The Audit Scotland ‘Primary care out-of-hours services’ study, which reviewed changes to the delivery of primary out-of-hours services following the introduction of the new General Medical Services (nGMS) contract for GPs in April 2004, states that the high level of GPs opting out means that out-of-hours medical cover is “not sustainable” in its present form. 

The study found that since the introduction of nGMS GP contracts, in which GP practices were given the opportunity to opt out of providing out-of-hours services, 95 per cent of GP practices have chosen to do so. The responsibility for providing and funding 24-hour care services passed on to NHS boards, the cost of which in 2005/06 was £67.68m and £67.93m in 2006/07.  

The report goes on to say that while 30 per cent of the cost of the new service across Scotland in 2005/06 was covered by the removal of additional funding for GPs who no longer provided out-of-hours care, known as ‘claw-back’, the rest of the money came from NHS boards’ budgets. This had a particular effect on NHS boards in rural areas, with NHS Highland funding 80 per cent of the new service from its unified budget, compared to 26 per cent by NHS Greater Glasgow. 

However, while stressing the challenge faced by NHS boards due to the timing and scale of the change and additional costs involved, the report goes on to say that 80 per cent of patients are satisfied with the service they received.  

In addition, the decision to allow GPs to opt-out of providing services on weekday evenings, weekends, bank and public holidays, which was seen as necessary to improve recruitment and retention of GPs, was met with a positive reaction from GPs – 88 per cent of whom said they were relieved to no longer have 24-hour responsibility for patients. However, despite their relief and the positive reaction from patients, 52 per cent of GPs felt that patient access and the availability of out-of-hours services have not improved. 

Commenting on the findings, Deputy Auditor General for Scotland Caroline Gardner said: “Since the changes to out-of-hours services three years ago, NHS boards have worked hard to maintain the care patients have traditionally experienced, and most patients are satisfied. However the way the service is currently delivered needs to change as there is a significant risk that it is unsustainable in its current form, particularly in Scotland’s rural and remote areas.  

“The Scottish Executive should look to healthcare professionals other than GPs and consider how to extend their roles and skills. Meanwhile NHS boards should continue to develop how they work with partners, such as NHS 24 and the ambulance service, to deliver out-of-hours care for patients.”

Bridget Hunter, UNISON’s lead officer for nursing care, echoed the report’s call for more out-of-hours medical care to be provided by non-doctors, but warned that for this to be effective other health professionals will need to be given the appropriate training. She said: “With more and more doctors dropping out of providing out-of-hours care, it is clear that the most effective way of covering the essential care is to extend the roles of other health professionals, such as nurses and paramedics. But if this is to be effective there must be an increase in the numbers and appropriate training for these professionals.”

UNISON also back recommendations for increasing the use of NHS 24 and the Ambulance service. David Forbes, UNISON’s Regional organiser for the Ambulance service, said: “Both the ambulance service and NHS 24 have had considerable extra demand placed on them already as patients realise that traditional GP cover is no longer there.

“Despite teething problems, the co-ordination between these services and the link with primary care within Boards is improving. That needs to continue – especially in rural areas, as does the increase in the care that can be given by paramedics and other health professionals in the home.”

Dr Dean Marshall, chair, BMA’s Scottish General Practitioners Committee, said that the report highlighted some of the fundamental issues that have “hindered” NHS Boards from developing integrated services for out-of-hours care and called for better communication and co-operation between those tasked with delivering 24-hour services. He continued: “With the additional cost of providing the new service at £31 million in 2005/06, it seems that the Government clearly did not appreciate the extent of the personal and financial burden borne by GPs in delivering 24 hour patient care under the old arrangements. The cost of delivering services out of hours is now being borne by NHS Boards who are struggling to maintain services at existing levels.

“The report highlights that the current model of care is not sustainable, particularly so for the more remote and rural areas of Scotland. BMA Scotland would welcome the opportunity to be involved in discussions on how the various service providers can work together to deliver out-of-hours care in the long term and to consider the potential for wider improvements to unscheduled care for patients across Scotland”.

Dr Marshall also welcomed the results of the patient and GPs’ surveys, which found that 80 per cent of patients are satisfied with the care they received from out-of-hours services. He added: “It should not be forgotten that the new contract, which allowed GPs to hand over responsibility for providing out-of-hours care, was designed to combat a crisis in general practice and ensure the sustainability of out-of-hours care for patients.  

“Before the new contract was introduced, morale was at an all time low, GPs were planning to retire early and recruitment was becoming impossible. Now, however, GPs have more control over their workload, work-life balance and morale has improved. Importantly, more than two-thirds believe that a career in general practice has become attractive again.”

However, shadow health secretary, Mary Scanlon MSP said she was “deeply alarmed, but sadly not surprised” by the report’s findings, which she said “confirms that the new contracts were not necessarily in the best interests of patients.”

As a result she said that the time has come for a complete review of the services, which she argued “must be patient centred and recognise the extra resources and demands placed on providing an out-of-hours service in rural Scotland.”

She continued: "It is damning that only 11 per cent of GPs think that things have improved, and nearly 1 in 5 patients are dissatisfied with their experience of the new and potentially critical service. There is now an impending crisis as fewer and fewer GPs opt to provide their services to NHS24, and the inherent danger that far less qualified medical staff will take over their responsibilities.

"The people of Scotland deserve the best health service - whatever the time of day and wherever they live."