primary care; GPs' night visits are more strongly influenced by the fees they are paid than by patients' needs, argues Steve Ainsworth

The past few years have witnessed energetic attempts to reduce the 'excessive burden' placed on GPs by their obligation to make night visits to patients.

In a sustained campaign throughout the early 1990s, GPs expressed alarm over ever-increasing demands for night visits. The government responded to GPs' calls for help in a number of ways: local publicity campaigns were mounted urging patients not to call out their doctors unless it was really necessary, and the GP contract was changed to allow payments to be made where the patient was seen at a night centre rather than at home. A further contractual change allowed GPs to transfer their night cover responsibility to another GP.

As for payment, GPs now receive a flat-rate out-of-hours allowance of£2,200 a year plus a fee of£22 for each out-of-hours consultation. The formula replaced the previous system, which paid a standard visiting fee of£48.45 and a lesser fee of£16.15 if a deputising service was used.

Additionally, an out-of-hours development fund was established -£39m this year,£43m next. The development fund has been used to provide for the direct reimbursement of almost any cost that will reduce pressure on individual GPs, such as the provision of mobile phones, call diversion facilities and radio pagers. In rural areas some doctors may claim the cost of locum cover.

The vast bulk of the development fund, however, is spent on reimbursing large parts of the cost of using commercial deputising services and in supporting and encouraging the formation of GP co-operatives and night centres.

Has all this activity had any impact? Apparently so. NHS Executive figures comparing 1996-97 with 1997-98 show that in England, GPs' income from night consultations fell from 53.8p to 37.7p per patient - a drop of 30 per cent, which suggests a reduction in actual demand for night visits of around 25 per cent.

The telephone helpline, NHS Direct, may reduce this figure even further. A 12-month trial of nurse triage in Wiltshire, covering 97,000 patients, showed that 50 per cent of calls could be dealt with without GP involvement- leading to a 68 per cent reduction in demand for GP telephone advice and a 38 per cent fall in GP consultations.

All well and good. The excessive demand on GPs' time appears to have been curbed. And even if their income has marginally declined this will be compensated for by increases in other fees.

So shouldn't everyone be happy and slap one another on the back? Maybe not.

One might ask where all that huge demand for night calls came from in the first place. If you ask a GP, the conventional answer is that it was all due to 'increasing and unreasonable patient expectation'. No doubt true, but the underlying cause of that expectation bears closer examination.

The most significant cause of patients' increasing willingness to call out a GP during unsocial hours has been the existence of commercial deputising services. The belief, often inaccurate, that one would not be disturbing one's own GP removed the constraint that had previously inhibited patients from calling out a doctor for relatively trivial matters.

This trend was undoubtedly reinforced by deputising services themselves, which for sound commercial reasons visited every patient who made a request - the deputising service could then charge the subscribing GP an additional fee for its services.

As long as deputising services make charges incorporating a fee per visit, there will always be an incentive to keep visit rates relatively high. GPs, of course, were distressed to receive their deputising bills, averaging£600 or so each month, and to find that the charges far exceeded the NHS fees they could, in turn, reclaim.

But GPs have long been too dependent on such services to cease contracting with them and have instead reduced the pain, first by obtaining the removal of the financial disincentive of the lower rate of night visit fee, and second by ensuring that a significant proportion of deputising charges can be directly reimbursed from the out-of-hours development fund.

Not that there is anything wrong with deputising services. The medical profession is now far too used to working relatively normal hours for the genie to be put back in the bottle. And rightly so.

Why are visit rates falling? It comes down to basic economics. GPs making their own calls would previously have to sacrifice almost£50 if telephone advice were offered instead of a visit; today the amount forgone is only£22.

And commercial deputising service charges have now often been modified to match GPs' own payment pattern: GPs are now more often charged a larger flat-rate fee and a lower call-out fee, so that deputising services' profits are maximised by making fewer house calls.

The conclusion is surely inescapable - the more GPs are paid per visit the more they will tend to make; the less they are paid, the fewer the visits.