Night work in the NHS - Essay 1

General Practitioners and out of hours working.

Written January and February 2014

I started writing this essay because one of the main items on the news on January 29^th was the huge increase in ambulances transporting patients over the age of 90 to accident and emergency departments. The government blames this on the change of the GP contract in 2004 and Andy Burnham, Shadow Health Secretary, attributed this to lack of social care and lack of support at home. The reasons are probably more complex.

There is an excellent history of out of hours care written by Dr Eric Rose in 2013  (1). He pointed out that from the creation of the NHS in 1948 to 2004 out of hours care was the personal responsibility of your GP 365 days and nights a year. From 1966 partners in group practices were allowed to take turns for being on call at night. in 1996 out of hours co-operatives were set up all over the United Kingdom.  A cooperative might have 40 to 100 GPs taking turns to provide evening, night and weekend care. These co-operatives were managed by the general practitioners. It was mandatory, in this area, to work for our cooperative. In 2004 Primary Care Trusts took over the management of out of hours care. GPs were allowed to opt out of working out of hours if they gave up £6000 of their income. Many GPs, including me, jumped at the chance of having a normal family experience. From April 2014, each patient over the age of 75 will have named an accountable GP. GPs will have the responsibility of monitoring the quality of the out of hours service for their patients. Jeremy Hunt, the Secretary of State for Health, thinks this will mean a return to traditional general practice.  What rubbish!!

I would now like to write about my personal experience and opinions of out of hours care. Both my parents were general practitioners in Castleford, West Yorkshire, and I was born in 1945, before the creation of the NHS.

My first experience of out of hours care in general practice was watching and listening to my parents. They were in a partnership of 3 so were on call two nights and two weekends out of three. I never heard them complain once about having to get up at night. It was simply part of the job and very tiring especially if there was a complication in a maternity case or very thick fog, which occurred often in the 1950s and 60s.

My first personal experience of working at night was my first house officer job at the London Hospital. This was a six-month appointment as a Receiving Room Officer. The receiving room was the accident and emergency department as well as undertaking the initial assessment of a patient who was to be admitted. After a period working daytime shifts one then undertook seven twelve – hour shifts working at night. After that there were two or three full days off duty. My diurnal rhythm got completely confused and I took a sleeping tablet (nitrazepam) to help me sleep during the day time. (It was in the news in late January 2014 that there was an increased incidence of heart attacks in shift workers. I am not surprised at this). On duty at night in the London Hospital receiving room were just one house Officer and a staff nurse. This was nice and cosy but no joke when the department became busy. One was allowed to call for extra medical help if there were 20 or more patients in the department. One night 19 firemen were brought in having being overcome by smoke and heat. The nurse and I dealt with them by ourselves. Actually, all they needed was rest and plenty of water to drink. The night receiving room officer was also on call for any disturbances on a ward. I was only called to a ward on one occasion. This was to at the orthopaedic ward where a man was wondering about, pulling his drip stand behind him and generally acting in a crazy manner. He had delirium tremens which results from withdrawing alcohol from an addict too quickly. I gave him an injection of a tranquilliser which seemed to sort things out. What amused me was that my friend Brian Colvin was the orthopaedic house officer and during his six-month job, never got out of bed once!

I first became a general practitioner in Cheltenham in 1973. There were 4 partners looking after about 10,000 patients. We did one night and one weekend in four, and more frequently if a partner was on holiday. I might not be woken at all or could have two or three visit requests during the night. It was pretty busy during the daytime on Saturdays and Sunday mornings. In the week, one had to go to work the next day even if one was exhausted. The most important observation I want to get over in this essay is that over 90% of the time I had never met these patient before. The government and press over recent years have been arguing that patients want to see their own doctor during the night and at weekends. If you ask that question in a survey of patients, obviously a significant number will say yes. Of course, there were some patients who frequently requested to see us in antisocial hours and these were often psychiatric cases (a patient once sprayed me all over with her perfume during one night visit!)

Patients with minor problems usually called us out before midnight. During the night, there were more serious illnesses to deal with.

I will never forget the night I had two visit requests within a couple of minutes of each other at about 2 AM. The first was to woman having an epileptic fit and the second to an 11-year-old child with breathing problems. I decided to visit the woman and call an ambulance to the child. (In those days it was frowned upon for the GP to call an ambulance without having assessed the patient). I was let into the woman’s house and what was happening was that she and her husband and had a huge argument and he decided to call a doctor to her. He had lied about the fit. I was pretty angry. When I got home, I had a phone call from the local hospital to inform me that the 11-year-old child had died. I was really upset and angry and got in my car again and drove to the woman’s house. It was about 5 o’clock in the morning and I was smoking a cigar as I walked up the path towards the front door. I was going to angrily inform them what had happened. As I got closer to the front door, I turned round and drove home. My next-door neighbour was a consultant neurologist, David Stevens. He felt that the child might have had an epileptic fit and although death from fits is rare, it is not impossible. This is the only time in the whole of my general practice career when I had two visit requests in the night at the same time.  I had been a GP in Cheltenham for three years when this event happened. I had never met either of these patients.

During the night, there was no access to the medical records unless I drove to the surgery, unlocked it and searched for the notes in the reception area. There certainly were no computers in primary care at that time. One had to write up the medical record the next time one was in the surgery. It was easy to forget to do this and to forget could have serious implications.

It always amused me that when I answered the phone in the middle of the night by saying “Dr Sloan speaking. How can I help you?”  a significant number of patients would reply “can I speak to Dr Mules, please?” or one of the other partners’ name. Did they think all four partners were up all night in the surgery? I did think of having a cartoon made with all four of us in bed together and telephone on each of two bedside tables.

Obviously, a GP should not drink alcohol when on call but I certainly came across a few that did. Indeed, one Christmas Day, I partook of a couple of sherries in a house and when I was leaving, shouted happy Christmas, opened what I thought was the front door, went through shutting it behind me, to find I was in a cupboard!

I worked as a GP in Cheltenham for about four years and left for personal reasons. My wife, Kath, and I decided, in 1978, to buy the house and surgery in Airedale, Castleford from my mother who had retired as a GP in 1976. This was the house I was brought up in. My mother’s patients had been distributed to other general practitioners in Airedale, Castleford. Castleford was designated as an “open area” and that meant there was a lack of GPs. The bureaucracy made it easy to set up a new practice. On 1 November 1978, we had a fully equipped surgery and Kath was the practice manager. However, there were no patients. My friends and contacts spread it around that I was starting and the practice very slowly but surely built up.

The rest of the general practitioners in Castleford took part in an out of hours rota. I was not allowed to use this and worked for two and a half months continuously without a night or weekend off call. This was a great strain. Because I was building up the practice, I did not refuse any visit request. Apart from one or two friends, I did not know any of these patients and it took over two weeks for a newly registered patient’s records to come through. It makes no difference whether one is working in practice with 10,000 patients or 200, one still does not know the great majority of patients one is dealing with at night and weekends. I advertised for help and two doctors, Ted and Ann McGrath, who were working in our local hospital at the time, helped me out at weekends. I am eternally grateful to them as I am to my good friend Dr Grahame Smith with whom I was at medical school. He worked in a group practice four miles away in Pontefract. That practice allowed me to join their out of hours rota. Of course, again, I knew none of their patients. I thought I had won the pools when some GP colleagues from Pontefract set up a proper mini deputising service and at long last I got some decent time off.

It took me quite a while to realise the significance of my contractual obligations to my patients. From 1948 to about 1996, each GP was personally responsible for his patients 24 hours a day, 365 days a year. That meant that if locum made a mistake while one was on holiday, one still was responsible for the patient. If a trainee doctor made an error, one was responsible.

In 1996 the government provided money for GPs to set up out of hours co-operatives. This was very popular indeed. It was mandatory for each of us to work regular shifts for our co-operative. There were two bases, one in Pontefract and the other in Wakefield. When the co-operative started, two GPs and a receptionist manned each base. One of the GPs stayed at the base and saw patients and there and the other went on visits with a driver.

I much preferred doing the visits as one could chat and get to know the driver during the break driving to another visit. On the back seat of the car was a fax machine which could communicate with the base. Details of visits were printed out by the fax machine and a decision had to be made as to the degree of urgency (this is known as triage). One of my colleagues got to know the driver particularly well (not whilst working!) and they are still happily married to this day! In the boot of the car there was a well-stocked emergency drugs bag. However, for legal reasons, one had to bring one’s own morphine and other controlled drugs.

On weekdays, the evening shift was 6 PM to midnight and the night shift from then until 8 AM. It was a crime for a GP surgery to accept a visit request at 5:50 PM, say, and phone it through to the out of hours service after 6 PM. It was a similar crime to tell the patient to ring again after 6 PM. I remember when my mother was still working and there was just one phone line for the house and surgery. She was in a rota of GPs for evenings and weekends. She was in the habit, when it got to about 5:45 PM, of phoning a friend for a long chat that always ended just after 6 PM! The phone line would be engaged!

It was always awful undertaking visit requests when the weather was poor. My father once walked over a mile to a visit request in dense fog and when the door was opened to him, the husband of the patient said “Doctor, this could have waited until tomorrow”. Snow and ice are particularly hazardous for anyone driving and for 10 years I drove a four-wheel drive Fiat Panda. I am sure that on some snowy and icy days, in our local housing estate, there was only I and hearses on the roads. One icy night, while I was working for our cooperative, the driver and I went to the boot to get some medications and the car started sliding downhill. Fortunately, we were able to stop it but it was sweaty moment.

Working in the co-operative’s base could be extremely hard work. I can remember one evening shift in Wakefield when I saw between 50 and 60 patients, had no time to eat my sandwiches and was drinking tap water from my cupped hands. The base doctor had to speak to patients on the telephone and decide whether this was a home visit or to ask them to come to the base. There was a bit of pressure to ask patients to come to the base and see them oneself rather than making one’s colleague in the car work too hard. One GP prided himself on hardly ever putting patients down for home visits. I once went along with my trainee to show her what went on at the Wakefield base. We walked in and that particular GP was on the telephone. We heard in say “Madam, I gave you my name at the beginning of this conversation and I do not intend giving you it again” and with that he slammed the phone down. I used to undertake teaching the skills of telephone consultations to the trainees and the above was not a good example. I had a tape recording of a GP who spent 20 minutes on the telephone trying to persuade a patient to come to the base. He failed.

Towards the end of my time working for the cooperative it started to employ nurses and a car to transport patients to the base. I did hear of one occasion where a patient was brought to the base when he was so ill he could hardly stand up. That was certainly bad practice.

A lot of the GPs working for the cooperative, including me, went straight into their general practice after a night shift and again this was bad. The pay for undertaking shifts was pretty good and some GPs undertook a huge amount of work for the cooperative and I thought this was dangerous for their daytime work.

Our practice had a problem with one of the three partners roundabout the year 2000 and we were effectively working as a two-man practice. The practice was allowed to withdraw from the out of hours work, which was very kind of the management.

In 2004 there was a negotiation between the Labour government and the British Medical Association that resulted in a new contract where Primary Care Trusts took over the responsibility of organising the out of hours service. GPs were allowed to opt out in exchange for loosing income to the amount of £6000 per annum. This was a very low cost indeed. Certainly a lot of my GP colleagues, including myself, withdrew from the out of hours commitment to enjoy a relaxing home life. Some GPs in the Wakefield district continued to work for the out of hours service but I think locum agencies had to be used to make sure it was fully manned. Again, I am pretty sure that most of these doctors did not know the patients they dealt with at night and at weekends.

When I was a child, GPs expected routine visit requests to be made before 10 AM. For my parents, home visits were the norm. As well as patients being able to telephone the surgery, messages could be left at two other houses in Airedale. This informal request for patients to phone in early has continued to the present day. In my parent’s day, each GP might do 30 visits after their morning surgery. In the early 1970s in Cheltenham, I felt hard done by if I had to do eight visits after morning surgery. There were a lot more visit requests than that made in Airedale when I started in 1978. The other doctors were persuading patients to come to the surgeries rather than having a visit and this is certainly more efficient. However, I was building up my practice and I visited at the drop of a hat in order to be different. Visit requests in the afternoon and early evening were regardedas different and more serious but actually many of them were not.

One afternoon when I was rather tired, a man phoned up and asked for a visit to his wife. I took the phone call and felt that visit was not necessary. I said “Don’t you realise that in the USA and Germany there is no such thing as a home visit?” The man replied “well, this is bloody England.”

There has been lots of coverage in the press (2) (3) in recent years of things going wrong in the out of hours services. Doctors are flown in for the weekend duties from other parts of Europe. Some have poor language skills and others are not familiar with how the NHS works. There have been some fatalities because of the wrong use of drugs. More and more patients have been going to accident and emergency departments manned by skilled doctors familiar with serious illness and accidents but not necessarily skilled in dealing with the minor illnesses that are attending. This has resulted in an increase of admissions, particularly of children.

It is very useful to have a primary care out of hours unit on the same site as an accident and emergency department. In 2011 I visited the new Royal London Hospital which has the most fantastic accident and emergency department and which also had access to an air ambulance helicopter on the roof. (I remember when this was officially opened, one of the consultants stepped backwards and fell off the roof. Fortunately, the roof has emergency netting in which he landed unhurt). Next-door to the accident and emergency department is a primary care led walk-in centre that is open in the evening, at night and weekends. It was about 11 o’clock in the morning when I was there and the primary care unit had two receptionists working pretty hard. The phone seemed to be continuously being answered. I had a word with them and realised I had forgotten what it was like working with London’s East Enders. These phone calls were from patients who had visited previously and despite being told it was not daytime service in the week. There were notices to this effect all over the place. They were calling in to arrange to be seen. Before that unit was established, the Royal London Hospital accident and emergency department had a general practitioner working alongside the A and E staff which I am sure prevented a lot of unnecessary admissions. Our local hospital in Pontefract is also employed a general practitioner to work in A and E  for a number of years.

What is the situation now? General practitioners are generally closed in the evening, at night and at weekends. However all GPs must provide some early morning and evening appointments. Very few provide appointments on Saturday morning. The government is looking at providing seven days a week primary care cover which will not be at all popular.

In 2013, the Conservative led coalition government introduced a 111 telephone service which can be used day and night 365 days a year. This was supposed to be for non-emergencies. However, what is an emergency in the eyes of a patient? The telephone was answered by a non-clinically trained person who goes through a list of questions according to a protocol. There are clinically trained staff on hand to give advice. There were great teething troubles when it started and GPs were convinced that more ambulances were being called. I had a medical problem two or three days after the 111 service was introduced and phoned them on a Saturday morning. I was asked a list of questions which was okay with me and then told me I would be telephoned back.  I had read in the newspaper that day that it was taking hours and hours for the 111 people to return calls. When I had heard nothing after an hour, I went to our local pharmacist to see if there was any information about out of hours services and they had none. I looked on the NHS webpages and these had not been updated to take into account the new service. I found out that there was a walk-in centre in Wakefield which is about 10 miles away from where I live. My wife took me there, and I was most impressed with the attention I received from an advanced nurse practitioner. The 111 service did phone back while I was in Wakefield but I felt I was far too late. I had to use that service again this winter and again saw a nurse practitioner who gave me an appropriate prescription.

The 111 service is theoretically good and can direct you to an appointment with your own GP surgery, to a nurse, to a dentist, to our walk-in centre, to a minor injuries unit or a primary care doctor attached to an A and E Department. There may be other services available. The 999 service is available as usual for emergencies and can be used by the 111 people. Some GPs feel that the 111 service recommends the 999 service to frequently.

As a patient, I have had very few experiences, thank goodness, of using any out of hours emergency services of the NHS. I was once in terrible pain from an abscess in an embarrassing place. I was working as a GP in Cheltenham a time and did not want to go to our own casualty department as I would be known. I was also praying that I would see a male doctor. I went to Gloucester casualty department and was examined by young woman doctor who knew of me because I was her mother’s GP! This abscess recurred when I was working in Castleford and was incised as I lay on the couch in our sitting room by a locum (John Papworth-Smith).

I had an urgent home visit from my GP and good friend Grahame Smith after I returned from a holiday in India and had contracted dysentery. I had an amazing home visit from Graham’s partner, John Waring, one Saturday morning in 1979. I was cracking up because I could not get any help at the weekends when I first started in the Castleford pratice. John insisted I had a break from work and actually took over and did the rest of my weekend duty himself. What a fantastic thing to do for a colleague.

A thread that runs through the whole of this essay is that it is extremely rare for an out of hours general practitioner to know the patient or she is dealing with. I did get to know my patient is pretty well when I was working as a two-man practice doing my own out of hours work and often knew the patient who called during the night or weekends. This was a very small part of my working life.

I started this essay by mentioning a news story about the increase in the very elderly being taken by ambulance to accident and emergency departments and that the change in the GPs contract in 2004 was to blame. As time goes on there will be an increase in the elderly with multiple diseases and on several medications most of which have side-effects. I therefore think there will be an increase in the number of the elderly sent to hospitals both by general practitioners and the 111 and 999 services. I am pretty sure that the change in the GPs contract in April 2014 will only have a minor impact. Our walk-in centre in Wakefield is open from 8 AM to 8 PM every day of the year and serves approximately 350,000 patients. I think there should be more walk-in centres manned by GPs and nurse practitioners but not open at all during the daytime on weekdays. They should be open during evenings, night and weekends and therefore existing general practice surgeries could be used. Our walk-in centre in Wakefield operates in an existing general practice surgery which has enough space for it to operate during the daytime.

References: Click on the bracketed numbers which are internet links.