Editorials

The new out of hours agreement for general practitioners

It has taken three substantial rounds of negotiation, two ballots, and the threat of industrial action for the government to acknowledge general practitioners' desire to opt out of the 24 hour commitment to patient care. In a reversal of government policy,^{1 2} agreed unanimously be the General Medical Services Committee, general practitioners will be offered the opportunity to divest themselves of out of hours work.³ If they can find another principal on the medical list of a family health services authority and agree a fee between themselves they may transfer all of their out of hours responsibility.

As two thirds of general practitioners have already made clear their wish to opt out of 24 hour commitment,⁴ the market of general practitioners willing to assume their colleagues' out of hours responsibilities will come from the remaining third. There is no restriction of list size placed on doctors making this extra commitment, and no limitation is placed on the number of doctors who can be fully relieved of their out of hours responsibility by another general practitioner. It remains to be seen how it can be in patients' best interests to allow a minority of general practitioners to add other doctors' out of hours responsibilities to their own swollen workload.

Before the 1990 contract, when a similar arrangement could be made, only a few dozen general practitioners did so (personal communication, D Grantham, General Medical Services Committee). The current deal permits doctors who take on this work to delegate it to a deputising service or a locum, though they will have to retain final responsibility for it. The involvement of fourth or fifth parties at stages removed from the original general practitioner is likely to lead to undesirable complexity.

Although adamantly maintaining that the "GP contract is a unified contract covering 24 hour responsibility,"⁵ the secretary of state for health has agreed to ask the review body to price separately the out of hours component of the contract. In return, the General Medical Services Committee has agreed (for how long?) that a notional value for this work "would not imply a contractual facility for doctors to opt out ... at the stated price." But when the breadth of the gap becomes clear between the market cost to general practitioners of transferring out of hours care, and the actual amount paid to them by the government (entitled the "notional cost" by Mr Dorrell), the issue of splitting the contract into "in hours" and "out of hours" will become the next battleground.⁶

The deal ushers in a new structure for night payments, which looks set to discourage general practitioners from performing their consultations at night. An annual payment of £2000 per principal plus £20 per consultation between 10 pm and 8 am places a low marginal value on getting doctors to leave the cosiness of their beds in the early hours of the morning.

The cost to the government of the new payment structure can be kept at present levels only if consultations at night fall by almost a half: an insufficient drop resulting in higher overall expenditure will be clawed back through the net target enumeration mechanism. The government has agreed to fund a campaign to educate patients, but if this fails the economic disincentive of paying so little for night calls is likely to be stressful and dangerous to doctors and patients alike (particularly in rural areas).

The new package includes £45 m taken from "elsewhere" in the health service budget (but not general medical services). This will be made available to family health services authorities on an equitable basis to help with the startup and recurrent running costs of local out of hours general practice rotas above the level of individual practices. Available for this financial year and subject to review in subsequent years, this money amounts to an additional 55% of the current costs of night visiting in general practice and shows the government's own calculations of the extent of its underfunding of the out of hours service as a whole.

Funds may be awarded only for projects initiated and operated by general practitioners. Responsibility for the development of cooperative rotas and new methods of delivering out of hours care is therefore to fall solely on general practitioners' shoulders. Success will depend on whether a professional group that perceives itself to be in a crisis of low morale and recruitment⁷ can muster the necessary reserves of energy and enthusiasm to develop a better service at night. The task is a substantial challenge, given the current high level of call outs, the rising number of 999 ambulance calls, and the progressively increasing rates of attendance at hospital accident and emergency departments.

The need for a responsive primary care service at night, separately organised and separately funded from the contract for general medical services, has never been more urgent. This deal hardly seems to bring us any nearer to its achievement.

General practitioner London N1 3NG

Brian Hurwitz 

1. Department of Health and Social Security, London: DHSS, 1984. (HC FP) 84.)
2. Department of Health and Social Security. Family practitioner services: general practitioner deputising services. London: HMSO, 1984. (HC(FP)(84)(2).)
3. Beecham L GPs accept out of hours offer unanimously. BMJ 1995;311:827-8. [Free Full Text]
4. Electoral Reform Ballot Services. Your choice for the future, a survey of GP opinion UK report. London: BMA, 1992.
5. Secretary of State for Health. Annex 1 in letter to chairman of General Medical Services Committee, Dr Bogle 19th September 1995. London: General Medical Services Committee, 1995.
6. Beecham L. General practitioners call for separate out of hours contract. BMJ 1995;311:7. [Free Full Text]
7. Beecham L. From the local medical committee conference. BMJ 1995;311:63. [Free Full Text]