New breed of daytime doctors

FAMILY doctor John Canning can't really understand what the fuss is about. If you believe some of the stories which have been appearing in the national press recently about the changes to after hours GP services, you could be forgiven for thinking that Armageddon was nigh.

Headlines like "Need a doctor in the night? You'll only get a nurse," which appeared in The Daily Mail recently suggest that a massive change in primary care is about to happen. But Middlesbrough GP Dr Canning argues that the changes are not as dramatic as people are being led to believe and are in the long-term interests of patients and doctors.

He points out that many people are now used to their after hours calls being "filtered" by a trained operator before being put through to a nurse, or being asked to travel to an emergency care centre. And the days of being seen by your own GP in the middle of the night are long gone, he adds.

The changes that are currently happening around the region follow a major shake-up of after hours care ordered by the Government, which will take full effect in January 2005. Some areas of the North-East and North Yorkshire have already taken the plunge and scrapped the old after hours arrangements.

In north Durham, patients with urgent inquiries can contact a hotline and speak to a trained NHS operator. A qualified nurse will assess their needs and give them advice on how best to proceed with treatment. Saturday morning services are offered from the Urgent Care Centre in Shotley Bridge Community Hospital, near Consett.

In the area covered by Durham Dales Primary Care Trust, two surgeries, Stanhope and Middleton-in-Teesdale, will continue to provide their own out of hours services to patients. All other GP surgeries in the Durham dales area will be served by the Urgent Care Centre at Bishop Auckland.

Transport is being made available for residents from Barnard Castle and other areas to take patients to and from the centre, where necessary.

In cases where a GP home visit is absolutely necessary, this will be arranged.

Since April, patients in Darlington, Middlesbrough, Hartlepool, North Tees and Langbaurgh who ring their GP after hours have heard a recorded message asking them to ring a new centralised number. By calling that new number, patients or carers are put through to a trained healthcare professional and offered a number of options, including advice over the phone or instructions on how to get to their nearest out of hours emergency care centre.

If it is really necessary, patients can still be visited by doctor or a new brand of health worker, the Emergency Care Practitioner or ECP, usually a former nurse or paramedic. Where the call relates to a life-threatening illness, arrangements will be made to admit the patient to hospital.

According to the trusts involved, after six months, the after hours experiment in Darlington and the Tees Valley appears to be working well.

In the first three months alone, the new ECPs handled a total of 1,723 out of hours calls. Emergencies are still dealt with via the 999 system. "We are not talking about a huge change," says Dr Canning.

Despite the headlines which have stoked fears, Dr Canning says the period of change dates back to 1996, when a new GP contract came in.

"The rules changed and since that time it is now very unusual for doctors to visit people at home. Expecting patients to travel to get treatment has been the norm from that period, apart from those who are so ill they cannot travel," says Dr Canning, who is on the national GP committee of the British Medical Association.

Dr Canning believes the changes are the best thing to happen to primary care NHS services for years, finally allowing family doctors to concentrate on the bulk of their patients - the people they see during the normal working day.

By switching responsibility for patients after the surgery closes in the evening and at weekends to the local primary care trust, GPs will be fresher and more alert and less likely to make mistakes, argues Dr Canning.

But not everybody is convinced of the wisdom of the changes. Michael Summers, chairman of the small but independent pressure group, The Patients' Association, recently told The Daily Mail: "Patients in my view will be greatly alarmed that they will not have access to a GP during the night." Mr Summers went on: "This is not what we were led to believe by the Government when they passed over responsibility to the primary care trusts." Nobody could pretend that the service provided by a qualified doctor could be replaced by a nurse or some other care worker, he said.

While the changeover is expected to be relatively smooth in towns and cities, the outlook is less certain in the countryside. Some organisations have expressed worries about the impact of the changes on remote, rural areas where GPs have traditionally done their own out of hours work.

The Health Service Journal last week reported that the NHS Confederation, which represents employers within the Health Service, has warned of particular problems faced by rural areas. A survey by the confederation carried out during the summer suggests that many of England's rural primary care trusts are having difficulties providing out of hours care. One anonymous rural PCT chief executive is quoted as saying: "We have been left holding the baby and are attracting public criticism for the outcome of events beyond our control."

Evidence that people in rural areas such as Wensleydale are concerned about the implications surfaced earlier this year. Only a month after the North Yorkshire Emergency Doctors (NYED) deputising service took over evening and weekend cover in April, local councillors began to complain that they were getting calls from residents unhappy with the new service.

It was said that one mother had been told by an NYED operator to drive to Catterick in the early hours of the morning with her daughter, who was suffering an asthma attack. When senior health officials held a public meeting in Wensleydale in May to discuss the changes, around 100 residents turned up to hear reassurances. Last week, the four primary care trusts in North Yorkshire reached agreement with the NYED doctors' co-operative over improvements to out of hours cover.

Under the new arrangements many local GPs will continue to work shifts for NYED but in some areas, traditional Saturday morning surgeries are to be discontinued after October 1. Patients who call the NHS Direct advice line will have their details automatically transferred to NYED if they need urgent medical attention so that the patient does not need to make a second phone call.

Elsewhere in the region, the changeover to new after hours service is progressing and within less than four months, everywhere will have switched. Dr Canning believes we should have no fears about the new system.

"I think what has happened has been good for doctors but it has also been good for patients because there is now a much more integrated service out of hours," the GP says. "The system is now providing a service that makes sure the right sort of health care professional is seeing the patient."

Even though this will mean most people will be seen by ECPs or nurses rather than doctors, Dr Canning believes there are sufficient safeguards to protect patients. "Doctors are highly skilled but we simply do not have enough of them in this country and we have to use resources as carefully as possible," he says.

To the Teesside GP, what is really important is to ensure that everyone has access to medical backup when required. "The new ECPs are making decisions about patients but if they have any conc erns they have access to appropriate specialists advisors, including doctors," he says.

He believes that by relieving family doctors of out of hours commitments, the medics will be able to work more actively with patients who need more time and resources. "It means we can concentrate on providing more personalised care to people with chronic illness such as diabetes, high blood pressure and asthma," he says.