STUART GIDDEN
MiP Editor

The looming general election this year means we are living in an uncertain climate. The possibility of a Conservative government after May (which seems the most likely time if hypothetical newspaper reports are to be believed) is the elephant stampeding in every room at the Department of Health and between the lines of every new government announcement.

Today (1 February 2010), for instance, the health secretary made the bold claim that by 2020 “only one in 10 people will smoke”. Mr Burnham outlined a package of smoking cessation measures to bolster these claims, but it’s difficult not to think: “What will the Tories do?” Will they commit to this policy, or will this be just one measure that faces the sharp blade of spending cuts?

The question, “What will the Tories do?” is enough to give every practice manager pause for thought, for Conservative election success will mean primary care is in for yet another shake-up this year. We know that they want to remove practice boundaries – as do the current government by October – which is not something that has been met with a great deal of warmth by the profession. Not judging by comments posted on this website, at any rate.

A change to out-of-hours (OOH) arrangements is also more than likely, and this, too, is divisive. In the wake of the inquest into the death of David Gray, 70, who was given a fatal overdose by a German locum GP providing OOH cover in Cambridgeshire, Shadow Health Secretary Andrew Lansley said that Labour had made a “serious error” in taking responsibility for OOH provision away from GPs.

Mr Lansley has again been criticised in comments posted to this site by those arguing that the terrible and tragic death of Mr Gray was a singular mistake by a negligent GP and a less-than-competent PCT-commissioned OOH provider. The argument goes that this has little, if anything, to do with the GP contract and the state of OOH services as a whole.

Policy should not be made – or remade – by focusing on one case, but OOH services in several areas have been seriously under-resourced for sime time. A state of disquiet, to say the least, has been in evidence with regards OOH since GMS contract changes in 2004, and does not look set to fade away.

Yesterday (31 January 2010), an investigation by the Sunday Times revealed that in Brighton, Bolton and Wigan, just one GP is responsible for dealing with late-night emergencies. This follows news that on some nights, just two doctors provide OOH cover for Suffolk and its 600,000-strong population.

According to the Sunday Times, a three-year old child died after a “gross failure” by the OOH duty doctor working for a service commissioned by Brighton and Hove PCT.

Of course, mistakes will be made and fatalities will sadly always occur. But serious questions have been hanging over OOH services and this issue continues to rear its less-than-satisfactory head. Last year, the Care Quality Commission (CQC) said a “nationwide problem” may exist, and its report said: “All PCTs should scrutinise out-of-hours services more closely.”

It would also appear that uncertainty about OOH services among patients has led to huge rises in ambulance call-outs and an increase in non-emergency A&E visits.

In August last year, Professor Steve Field, Chairman of the Royal College of GPs, called for a “radical review” of OOH care, in particular over concern at the quality of care provided by overseas doctors flying to the UK to cover shifts in some areas.

Forcing GPs, who already work long hours – now longer thanks to extended hours requirements – to provide late-night cover in a tired or even exhausted state will of course not make OOH care any safer. Furthermore, the profession is unlikely to agree readily to a change of contract, especially since the 2004 contract was partly designed to remedy GPs’ working hours widely seen as unfair.

Yet the unfolding drama of OOH errors and thin resources suggests that reform, not reviews, is indeed required to ensure quality care and to let patients immediately know where they should go if they have a non-emergency medical problem, which nonetheless requires attention, late at night.

The NHS Alliance put forward what seems to me a reasonable solution in April 2008: practices should reclaim responsibility for OOH services through practice-based commissioning (PBC). That is, that GPs should commission and monitor OOH services, and remain accountable, even if they do not provide OOH care themselves.

A recent comment posted on this site from Jim Bond in Manchester, objecting to Lansley’s proposal, would appear to support the NHS Alliance’s proposals and suggest it works: “OOH in our area seems pretty solid – could that be because GPs were involved in the commissioning process?”

The NHS Alliance proposals would also seem in line with Conservative plans to give GPs more commissioning power by giving them direct control over budgets.

Could budgets be allocated for OOH cover? Again, we’re back to the initial speculation and state of limbo as we’re forced to ask – even as we acknowledge that the outcome of the general election is not certain – “What will the Tories do?”