Published: 15/01/2004, Volume II4, No. 5888 Page 26 27
As GPs consider opting out of out-of-hours care, the health service is left in an awkward position.
Emma Forrest visits a London GP co-operative that is exploring the new opportunities available to those seeking to fill the gaps
Out-of-hours care is in a state of flux.With GPs able to opt out of provision from April and the responsibility falling to primary care trusts, alternative ways of supplying services are being offered from both private and not-for-profit providers.
Not-for-profit providers, or co-operatives, have been around for 10 years. But the new GP contract means many are adopting a more entrepreneurial spirit.
Seldoc (south east London doctors on call), which was founded in 1996 with out-of-hours government funding, has gradually increased its services from straightforward provision of out-of-hours care.
Tucked away behind Dulwich Hospital, its offices are almost deserted during the day. But chief executive Mo Girach assures HSJ that, should we return that evening, we would witness out-of-hours care at its busiest.
Covering an area containing around 1 million patients, anyone who telephones a GP surgery in Southwark, Lewisham or Lambeth in the evenings, weekends or bank holidays will be told to call Seldoc.
When people phone or visit, they can speak to a GP and are told to visit the surgery, receive a house call or go straight to hospital.
Psychiatric cases can be dealt with by Southwark social services, whose out-of-hours mental health workers are also based at the centre.
The centre contains four examination rooms, a waiting room with a TV and a 'calm' room, painted purple, for duty GPs to sit or lie down in if they need a rest. Outside is a small fleet of Seldoc cars. All duty GPs are chauffeured during their shifts, both for security and because 'the last thing they want to do after a day in the surgery is drive', says Mr Girach.
Seldoc's selling point as a co-op is that its duty GPs have chosen to be there. The service is comprised of 450 GPs (95 per cent of local GPs), mainly principal partners in their own surgeries, who act as equal partners in the business and each agree to do 12 shifts a year. Seldoc company secretary Dr Mathew Kiln, himself a south London GP, insists there are enough people wanting to do enough shifts to cover those who ask for time off for holiday or family commitments.
He puts this down to two factors: principally the rates Seldoc pays (£60 an hour, rising to£100 an hour at weekends), but also a genuine interest in wanting to provide out-of-hours care.
A BBC survey last month seems to prove their point - 83 per cent of 3,000 GPs surveyed said they would opt out of out-of-hours care and would do such services only when working for someone else at the market rate. This could, of course, include private firms, but Mr Girach insists that a co-operative can offer doctors other benefits, such as temporary stays in local housing association flats when doing locum work.
Seldoc is changing its name and will in future be called Seldco (south-east London doctors co-operative) to greater reflect its five core businesses: out-of-hours cover, GP locum cover, bulk purchasing (currently carried out for 146 practices to secure substantial discounts), police surgeon cover and providing GPs within accident and emergency at Guy's, St Thomas's and Lewisham hospitals.
There are also plans to extend the locum service to nurses, and they may be used to triage Seldoc calls and treat patients, freeing GPs' time. Research has also begun into the possibility of a 24-hour travel clinic.
Seldoc is also participating in a pilot to take calls on behalf of NHS Direct. Currently running on Saturday mornings until April, it may then be integrated into NHS Direct over the next three years.
Mr Girach claims to be sanguine about the future. 'As a true co-operative, we can offer additional services to GPs, and our objective is to do anything they want us to do.We do not feel threatened by doctors opting out of out-of-hours. It is an opportunity, ' he says. 'We have told our members what the consequences will be. If they all pull out then Seldoc will disappear, but the other businesses will still exist.'
'PCTs are facing up to the fact the private sector can cut and run from offering out-of-hours care.We offer more stability and are paying GPs, who keep this income for their pensions, ' adds Dr Kiln. l How to unlock capacity: location-specific solutions A survey by North East London strategic health authority showed that patients in the area were not happy with their out-of-hours care.They wanted better provision for patients with language difficulties and practices that were open for longer than the 9am-5pm norm.
A service transformation, redesign and innovation project was started by the SHA in October 2003 to address out-of-hours provision and consider all traditional and non-traditional settings.
'What we intuitively knew was happening was reported back to us by our patients, ' says service transformation director Stephen Langford.'Historically, we have concentrated on getting in-hours services right.But our research showed that capacity had to be unlocked in what are often thought of as dead times, such as early evenings and weekends.'
Work has begun on six pilot schemes while other ideas are developed.
The most radical idea proposes local GP surgeries opt to be open from 8am-8pm, seven days a week.
Other ideas include ethnic community service access guides - a pool of people recruited directly from their communities to help patients overcome language or cultural barriers; 'pills on wheels'pharmacy services, through partnership with companies like Tesco; and a 'frequent flyer'club of patients with good knowledge of their chronic conditions.A primary care trust in an area with a shopping centre with unleased space will be identified to house a walk-in centre-style service, through a one-stop shop with extended opening hours.
Professionals with non-traditional working schedules and high career satisfaction are being sought as examples of working differently.
'We are interested in location-specific ideas because of the diversity of the population and economy from area to area; it is not a case of one size fits all.We must make a significant difference within the year, 'adds Mr Langford.
A south-east London GP co-operative has expanded beyond provision of outof-hours care.
Skill mixing is to be introduced to free up GPs' time.
Pilots in north-east London are working on continuity of care.
www. out-of-hours. info
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