News from nowhere

The government and the medical profession are squaring up for another quarrel. Not about the under-resourced NHS this time, nor about local pay-bargaining, but about night and weekend calls by general practitioners.

The demand for medical attention out of normal working hours has grown steadily over the last twenty years, with a sharp rise in the last five. General practitioners are undertaking more unsocial hours work than ever before, while attendances at casualty departments are rising in parallel.

This is unlikely to be because we are all getting iller, and probably reflects different perceptions of health and illness, shaped in part by the availability of a responsive NHS. Increasing use of out-of-hours services is likely once the availability of these services becomes known, especially if they help reduce individuals’ anxieties about serious illness.

Calling a doctor who reassures you that your child’s ailment is not meningitis, or taking the ill child to the apparent safety of a hospital, with its assembled professionals and comforting technology, makes particular sense when planned access is becoming harder as waits for appointments lengthen and waiting lists grow.

The general practitioners who have so carefully dammed public anxieties behind a barrage of reception staff and appointment systems may have re-routed it into out-of-hours demand, which many meet by subcontracting the work to ever larger commercial deputising agencies. These increasingly efficient services then create a ‘supply pull’ that recruits more patients calling for attention, and relieves more beleaguered general practitioners.

At a time when pizzas, cash, petrol and entertainment can be bought at almost any time of day or night this makes a kind of sense, but predictably the government is not willing to pay for expansion of services to meet demand. This is the basis of the current conflict between the BMA and the Department of Health, for the rewards offered to general practitioners for out-of-hours work are seen by the doctors’ representatives as insufficient, at £2,000 a year and £9 per night call.

An earlier government move to make out-of-hours work an optional part of the general practitioner contract was resisted by the profession because the doctors saw it as the thin end of a wedge of privatisation. Once night calls were covered by a separate contract, and open to tender, other parts of general practice, like maternity care or contraceptive services, could be hived off and the monopoly position of general practitioners would be undermined.

Maintaining a monopoly and then maximising the price of services is the medical profession’s strategy, and there is little embarrassment at the enthusiasm general practitioners themselves are showing for hiving off out-of-hours tasks to commercial organisations. It seems privatisation is acceptable to general practitioners if kept under professional control, but unacceptable if not.