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The National Association of General Practitioners (NAGP) made a submission to the HSE Primary Care Division last week as part of a review of GP out of hours (OOH) services. The association, representing 1,956 members, claimed that a 24/7 GP owned and organised Co-op would provide the best model for OOH care, and have stated that it should be made available on a uniform basis. They believe that this system functions best to optimise clinical outcomes, continuity of care, patient and practitioner safety, consistency in care delivery, efficiency and cost control, and opportunities to expand the role of other health professionals.

In addition, they claim it would leverage new technologies like video consultations, self-help modules, cloud-based shared Electronic Health Records, and the remote integration of incidence based care models, such as the management of falls, with secondary care.The submission emphasised that it is “critical” that Ireland does not “make the mistake of handing over out of hours care to standalone corporate entities removed from the continuum of care of the whole population GP system”. “Such a development would result in a negative loop whereby clinical decisions made in isolation, during OOHs, are passed back into daytime practice in a chaotic manner. Were this to happen, it will further impede the ability of practices to engage in more comprehensive and wide-ranging chronic disease management programmes and also result in longer waiting times in daytime practice. This has been the clear experience in the UK leading to prolonged waiting times for routine GP services”. The report states: “If we wish to expand the scope of daytime practice, it is essential to optimise the clinical management of patients out of hours. The NAGP has already taken steps along with leading IT companies to deploy the technological infrastructure to help achieve this”.

The NAGP have called for the removal of the stipulation under the 1972 GMS contract that GPs are obliged to be “contactable for urgent cases 24/7 whilst also providing 40 hours of routine availability” in the new GP contract.

They point out that Ireland’s older population is placing increasing demand and strain on the GP during the working day and the country’s current demographic of GPs is too old to support such a burden of work. In addition, newly qualified GPs are unwilling to commit to such an “onerous work commitment”; particularly as such a contractual commitment does not feature in the healthcare systems that are actively recruiting them, such as Canada, Australia or the UK.They have recommended that finance be provided to practices to increase their own capacity so that some of the current OOH patient demand is instead facilitated in his/her own practice. The submission underscored the need for a change on the current model: “The present and future demographics of our profession alongside the very real manpower crisis, mean that the current model of OOH is completely unsustainable, and is not safe”.

NAGP Proposals

Current GP contract negotiations should commit to the removal of compulsory out of hours working for GPs. The budget for OOH should be negotiated separately from the core contract. Negotiations should commit to the concept that the optimum model for OOH care is via GP-managed Co-Ops. The Department of Health must commit to other OOH services such as Palliative Care, Forensic Care, Nursing Home care and Dental Care, for example.

GPs who opt to work solely OOH should have access to a clear pension structure, to be negotiated. GP Co-Ops should look to up-skill other healthcare staff so that less complex cases can be dealt with under the supervision of but not directly by GPs. New models of consultation such as telemedicine should become core components of new, more efficient, OOH services. Economies of scale savings should be looked for throughout the service. A GP-led OOH service will create considerable opportunities for efficiency through consolidation at all levels.