Not necessarily that much of a problem. We probably need to change the way
we work. Basically we can accept that a lot of primary care will come to us
and deal with it (if you want to go down this route it may be worth
negotiating with your PCT to take on all or a proportion of the out of hours
primary care in return for all or a proportion of the funding- they may well
be pleased to have it taken off their hands) or alternatively send the
primary care problems to the primary care team.
Establish that your A and E department is not a drop in primary care centre
and people will stop using it as such; see and treat all primary care
problems and you'll be seen as a drop in centre. First option needs a bit
more empowered triage at present but will transfer some of our current
patients to other providers; second option needs more staff, but will
attract more money.
The key is to keep talking to your PCT and work out and integrated system.
> Some GPs may
> even look at a career in OOH primary care - priced at a minimum of £50
> per hour it will not be difficult to earn £100k.
Yes, and indeed salaried posts offering 100k for WTE are on offer- although
at £50/ hour that means working a 46 hour week all nights, evenings and
weekends which some people might find clashes a bit with family and social
commitments. I'm not sure many people would want to take up a pure out of
hours post- and the lack of ongoing experience of much of the daytime stuff
in general practice would make it hard to move to a 'normal' GP post if it
got tough going in a few years. If you do it as the odd session, you can
knock off a bit more for lack of pension, sick leave etc.
Trouble is that (for a partner on parity) by working entirely between 08:00
and 18:30, weekends and bank holidays off average pay is estimated at 80-
85k from NHS work with the new contract; and I know a lot of GPs who reckon
they should be able to make between 100 and 120k. Add on to this around 10-
15k from non NHS work and the pure out of hours doesn't seem so attractive
(I accept that I am in a high earning area).
Likely to attract people currently working for deputising services (which
creates an additional problem in itself in some urban areas) more than
> Their may not be enough GPs to fill all sessions (speculative) so that
> there will be a need for involving other healthcare professionals of
> which there are many pilot schemes throughout the Country. In Kent, we
> are looking at the combined skills of paramedic, nurse in a
> response car
> to cover a mixture of GP home visits, night nursing calls and
> additional
> first response capability which hopefully will be a cost efficient and
> effective model.
Couple of concerns about this model: a GP has a minimum of 9 years training
under their belt. The average GP has a lot more. I'm not sure that
paramedics or nurses could cope with everything a GP copes with at present.
If there isn't a GP to back them up, who takes the cases they can't deal
with? Also, how about referrals for admission. Has it been cleared with the
inpatient teams that they'll be taking referrals from nurses now, or are
they going to (particularly for the 'iffier' cases) want an A and E opinion
first? Might be great, might mean a lot of extra work for A and E. What
happens if it does turn out to mean extra work for A and E?
I may have got you wrong- if the scheme is using nurses, paramedics etc.
with GPs still available to back them up, then chances of success are
higher. I think you can take over all home visits (except for terminal care)
using a nurse or paramedic and taxi service though.
>
> GPs will have effectively dropped their OOH responsibility - perhaps
> something the consultants could look at getting paid for 9-5/ 8-6 or
> whatever and pulling together OOH or when work intensity is
> low covering
> 2-3 A&E depts at fulltime rates?? Obviously area dependant and quite
> appreciate will be impossible in some centres.
If there are 3 A and E departments close enough that consultants can cover
all 3 adequately you might want to look at merging a couple of them.
Certainly locally I can't think of any way to do it without having some
consultants taking a hour or more to come in- also I can cope with a couple
of critically ill patients in my own department, but obviously couldn't if
they were in different departments. Works for some specialities (GU med,
public health, dermatology are obvious ones); but for A and E it would mean
going back to the idea of a consultant not being involved in the sickest
patients.
> He was saying that the devil
> as
> ever is in the detail. This year they lose 6K if they drop
> OOH but this
> is
> not a permanent rate and next year the cost may be higher so
> there is a
> significant threat that if too many drop out there will be a
> big hike in
> the cost of that drop out. He reckons the PCT will use this
> to maintain
> the
> cover.
PCTs won't want to upset GPs. If anything, this makes it more likely that
they'll try to provide the service on the cheap. Cheapest way I can think of
is to have a nurse or paramedic practitioner who passes everything dodgy on
to A and E. Particularly if any cases that may need admission or may prove
difficult get sent straight to A and E from telephone triage. After a couple
of years, patients appreciate that they'll be told to go to A and E anyway,
so might as well turn up.
This is obviously a worst case scenario. Important to stop it from happening
though- work closely with your PCTs (which is also the best deal for
patients). There is a lot of money for providing GP out of hours (maybe £1-
1.5 million for the population covered by a typical A and E department). As
long as you make sure the money follows the workload it's more of an
opportunity than a threat. Decide what you want to happen and get proactive
in making it happen.
Matt Dunn
Warwick
This email has been scanned for viruses by NAI AVD however we are unable to
accept responsibility for any damage caused by the contents.
The opinions expressed in this email represent the views of the sender, not
South Warwickshire General Hospitals NHS Trust unless explicitly stated.
If you have received this email in error, please notify the sender.
|
