Is GP out-of-hours running out of road?

“And why are you ringing me about that tonight?”, I tentatively asked him. Maybe I had nudged him a little too far. Silence on the phone – a long pause. I sensed him considering his reply and possibly even feeling a little miffed. Had I overstepped the mark? Was my tone a little too firm?
His symptom was present for over a month with the history not offering any reason why he chose to ring me that Sunday night. Then I reflected on why I had bothered to ask him. Was this not just adding to my stress? Maybe so, but at some level I was educating him about contacting his GP appropriately. 
The provision of out-of-hours care in Ireland has been transformed in line with advances in the technology of communication. The landline was superseded by the mobile phone which, in turn, gave way to call centres. Where once patients called to doctors’ homes, soon colleagues pooled resources to work in rotas of various sizes before this arrangement evolved into the formation of GP co-operative models of care.
This collaboration between GPs and the HSE helped to make it easier for patients to access urgent primary care in an organised manner. The GP had moved from being shackled to the home to working with colleagues for defined periods alongside receptionists, drivers and, sometimes, nurses.

First co-op highs and lows

Caredoc was the first GP co-operative to launch in Ireland in 1999, with many other co-ops starting soon after. GPs were enjoying new-found free time leading to improved wellbeing which enhanced doctors’ lives both on a personal and professional level.
Yet, it soon became obvious that there was considerable variation within the co-operative model nationally, with some colleagues opting out and instead paying locum doctors to deputise for them. In rural areas the participating GPs work more frequently than colleagues working in more densely-populated urban areas. The triaging of calls is performed by nurses in some areas and by doctors in others and, in some treatment centres, nurses work alongside doctors.  
However, things have changed. The initial boon seems to have receded; the sparkle faded as colleagues soon realised that working within the co-operative brought its own challenges. Large numbers of people began contacting the service, placing considerable strain on colleagues. Doctors began to raise understandable questions about operational aspects and one sensed morale had begun to dip.
The once-feted solution had quietly but inexorably become a thorn in the side of Irish general practice. This change in attitude among many colleagues was a very interesting dynamic to observe. I decided to explore the wherefore and the why.  
But before we can answer these questions we must look at the backdrop to general practice in Ireland at the moment. There are many moving parts within Irish general practice and the provision of out-of-hours care is tangled up in the middle of all of these. There are also a number of players within the delivery of care including patients, doctors, the HSE, owners of private residential long-term care facilities, An Garda Siochana, corporates and providers of accommodation, for example, hotels.
The delivery of out-of-hours primary care is the nexus where all the fault lines in Irish general practice intersect. It’s also the safety valve that is releasing the pressure steadily building within our speciality. 
There is a vast swathe of people who cannot find a GP to take them as patients so that they must turn to doctors working out-of-hours. Practices are struggling to provide care to patients already registered with them. Also, the work we do has become more complex.

Primary care changes

The practice of primary healthcare has moved to become multi-dimensional, more collaborative and more focused on disease prevention. While this is very appropriate, it means an episode of care takes longer than before to complete, often spanning a number of weeks awaiting investigations and a secondary care review.
Chronic disease management lies within these therapeutic strands and, while competently managed by practice nurses, it still consumes significant chunks of the doctor’s time. Managing urgent cases and possibly visiting long-term care facilities are also in the mix, not to mention the growing mountain of administrative tasks. So time is at a premium in our daily work. 
While the aim of working out-of-hours is to provide urgent primary healthcare, this aspiration is dependent on both the expectations and coping skills of patients. These patient variables interplay with perceived societal norms and pressures. For example, having a child seen by a GP to ascertain whether he or she is ok to go to creche can result in the consultation occurring early in the natural course of the illness when signs are not yet evident. The biomedical model of evolving illness is too slow-paced to compete in a society where people are used to seeing results at the press of a button or the swipe of a screen. The fact is that we live in an era where there is no time to get sick.
The future of out-of-hurs care
I decided to interview a number of colleagues to seek their opinions about the positives and negatives about providing out-of-hours care and to hear their views on the future of doing so. I saw the staging of WONCA Rural in Limerick as the spark to commence my work. I felt it was totally appropriate for the conference to reference such a game-changing advance in the lives of all GPs, especially those in rural practice.
The doctors I spoke to had varying degrees of experience as GPs. Two had just retired, others were approaching retirement, some were just recently qualified and two colleagues were positioned within this range. What surprised me most was to hear newly-qualified GPs speak highly of some aspects of working out-of-hours. This ran counter to what I was hearing ‘on the street’.
More than one described being glad of the opportunity to manage urgent cases, stating that it kept them up to date with providing this type of care. Also, the concept of providing acute care compared to chronic care was appealing. All participants enjoyed the camaraderie and positive social aspects of meeting and working with colleagues and staff, noting the salient finding that this was especially relevant for single-handed GPs.
All participants gratefully acknowledged the freedom conferred by the co-operative system. As one colleague succinctly stated: “There was no going back”.
However, participants expressed concern about the increasing volume of patients contacting the service and the growing expectations of patients. Some expressed doubts over the sustainability of the current situation and all wanted to have the choice to opt in or out of out-of-hours work.

How to address concerns

So what can be done to address these concerns? At a population level the HSE could resume its effective messaging that it operated during the pandemic. The online explanation of the role of the co-operatives and how to access them is quite clear but this message needs to flow across the airwaves, on social media outlets and on TV. It could be coupled with the effective HSE public information campaign of ‘Under the Weather’. Concise messages explaining the difference between urgent and routine care would be helpful.
Optimising the role of staff and making them feel valued would also be very welcome. Triage nurses have been shown to manage up to 14% of calls on their own without involving a doctor.1 Efforts should be re-doubled to address any local tensions between staff and management. The support from the HSE in funding locum cover where patient volume per doctor is very high or in remote areas is very welcome.   
We need better workforce planning to retain and recruit more GPs, thereby increasing capacity so that everyone can register with a GP. Future GMS contract negotiations might look at incentivising doctors to opt in to providing care, noting with caution the mass exodus of GPs from providing out-of-hours care when the NHS revised its GP contract in 2004.
Ultimately though, it comes back to each GP and patient either sitting in front of each other or communicating at the end of the phone. While patient education is clearly under erosion in a busy and fast-paced setting, we still need to try to grab the opportunity, when possible, to make a critical positive intervention or even to simply affirm and enable a struggling parent.2
Patients will get sick out-of-hours and caring for them can be very rewarding. We need to advocate for the conditions where urgent primary healthcare can be provided safely and appropriately.
The GP co-operative is the dominant model of out-of-hours care in Ireland at present. It reminds me of a busy, high-speed train. There are a lot more carriages on it now compared to even five years ago. Each of us steps on and steps off again after an honest and tiring shift. Two questions pertain: who is driving the train and where is it going?

References

1. Mulcahy D, O’Callaghan C, Hannigan A. Nurse Triage in an Irish out of Hours General Practice Co-Operative. IMJ; March 2017. Number 3.
2. Howie JG, Heaney DJ, Maxwell M, Walker JJ, Freeman GK, Rai H. Quality at general practice consultations; cross sectional survey. BMJ 1999;319;19;738-43