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Open all hours

There is plenty of competition to be the canary in the NHS coalmine, but GP out of hours services probably have a strong claim.

Since changes to the system back in 2004, these services have relied on a mix of jobbing doctors and local GPs who are willing to do an evening or weekend shift for extra money.

But as working as a GP has got tougher – with practices often functioning one GP down – and indemnity insurance rocketing, out of hours services are finding it harder to fill their rotas. After a long working day in the practice, the money on offer just isn’t enough to tempt sufficient GPs to trade their leisure time for home visits across a wide area or seeing patients in a base. 

At the same time, GPs who do want to work a few extra hours, or those who make a living from this kind of work, are also in demand for extended hours surgeries and GP “streams” in accident and emergency departments.  

As HSJ reports, this means out of hours services sometimes end up with fewer GPs on duty than planned. IC24, the service provider across much of Kent, had just two GPs on duty overnight to cover a population of 1.4 million during one weekend in September. Both were based in east Kent, leaving palliative care patients in west Kent waiting for home visits. Staffing also meant that some bases – a time efficient way of GPs seeing unwell patients – were closed.

Kent is unlikely to be the only area with problems. The Care Quality Commission reported in June that the urgent care sector faced many challenges, including workforce.  With contracts for out of hours priced at about £8 per patient per year, there is not much money to play with.

There’s no obvious quick fix to this problem (although government intervention on indemnity costs from April may help a little). But the result if patients can’t access primary care services overnight and at weekends in a timely way is likely to be additional pressure on A&E and ambulance services.

When the out of hours canary falls off its perch, the rest of the NHS may be heading for trouble.

The Weston question

The fate of one of the NHS’ smallest emergency departments will be decided “later next year”, commissioners have announced – a decision which will be closely watched by other health economies with similar headaches.

Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group said the future options for Weston Hospital’s emergency department would be discussed as part of a wider public consultation scheduled to be launched in early 2019.

The unit has been closed overnight since June 2017 after the CQC rated the A&E department “inadequate”. Difficulties attracting senior doctors, particularly to work overnight, and growing demand contributed to overcrowding and patients waiting too long, inspectors said.

These problems are, of course, far from exclusive to Weston. Grantham and District Hospital, run by United Lincolnshire Hospitals Trust, began an overnight closure in August 2016 after it faced similar problems attracting staff.

A permanent model for small hospitals facing these kinds of problems – comprising a consultant led A&E during the day which is then downgraded to an urgent care centre overnight, with serious cases diverted to larger regional centres – has the support of a number of influential system and clinical leaders.

But others argue the system is best served by retaining full service A&Es on these sites.

A Nuffield Trust study, commissioned by NHS England and published last month, set out a range of innovative options for addressing the staffing shortages, including financial premiums for remote hospitals and consultant contract changes.

The report criticised NHS policy makers for too often opting for “the kneejerk reaction” of closing or downgrading smaller hospitals rather than developing more tailored arrangements.

Weston will be a crucial test case for a lot of the arguments which other health economies are already grappling with – or will need to in the near future.