to get calls from patients either directly or through an intermediary and we used to respond to those calls. You might give advice, you might get the patient to come round to your house, but more usually you'd end up going round to their house.
PORTER
And this is when - and you do it on a one in five - say if there were five of you in the practice you'd be one night a week and one weekend a month thereabouts.
BUCKMAN
Certainly most of us couldn't cope with an entire weekend on call, so many larger practices broke up the weekend because it was just too hard. My worst Sunday ever I saw 40 people on a Sunday, some of them in the surgery but an awful lot asked for visits and that's very hard, you certainly don't have a social life if you're doing that kind of thing.
PORTER
And of course it's on top of your normal working week - you didn't have the next day off did you?
BUCKMAN
Patients think that you do the work in shifts but of course it isn't like that, we used to do the calls, possibly overnight as well - in fact quite often I'd had a very disturbed night - and then you carry on from Sunday to Monday and of course doing a full Monday day after a full Sunday day and night is quite challenging, particularly by the evening.
PORTER
Now we got round that by joining up to form basically large practices, cooperatives, where instead of being five GPs there might have been 35, 70 GPs together, which seemed to work quite well I thought, there was less on call for us, when we were on we were much busier. But what changed so that we're now in the current system where some GPs have been allowed to drop their out-of-hours altogether?
BUCKMAN
Most GPs felt that they couldn't go on working day and night because you find that if you're up all night and you're then trying to work the next day you're tired and by the end of the next day you're starting to worry about making mistakes, even if you don't actually make any. So people wanted to actually stop doing out-of-hours. And after a lot of discussions between the doctors and the government it was agreed that we should stop doing out-of-hours if we wanted in return for a pay cut and most GPs have decided they'll have the pay cut and not do the out-of-hours.
PORTER
So who has the responsibility for out-of-hours now?
BUCKMAN
The organisations that run primary care, that's general practice and community services, now provide the out-of-hours service too. And generally they buy it from either what were doctors' cooperatives or from other companies providing out-of-hours services.
PORTER
Well, around the time that GPs were banding together to form those out-of-hours cooperatives, the government was launching its own initiative to provide easy access to health advice and information, irrespective of the time of day and night. NHS Direct was born - and like Topsy it's grown.
The service now operates 24 hours, seven days a week, it can be accessed via the telephone - 0845 4647 - through the website - nhsdirect.nhs.uk - or via an interactive service on digital satellite TV. Last year it handled around two million enquiries a month.
I visited one of NHS Direct's call centres in Beckenham to find out what sort of calls they get, how they handle them, and what proportion of the callers end up needing to speak to a doctor. Stephen Wibberley is the London Regional Director.
WIBBERLEY
Out of every hundred about 30 of them are actually phoning for information anyway, they don't need to speak to a clinician at all. As to the rest of them, out of the 70 that are left, about 10% of those might be advised to go to an accident and emergency department, about probably another 30% will be advised to contact a GP urgently within the next few hours, another 15% or so might be advised to contact their GP the next time their surgery's open. And the rest will be dealt with through home care advice - they don't need to go anywhere, they dealt with, with advice from the nurse.
PORTER
Can you make appointments with general practices directly?
WIBBERLEY
No we can't, we can slot people into appointments for out-of-hours, where we've got those relationships of out-of-hours services but not into routine general practice - at the moment - some practices are talking to us about that and that would be a great thing to do in the future.
ACTUALITY - NHS DIRECT
NHS Direct. My name's Lynette, I'm a health advisor. May I take the telephone number you're calling from?
PORTER
Lynette, now you're the first port of call, you're actually answering the phone direct from the public ringing in. So when I ring NHS Direct it's Lynette I'm going to be speaking to or somebody like you. What's the first thing you do?
LYNETTE
I immediately open up the screen and I would capture your essential details, which would be your telephone number, your post code and the house number. Thus being if you did collapse we could get an ambulance to you immediately.
PORTER
So we've got all of that, I'm ringing because my baby won't stop crying. How do you assess that?
LYNETTE
Right, okay, so is baby crying at the moment? No. Can they react normally to you? So just say - is baby able to understand, is baby reacting to you?
PORTER
Well if I say no, presumably that's a bit more worrying than yes.
LYNETTE
It would be and I mean if you said ...
PORTER
A little bit floppy.
LYNETTE
Yeah, I'd end up calling an ambulance.
PORTER
So it's the computer really that's, if you like, triaging, deciding ...
LYNETTE
It's prioritis - it's not triaging, it's a prioritisation tool. So I can say the priority is an ambulance, I would advise you to go to A&E yourself or to speak to a nurse. The nurse is the one that triages the calls.
PORTER
Martin O'Connor is one of those nurses. And dealing with a father concerned about a crying baby over the phone, is very different from assessing the same child face to face in the A&E department he used to work in.
O'CONNOR
Obviously it's very different from - in accident and emergency, you can see the baby, we can't see them, so we're relying on the questions that we ask and the answers that we're given. Most things are taken into consideration with their prioritisation tool, though obviously we do ask our own questions as well.
PORTER
And presumably you're erring on the side of caution anyway, if there's any doubt you would want that baby to be seen face to face.
O'CONNOR
Yeah, absolutely yeah.
PORTER
Let's assume that my baby's got a funny rash, has got a fever, is crying and you think it needs to be seen, how do you organise that baby being reviewed, let's assume this is 7 o'clock in the evening, my GP's surgery is shut?
O'CONNOR
We have access to the out-of-hours doctors around the country, so if somebody in Birmingham calls us down here in London we can actually refer to their out-of-hours doctor in that area. So we just send it through an electronic fax, which is sent to the out-of-hours provider in that area, we give a clinical summary of what we have found and then it's passed across.
PORTER
One of the frustrating things in dealing with call centres, full stop, whatever the reason for you calling is if you have another problem and you need to go back it can be difficult to speak to the original person, you end up going through the whole process again. What happens if my crying baby takes a turn for the worst and I want to get back and speak to you?
WIBBERLEY
If you call back it's not very likely you'll speak to the same person, we have different people on duty, your call might even go to a different call centre but we'll be able to pick up the records. So the member of staff will see exactly what advice you were given before and can often assess appropriately then, particularly if your baby's got worse, they'll advise you perfectly what to do.
PORTER
So wherever you contact NHS Direct there's a central software - central program, central record, if you like, that's accessible from anywhere?
WIBBERLEY
It's a central patient record, we've got a database of all our patients that's held centrally, just for NHS Direct, but wherever you call from, so even if you travel across the country and end up going to different call centres we'd be able to see that same patient record.
PORTER
One of the criticisms that's been levelled at NHS Direct from within the general practice is that it's like another layer that people have to go through and in fact what happens is that people speak to the first line and then the second line, then they get their advice and then eventually a significant proportion of them, not all I understand by any means, will be told to go and see their doctor. And some GPs say well why don't you just cut out the middle man - ring the surgery direct and get some specific advice so we can deal with it more quickly.
WIBBERLEY
I think there's a number of reasons. One, we're here 24 hours a day, your surgery isn't. We've got the capacity to answer a huge number of more calls, often when I try and phone up my own practice at home, if I need to see the GP, it's difficult to get through. And obviously some people are advised to go back to their GP but an awful lot of our callers aren't - a lot of the callers can go to the more appropriate bit of the health service, taking time away from the GP, and a lot of them are after information - they don't need to speak to a clinician at all, they might have just moved into the area and want to know details of the local pharmacist, might have been diagnosed with a long term condition and want background information, so we've got a team that can give type of detailed information as well.
PORTER
Stephen Wibberley from NHS Direct.
You are listening to Case Notes, I'm Dr Mark Porter and I am discussing out-of-hours cover in the NHS with my guest GP Laurence Buckman.
Laurence, what are your experiences of NHS Direct?
BUCKMAN
Well clearly I can't talk about the calls that never come through to me but a goodly number of patients who do tell me about their experiences with NHS Direct are quite puzzled by either being told to call me immediately because the computer tells them that this is an emergency and I've found that pretty consistently it is not an emergency and quite often I've been passed calls that don't appear to actually need a doctor at all, let alone in an urgent case. And the other thing that seems to happen quite often, particularly in the middle of the night, is that the computer directs the call handler to call an ambulance when that doesn't appear to be the appropriate response that a doctor or a nurse might necessarily direct.
PORTER
So I would imagine from that that you're not encouraging your patients to use NHS Direct as a first port of call to answer their query - you'd rather they rang you?
BUCKMAN
I'd much rather a patient called me or my practice and spoke to one of my nurses who of course can look at the notes directly and do know the patients very often by first name, or they can call me - I'm always happy to speak to my patients, it's much easier for me to deal with it than it is for someone who doesn't know the patient so well.
PORTER
Do you have any idea of the impact it might have had on your workload, have you seen a decrease at all in the number of calls, for instance, that you get at your surgery? I know that's not - that might not be relevant for the rest of the nation but you can only go by your own personal experiences.
BUCKMAN
I haven't noticed any decrease at all since NHS Direct appeared. Possibly I've noticed a slight increase in out-of-hours calls - patients phoning through who wouldn't otherwise have called because the NHS Direct computer told them that they needed to speak to a doctor urgently. I certainly haven't noticed any easing of my workload.
PORTER
And what do you think is the opinion of NHS Direct amongst your colleagues - do you think your views are reflected elsewhere?
BUCKMAN
I think most GPs find NHS Direct an interesting idea, of course politically it's very welcome because it's more service for patients than they were getting before but it seems to be pandering to a need that might not be the best way of approaching it, patients do need information, advice and guidance and much of that doesn't have to come from their practice but that could equally be delivered by a website or indeed a telephone service but to tack that into an emergency service as well seems to be a bit inappropriate.
PORTER
Now one of the things that we were talking about when I was there was the possibility that one day they might be able to book an appointment for your patients at your surgery, how would you feel about that?
BUCKMAN
I will pull the plug if that happens. The thought that somebody using a computer triage system, even though they tell us that it isn't, of course that's what it's doing, can then decide to book patients in when my experience of the use of that service is that it is excessively cautious means that I would lose all my appointments to NHS Direct and many of the people booked in wouldn't need a doctor at all, let alone one under even remotely urgent circumstances, so I think I'll disconnect if that happens.
PORTER
Well if your surgery is shut and NHS Direct can't help you with phone advice, then it's likely you'll need to contact your local GP out-of-hours service. When GP surgeries in Leeds shut for the night at 6.30, or for the weekend on a Friday evening, Local Care Direct takes over. It's staffed mainly by local GPs and is the UK's largest not-for-profit provider of out-of-hours primary care services with two million potential patients. Lesley Hilton joined one of their GPs for an evening shift.
LOCAL CARE DIRECT ACTUALITY
Local Care Direct, Mal speaking. Right. Okay. Can I take the home telephone number first please? And can I take the patient's name?
HILTON
When calls are received at the out-of-hours service they're assessed. If an ambulance is needed one is sent for straight away. Other patients are either advised on the phone by a doctor, given an appointment at the clinic or allocated a home visit.
ACTUALITY - HOME VISIT
Hello there. It's Dr Alpin from Local Care Direct. How are we doing?
I'm not doing very well.
Are you not?
HILTON
Dr Helen Alpin is a GP with an inner city practice in Leeds. She's just finished her day job and is now doing a night shift with Local Care Direct. She's off to visit an elderly lady who's just been sent home from hospital but is having trouble breathing.
ACTUALITY - HOME VISIT
Can I just pop the big light on?
Yes.
So what's been happening to you? Have you got any pain anywhere.
No I haven't any actual pain.
Are you coughing up any phlegm at all?
Not yet no.
HILTON
She has a severe chest infection. Helen gives her some medication and arranges for the local intermediate care team to come in and look after her at home, so she doesn't have to go into hospital.
ALPIN
Clearly there are challenges when you don't know patients and you have to make sure that follow up arrangements are secure, sometimes information could be very limited and patients aren't always able to give you the information that you need to make perhaps the best clinical decisions. But the service itself is well run, and it's well staffed and it's one of the few times in my life when all I have to do is see patients.
HILTON
What would make it better?
ALPIN
The integration of medical records. In other words, access to people's medical records would make a significant improvement in your ability to care for patients appropriately.
HILTON
Home visits are time consuming and expensive and are only allocated to those judged to be most in need, usually the very elderly or those receiving end of life care. Demand can vary so staffing levels have to be flexible. Andrew Nutter is the director of organisational development at Local Care Direct.
NUTTER
The peak demand periods for us are the weekends and in particular Bank Holiday when surgeries are closed for an extended period. In terms of our arrangements for the number of doctors, we look at information in terms of patient demand and then adjust our staffing accordingly so there are sufficient doctors to cover that demand. Typically in Leeds, for instance, that would involve perhaps a dozen doctors on a weekend, four or five on a weekday evening.
ACTUALITY - HOME VISIT
Hello there, it's Dr Alpin from Local Care Direct. Thank you. Now what's the problem?
Well I keep getting these horrible hot sweats as if I've just stepped out of a shower.
HILTON
Helen's next patient is a woman with a number of problems. She gives her a prescription and advises her to see her own GP. These two patients were pleased with the fact that they had a home visit reasonably quickly and didn't have to go out on a cold winter's night. Others are not always so satisfied. When Rozina's six-year-old son was ill over a weekend she rang the out-of-hours service. Although the medical care she eventually received was excellent she had a long wait to get it.
ROZINA
We were told that we could go to one of the fairly local emergency practices, which is probably about two or three miles away from where we live. But I have two other young children so I had to take them as well and the waiting room was fairly packed, probably about 40 or so people. You know when you've got three young children in a packed room full of people you don't know in a practice that you don't know nothing's familiar, I just estimated it was going to take two hours to be seen so we actually came back, because it was near lunch time, they were getting all cranky and we went back later and we waited in the end for about an hour before we were seen.
HILTON
It's felt that the service in Leeds is working well and meeting its targets and the patients mostly seem to be satisfied. But what about the doctors? Helen Alpin.
ALPIN
Dare I say it that I actually like being a doctor and I like seeing patients and the fact that you don't know some of these patients before you come across them means that you've got to be able to collect that information to make reasonable clinical decisions, it's a skill set that you need to keep going otherwise I'm sure that you quickly lose the ability to deal with urgent medical problems because in everyday practice they're not that frequent. And then of course there's the money. It is well paid and doctors are no exception that sometimes extra money doesn't go amiss.
PORTER
GP Helen Alpin talking to Lesley Hilton in Leeds.
Laurence, first of all let's start with those targets, what targets were they referring to there?
BUCKMAN
All out-of-hours services have to meet certain centrally set targets for how quickly they answer the phone, how quickly they see you in their call centre or how quickly that you get a visit if you need one.
PORTER
So Leeds there was meeting all of the targets. Do you think we paint a slightly rosy picture of the new system there, is Local Care Direct in Leeds typical?
BUCKMAN
I think it's fairly typical, it's probably slightly better than average because it's run by GPs and I think a lot of the services that are run by doctors are much closer to the traditional model of out-of-hours care, in fact they're quite similar to the coops they replaced.
PORTER
So compared to run by who?
BUCKMAN
A lot of services are run either by the local health service or by the ambulance services and although there's nothing wrong with them at all, they're not as general practice centred as the ones that are run by GPs.
PORTER
Because the criticisms I hear on the ground, and my local cooperative works very well as well but you hear about delays, sometimes in four or six hours before people are visited, you hear about staffing crises where doctors are flown in from Germany to cover holes in the shifts. Is that just the press picking up on the odd bad apple in the barrel or do you think there is a problem?
BUCKMAN
I think the problem is that the out-of-hours service is seen as a continuous thing and it's something that any patient can access when they want to. Now of course if they're acutely ill, as an emergency, that's exactly what they're meant to do. But many people use out-of-hours services as an extension of daytime, indeed that's the reason why many GPs stopped working out-of-hours because they couldn't cope with the demand that was just an extension of day time into night time. And so the services inevitably run out of capacity, they don't have enough doctors to see the number of patients who are genuinely ill as an emergency, as opposed to ill at that particular time and coming into the call centre for example.
PORTER
Is one of the problems that we had when we did it, I mean I don't know what the average GP would have earned for their out-of-hours, it wasn't very much, around 拢6,000 or something wasn't it, that was quite a cheap way to run the service and presumably they've not paid us the money and therefore they've kept it and they've found that they can't run an equivalent service for the same money, is that the problem?
BUCKMAN
I think GPs ran their services almost as a sort of charitable act because that was seen as part of the job and now it's no longer seen as part of the job because younger GPs just don't want to work like that anymore the government is now faced with the task of having to fund it somehow. And doctors working round the clock are inevitably quite expensive. And once the money was taken away from us GPs it was clearly never going to be enough to pay for the infrastructure, the nurses, the call handlers, all the kit that goes with running an out-of-hours service. The only kit I had to provide was my bag that I stuck in the boot of my car.
PORTER
Well, according to some recent newspaper headlines, frustrated would-be patients fed up with trying to get the help and advice they want via NHS Direct or their local out-of-hours services are turning up at the nearest accident and emergency department. Simon Carley is a consultant at Manchester Royal Infirmary's A&E Department. So have they been swamped by patients who should be seeing their GP?
CARLEY
We haven't noticed a massive difference, we're seeing a gradual rise in numbers anyway but I think that's been going on for several years now. In our department we've done a few sort of things where we've actually incorporated GPs into the department, so we see maybe a small but probably less than 1 or 2% change in attendances due to that.
PORTER
Because the patients that I've spoken to have actually said it to me many times as their GP, look you know I think it's just simpler just to go along to the local A&E department, rather than go through the out-of-hours service. Do you get complaints like that?
CARLEY
We do, we get quite a few people who come along and say they've had difficulty accessing their GP. I think it's a difficult one, I mean within a complex system, such as the health service, you really would like people to go to the place where they could be dealt with best and for some of the primary care and the GP complaints that's obviously their GP. But you've got to have some form of safety net and if people can't access care then they've got to go somewhere and I think A&E has served that purpose for a long period of time and probably will for a long time to come.
PORTER
Okay, what sort of problems do you get at the department that would perhaps be best looked after by a GP?
CARLEY
I think chronic problems, so things about chronic disease management, so long term management of asthma, people running out of inhalers, changing their medication, worried about blood pressure, occasionally we get people turning up with those which I would really describe as true primary care problems.
PORTER
And what do you do if someone comes up with a true primary care problem like that, I mean do you send them back to their GP or do you deal with them anyway?
CARLEY
We make a best effort. We're very fortunate we have a primary care centre attached to us, so we stream them to see a GP or a general practice nurse, during working hours of about 0900 to 1000 at night we can do that. Out-of-hours it's difficult, I mean we don't really want to start getting involved in the very minutiae management of chronic diseases because I think that really is something the general practitioners do best. So what we tend to do is, I guess, almost patch people up until the morning and recommend that they go and see their GP then.
PORTER
One of the changes in the A&E department is that waiting times have come down, people are being treated more quickly, and therefore it probably makes it more convenient.
CARLEY
Absolutely and we are seeing this now, patients perceptions have definitely changed and people's expectations have definitely changed. The only way that you can manage to get 98% of your patients in and out of the door within four hours is to really make sure that the people at the less severe end of the spectrum are seen very, very quickly. So your time to be seen with a minor illness or injury is often certainly within an hour, often within 30 minutes, patients know that and they often pop in from work or on the way home because they can do it. And patients are smart - they're not stupid - and if they can access healthcare very easily that's kind of what they're going to do.
PORTER
And how good are patients in your experience at choosing the most appropriate place?
CARLEY
I think they're a lot smarter than people give them credit for actually. If you look at say - give an example such as headache, we often say oh we see quite a few headaches in A&E and people say that's ridiculous, what on earth are you going to your emergency department with a headache for. But if you look at the people who come to us with a headache about 10% of them have either got meningitis, a brain bleed or a brain tumour and that's a huge percentage - its' clearly very different from those who go to see their GP. So the patients are actually making that decision and judging their own severity very, very well. And I think one of the things we should really avoid is the potential for pushing everybody with what appears to be a potentially minor complaint out of the system when in fact the patients are probably better than any of the triage systems that we've got.
PORTER
I mean do you think that's a future model for out-of-hours cover, you know you've got an established centre of excellence in your A&E department and you can bolt on things like walk-in GP clinics alongside, might we in 10 years time see the A&E department as the hub of out-of-hours cover for both primary care and accident and emergency?
CARLEY
I think that's probably very likely to happen, certainly in the big cities and one of the concepts we sort of talk about sometimes is having like an emergency village, so you come into the village and you're obviously streamed off to one particular place which best suits the care that you need. I think we're always going to have people coming through the door, so we've got to manage the problem that we have and not try and pretend that we can make it go away.
PORTER
A&E consultant Simon Carley talking to me earlier.
Laurence, do you think emergency villages could be the way forward?
BUCKMAN
I think we already have them to some extent. Quite a lot of emergency services are grouped together, you often find the coop or what is now the out-of-hours service provided with the casualty and an NHS walk-in centre in all one place and that's mainly because it's more economic to park them all together and have one doctor awake that looks after all three lots of people. Although actually that's quite a lot of work for one person to do and they're going to start making mistakes if they get too busy.
PORTER
What about - what happens on the continent because they're casualty led there as well aren't they and that's often the first point of call if you have an out-of-hours problem?
BUCKMAN
The difficulty with seeing patients in casualty only is that the doctor seeing them in casualty may well not be your GP and GPs provide more senior care than many of the doctors who routinely provide out-of-hours care, both on the continent and in the UK.
PORTER
Because with deference to my hospital colleagues, our hospital colleagues here, I mean that's a good point because if you have a gynaecological problem, for instance, there's a chance - let's say you're threatening to miscarry - there's a chance that your GP, in fact it's very likely your GP will know far more about that then a junior doctor in the hospital who's likely to see you in casualty.
BUCKMAN
That's certainly possible and also because GPs have a very broad training they're likely to spot the various alternative problems you might have and won't go for the easy obvious diagnosis necessarily and can take a broader view and sometimes that broader view's very important. People who are ill aren't necessarily ill with what they think they're ill with and it needs a doctor with a broader range of experience and knowledge to be able to pick that up.
PORTER
So casualty based care isn't always better is what we're saying than general practice care.
Let's take it on a bit further - walk-in clinics, doctors' surgeries in supermarkets, private companies tendering to provide out-of-hours cover - is the demise of the traditional out-of-hours cover, we're talking about the Dr Finlay type of cover where you were rung at home, just a thin end of the wedge for the demise of the traditional role of the GP?
BUCKMAN
We hear this all the time of course, it is always the end of general practice as we know it and that's because invariably some new idea comes out of one government or another or because the population wants a different kind of health service. Dr Finlay passed away an awful long time ago - we aren't delivering that kind of care anymore. We have to deliver modern care. I don't think we really want Dr Finlay back because whilst that was terrific for the folk of Tannock Brae it wasn't much use for the people in inner city Leeds.
PORTER
We must leave it there - Dr Laurence Buckman, thank you very much.
If you want more details on accessing NHS Direct, and the services it offers, then all the various contacts can be found on our website at bbc.co.uk/radio4 - or you can call the radio 4 action line on 0800 044 044.
Next week's programme is all about the hand and the latest management of everything from broken wrists, and little fingers that won't straighten, to arthritic thumbs and pins and needles that strike in the middle of the night.
ENDS
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