THE PROVISION of a round the clock service has been one of the fundamental features of British general practice. In recent years, patient demand has led to increased activity out of hours. Because the workload has increased during the day the need to be available night and day has become exhausting. Many principals have turned to other options for OOH care.

The option to choose was made easier in 1995 when the OOH issue came to a head. Changes to the Red Book gave GPs the right to transfer responsibility for organising OOH care as well as transferring the work itself. A new annual OOH development fund (£52 million 1997/8) provides money to meet the cost of organising OOH care. In rural areas this money can be used to employ locums to provide cover.

The 1997 review body report found that almost 60% of GPs still did some of their own on-call, but increasingly principals are turning to co-operatives or deputising services to provide OOH care. Such work can be lucrative but can also be difficult. The duty doctor usually has no knowledge of the patient’s history and is unlikely to know what happened to them after their attendance.

Security is an important issue - deputising services usually cover the roughest areas of the country. Having a driver helps with this. (Strategies that may protect you include leaving the mobile phone on, with the driver listening in or, asking the driver to call you on the mobile after x minutes and if you don’t reply he can call the police!). Some citizens may view the duty doctor as an easy source of controlled drugs - others just get angry at the delay in attending. It may be worth attending a course on dealing with aggressivepatients. Dressing down may help to avoid attention although appearing smart may be intimidating to some and reduce aggression. Ties are probably best avoided overnight (if not always!)

Duty doctors may be supplied with a certain amount of equipment and emergency drugs. Be sure to know the extent of this before you start. It might be better to use the bag you know. If there is a nebulizer, check whether there are any nebules, check it works and that all the bits are there. Ensure you have sufficient stocks of frusemide, analgesia, prednisolone and starter packs of antibiotics.

If you are covering a large number of patients, it is essential to know the phone number of a ‘second-on’ GP in case there are two cases of meningitis, two heart attacks or severe asthma all at once, or in case your car breaks down!

Healthcall
Commercial deputising firms employ GPs. Practices pay the firm to provide care for them. Healthcall is the largest deputising firm and was established over 30 years ago. It has 9,000 GP subscribers and employs about 1600 deputies. Some deputies are salaried, most are employed on a sessional basis. Full time employees receive a £300 a year allowance towards medical education. The majority of these doctors are local principals. Healthcall now runs over 37 primary care centres across the country where patients can receive telephone advice, attend for a consultation or, if required, be visited. Doctors doing visits are driven by Healthcall drivers in Healthcall cars. Centres have crèches and security staff. Some are used during the day for physiotherapy, chiropody and other health related activities.

The BMA receives 0.5% of turnover in return for providing professional monitoring. This occurs at a national level through the Joint Board of Professional Management (consisting of BMA Council representatives and Healthcall Managers), at regional level through regional liaison managers and at local level the service is monitored by local medical advisory committees made up of BMA and LMC representatives, duty doctor representatives, Healthcall’s local medical director, and local GP subscribers.

Healthcall doctors earn £100 - £120 per session depending on the locality, the hour and whether paid as a flat rate or on a ‘visits done’ rate. The employed doctors earn between £23,000 and £46,000 for a 24-48 hour week working 48 weeks per year.

To work for Healthcall contact their Senior Medical Director at their head office in Milton Keynes. Head Office: 401 South Row, Central Milton Keynes, MK9 2PH. Telephone 01908 691919. Fax 01908 690169.

Healthcall generously sponsored the first Non-Principal of the Year Award in 1997.

Co-operatives
Co-operatives are defined by the National Association of Co-operatives as non-profit making organisations equally and thoroughly owned by GPs and mostly staffed by local GPs. Some 20,000 doctors now use co-operatives for their out of hours work. At the time of writing there are over 250 GP co-ops in the UK. Generally co-ops require principals to work some sessions for them and this helps to reduce the costs to principals. Many though allow principals to sell their sessions and so non-principals can do OOH work in co-ops. The Council of the National Association of Co-operatives encourages this flexibility but some do not permit non-principals to work for them and others aim to use locums only for a limited number of sessions. Increasingly co-ops are employing a non-principal to do the overnight sessions on a regular salaried basis.

The National Association of Co-operatives supports Staffordshire LMC’s visiting guidelines (see below). Their secretary, Dr Prasad Rao reported that many co-ops had now adopted them and as a consequence the proportion of calls resulting in a visit being made had fallen to about 20%, with 40% of calls being dealt with by a telephone consultation and 40% requiring an attendance at an out of hours centre. Dr Rao hopes that the visiting figure will eventually fall to about 10%.

National Association of GP Co-operatives. Telephone 01782 592882,. Fax 01782 592880.

Pay for Out of Hours
Rates of pay for out of hours work vary depending on the work that is being done. BMA suggested rates for OOH care are very difficult to apply, and increasingly out of date. When working for a single practice or group of small practices, non-principals should calculate the value of their time and the amount of work that they are likely to be doing and then negotiate. A flat rate may be easier to negotiate than an hourly retainer and visit fee. Don’t forget any mileage costs and remember such work is not superannuated and there is no holiday, sick or study leave. Rates of pay from co-ops depend on the number of patients being covered, the size of the area, the time of day and the availability of locums. Many co-ops report difficulty getting locums despite relatively high rates of pay for such work (day/evening sessions £15-£40 per hour, after 10pm/bank holidays £30-£50+ per hour). Figures of £50 per hour (and more) for the overnight ‘red eye’ shift are not uncommon.

Keeping Records
When working for co-operatives and deputising firms, copies of notes from consultations with patients are usually sent to practices within a few days and these organisations often retain their own copy and enable you to give one to the patient. It is sensible to keep a record of your own so that if there are any problems in the months to come you have something to fall back on. Carbon copies tend to fade and are difficult to store. A small notebook that you can easily keep is probably worth the investment.

Visiting Patients
Paragraph 13 of GP’s amended terms of service states that in the case of a patient whose condition is such that it is for the doctor to decide, based on the “doctor’s reasonable opinion” as to whether the patient should attend a doctor’s premises or be visited at home. Doctors should also note that it is specifically stated there is nothing in the Terms of Service that prevents a doctor referring a patient directly to hospital without first seeing them, providing the “medical condition of the patient makes that course of action appropriate”.

Staffordshire LMC’s Visiting Guidelines
These were published in 1996 and in some areas have reduced the proportion of out of hours calls needing a visit to 20%.

Clarification and Examples of Visiting Guidelines in Action

1. Situation where GP home visiting makes clinical sense and provides the best way to give a medical opinion:

• The terminally ill;
• The truly bed-bound patient for whom travel to premises by car would cause a deterioration in medical condition; or unacceptable discomfort.

2. Situations where on occasions visiting may be useful.

Where after initial assessment over the telephone, a seriously ill patient may be helped by a GP's attendance to prepare them for travel to hospital. That is where a GP's other commitments do not prevent him/her from arriving prior to the ambulance. Examples of such situations are:

• myocardial infarction;
• severe shortness of breath;
• severe haemorrhage.

It must be understood that if a GP is about to embark on a booked surgery of 25 patients and is informed that one of his patients is suffering from symptoms suggestive of a myocardial infarction the sensible approach may well be requesting emergency paramedical ambulance rather than attending personally.

3. Situations where visiting is not usually required:

• common symptoms of childhood, fevers, cold, cough, earache; headache, diarrhoea/ vomiting and most cases of abdominalpain. These patients are almost always well enough to travel by car. The old wives’ tale that it is unwise to take a child out with a fever is blatantly untrue. It may well be that these children are not indeed fit to travel by bus, or walk, but car transport is sensible and always available from friends, relatives or taxi firms. (It is not a doctor’s job to arrange such transport);
• Adults with common problems of cough, sore throat, “flu”, back pain, abdominal pain are also readily transportable by car to a doctor’s premises;
• Common problems in the elderly, such as poor mobility, joint pain, general malaise would also be best treated by consultation at a doctor’s premises. The exemption to this would be the truly bed-bound patient.

The editor advises readers to discuss with colleagues and their defence organisations the situation where a visit may be refused, because a patient is, in their view, medically capable of travelling to the doctor, but is practically unable to do so because of a lack of transport. It is not known whether a doctor could be found in breach of terms of service in such a situation because there is yet to be a test case. Current advice from one of the defence organisations is (somewhat un-helpfully) to assess each case individually.

Although non-principals cannot be found in breach of terms of service as they do not (usually) have a contract with the health authority or board they should avoid any breach as the principal for whom they are working may still be responsible for non-principals’ actions.

Further Information

Working as a deputy in general practice. Jones M, Careers Focus, BMJ 4/10/97.

National Association of Deputising Doctors (Dr Cornel Fleming) Dartmouth Park Hill London NW5 1HL. Telephone 0171 272 1337.

MediCall provides deputies in the North Thames area. Telephone 0181 354 3636.

See the GP press for other agencies that provide locum cover for out-of-hours work.