The new contract for general practitioners introduced in 2004, which allowed practitioners to opt out of 24 hour responsibility, has led to a situation in which the best trained general practitioners concentrate their efforts on daytime care, while patients who become ill at night risk being seen by less experienced doctors, argues Roger Jones, Professor of General Practice at King's College London.
He warns that not only does a parallel out of hours service lead to fragmentation of care and potentially dangerous communication errors, it is likely to be more expensive, in terms of both running costs and unnecessary inpatient costs.
He says: "I am not suggesting that all general practitioners resume out of hours responsibility for their entire professional life. And I am certainly not supporting the view that surgeries should be open at all hours for routine care - this entirely misses the point. However, during vocational training and in the early years of practice, seeing patients in their homes, assessing acute medical problems, and making appropriate decisions about treatment and hospital referral should be regarded as core aspects of training and professional development, just as they are in hospital medicine."
Having covered out-of-hours care himself, Jones does not underestimate the difficulties of re-engaging with personal out-of-hours care but he is convinced that for many doctors and patients a return to a more personal approach to 24 hour responsibility would reap enormous benefits.
The relinquishing of out-of-hours responsibility has led to accusations that general practitioners do not care about their patients. But it is precisely because we want the best care for patients that the change was made, writes Helen Herbert, Chair of the Royal College of General Practitioners in Wales.
She describes her experience of covering out-of-hours care, often in a state of exhaustion, and argues that sleep deprived people should not be making life threatening decisions.
General practitioners are blamed unfairly for the state of out-of-hours services when the responsibility for commissioning and providing these services resides with primary care organisations, she says. She acknowledges that some out of hours services are confusing and fragmented, but believes that general practitioners are the solution to improving urgent care services, not the problem.
And she points out that where out-of-hours care is properly organised and resourced, it works well, and many studies have shown high satisfaction with the care provided.
The profession made the difficult decision to withdraw responsibility for out-of-hours care to ensure the safety of our patients and recruitment of future generations of doctors, she writes, but we must maintain responsibility for these values by providing excellence in preventative care and by influencing the providers, commissioners, and policy makers to ensure provision of the high standards of care that we expect for our patients.