Published: 09/09/2004, Volume II4, No. 5922 Page 8 9

Bills on hunting have done little to make New Labour popular in remote areas - now there are fears that the NHS is headed for the same PR nightmare with some country GPs angry that new out-of-hours services show little consideration for rural implementation. Jennifer Trueland reports

The headlines are unequivocal, and not a little frightening.

The Daily Mirror says 1,000 square miles in Northumberland will be covered overnight by just one GP - and the tabloid's leader column talks of services in 'crisis'.

In Scotland, headlines shout that 'GPs warn patients may die', as a result of new out-of-hours arrangements.

Politicians are getting in on the act too. A Commons health select committee report speaks of patchy preparedness throughout the country, while MSPs, particularly Conservatives and Scottish Nationalists, have been whipping themselves into a frenzy over the issue.

It is less than four months until primary care organisations across the UK have to take responsibility for provision of evening and weekend services as a result of the new contract, which allows GPs to opt out of out-of-hours services.

In practice, most are expected to begin providing alternative out-of-hours services this autumn.

Some have already moved to their new arrangements.

But while all the UK's primary care organisations have faced challenges such as finding extra money for the new services - or even persuading enough GPs to fill rota slots - It is the remote and rural areas where the most discontent lies.

The blame for this lies with the new policy's alleged failure to recognise that providing out-ofhours cover is more expensive in rural regions because of the greater area that needs to be covered and the lack of alternative providers. However, there is also concern among GPs over how primary care organisations are implementing the contract.

The discontent is reaching such levels that out-of-hours is shaping up to be health's fox-hunting - a totem for those who believe policy is dominated by city-based issues and pays little heed to those who live beyond the urban sprawl.

'There is quite often an urban bias in drawing up health policies such as this, ' says the Rural Health Forum's Helen Swindlehurst. 'A lot of GPs live in urban areas and they do have problems, particularly in inner cities. But, maybe there is not as much attention paid to those in rural areas.'

The forum, which promotes the health and well-being of rural communities, might be expected to have a bias of its own. But the organisation is not alone in its concern that there hasn't been enough attention paid to our most isolated populations.

The NHS Confederation has also warned of particular problems faced by rural areas, as have other influential groups, notably primary care lobby group the NHS Alliance.

A survey carried out by the alliance over summer has led it to claim that England's rural primary care trusts are 'indicating particular difficulties' over out-of-hours.

The report quotes one PCT chief executive as saying: 'The provision of out-of-hours services in rural areas poses real problems that were not addressed in the new contract. We have been left holding the baby and are attracting public criticism for the outcome of events beyond our control.'

Another notes that 'expectations are not matched by support'.

A third PCT chief executive responded to the survey, saying they had been unable to find GPs to cover 11pm-8am shifts, so its service would be provided by First Contact Practitioners. These healthcare professionals - not necessarily doctors - have been trained as part of an NHSU programme designed to equip staff with the ability to carry out primary assessment of patients. FC practitioners providing out-ofhours cover would be supported by community nurses and generic health workers.

Others responding to the survey expressed concern that NHS Direct would not have the reach to provide Saturday cover in many rural areas.

The survey follows on from a Commons health select committee report, published this summer, that found PCTs were in 'varying states of readiness' for taking on responsibility come the beginning of next year.

And the Royal College of GPs is worried too. Its response to the report warned: 'The RCGP is concerned that plans for the provision of-out-of-hours services in rural areas are still inadequate and hopes this will be a priority for PCTs to address.'

Some of the more lurid headlines may be dismissed as spin and scaremongering - the move to new arrangements for out-of-hours was never going to be a public relations dream, but There is no doubting that the ire of rural GPs has been raised.

This is particularly the case in Scotland, where geography dictates that a higher proportion of the population lives in remote areas than in the rest of the UK.

Feelings were running so high that in July, 30 rural GPs signed a letter to health minister Malcolm Chisholm, warning that out-ofhours services were being cut to a 'skeletal' level and proposals would be 'totally inadequate to respond to life-threatening emergencies'.

It warns that groups of patients such as the vulnerable elderly would have their care compromised. 'The proposed new rural out-of-hours system is fundamentally unsafe, ' the letter went on.

As if that was not enough, one of the principal signatories, Dr John Macdonald, a GP in Wigtown, Dumfries and Galloway, gave media interviews with the stark message that 'patients might die'.

Since then NHS Dumfries and Galloway has changed its proposals to include more GP cover.

So does he regret being so outspoken? And was he scaremongering? 'No, I do not regret anything, ' Dr Macdonald says.

'The system as it was proposed was unsafe and I've no doubt it was the publicity that persuaded the board to amend its policy.'

As is the case across the UK, most GPs in Scotland have decided to opt out of responsibility for out-of-hours.

One exception is Orkney - which has one of the most scattered and isolated populations in the UK.All 20 whole-time equivalent GPs have decided to opt in to providing out-of-hours cover.

Orkney NHS board planning and communications officer Ken Harris-Jones says It is a matter of common sense. 'Our GPs felt they wanted to continue to provide out-of-hours care but we have also agreed to provide more support to provide cover for continuing professional development.'

A much more common situation prevails in Shetland, the archipelago furthest from the mainland. Here, half of the 10 GP practices have chosen to opt out and the new system goes live this month. Shetland previously worked on a system of extended rotas among the main practices and has not even experienced having a co-operative.

'We are having a primary care emergency centre in Lerwick that will be staffed by three salaried GPs, ' explains Shetland local healthcare co-operative head Michael Johnson.

On Shetland's outer islands the status quo will pretty much remain but with more co-operation and back-up to allow for absences due to holidays or continuing professional development.

Costs are significant at£366,000 each year, 'but we do not see that as cost - we see it as investment, ' says Mr Johnson. 'It is a big change for Shetland and some folk are anxious about change.'

The anxious could do well to look at the Western Isles for reassurance. Their new out-of-hours system, again based on a primary care centre, started on 21 June and, says Western Isles medical director (communities) Dr Brian Michie, it is going well. 'Our concerns were filling rotas and getting patient information out. But the rota is filled until January and patients have responded well.'

Nonetheless, he believes the new arrangements were more applicable to urban areas. 'There is a tendency to have centrally built solutions that do not necessarily work in rural areas [but] I do not want to criticise the British Medical Association negotiators because It is not a job I would have been prepared to do.'

The BMA strongly refutes any suggestion that rural issues were not on the agenda when the GP contract was negotiated. Indeed, there was even a rural subcommittee that fed into the overall process. Scottish GPs Committee member and rural GP Dr Andrew Buist says: 'It is not the contract itself that rural GPs have a problem with; It is the arrangements proposed by some of the primary care organisations they do not like.

Most people accept that the BMA did everything it could.'

Allowing GPs to opt out of out-of-hours is a vital tool in improving recruitment and retention - a key problem in rural and remote areas, the BMA stresses.

It also adds that anyone who is not happy about the new arrangements can decide not to opt out of responsibility.

This is true only up to a point, says Dr Macdonald, who claims the financial deal for opting 'in' makes it not viable for most GPs.

Dr Rachel Weldon of the Small Isles medical practice, which has some 150 patients on the Scottish islands of Eigg, Muck, Rum and Canna, agrees.

She is the islanders'medical lifeline - getting to any other help requires crossing the water - but the ferries do not run at night.

'If I did decide to opt in, I wouldn't be able to get insurance to get a replacement if I was off or ill, because nobody else would do it for that money. Financially I am forced to opt out, ' she argues.

But despite doing this Dr Weldon will, because of the lack of alternatives, effectively still be providing on-call cover. 'It is the only way to provide a safe service, ' she says. However, what is unclear is the level of resource she will now be given to provide this service.

'I am afraid the new proposals are not doing anything for remote and rural practice.'