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Is it an emergency?” the patient was asked. “This is an after-hours clinic and we only deal with emergencies.” The perception is that patients don’t think the same way as doctors or the HSE. Some see out of hours (OOH) as a very convenient service that can be used after work hours and after crèche alarm bells. Is this an opportunity to see every patient very early in their every illness, or the last straw that will break general practice? OOH services around the country are grappling with the growing demand for GP visits. Their own doctor has shut-up shop after a full day, in an attempt to achieve the modern phenomenon of work-life balance. Doctors constantly tell patients to give up smoking, so we had to give up smoking ourselves. We constantly told them about exercise and stress. We have to lead by example. Now we doctors are trying to cope with, understand, and manage this accelerating demand for OOH.
There is the stress of the increasing demand to see more patients more rapidly at the same time as the Government pays the same rebate for evenings up to midnight as they do for red eye consultations. The same pay for weekends as during the week. The same pay for Christmas Day as for Wednesday evening. But the pharmacist is probably closed and the dentist is closed. On Christmas Day and at 4am on any day, the GP is the last wo/man standing. GPs have a problem with this and want to be like the UK. We want OUT. Out of the unreasonable EXPECTATIONS. Taken for granted. The expectation of care 24/7/365 is a human rights issue. In the modern age, it is no longer suitable for purpose.
On the one hand, doctors are trying to move from the old model of care, where an isolated doctor often worked independently, caring for their patients 24/7/365. That GP did their best in a more forgiving world. Then, doing their best, in a pragmatic way, was not only acceptable, but respected. Doctors were appreciated for being available generously for their patients, day and night. Now this constant availability is an expectation of health and human rights for the patient. What about the doctors?
In olden days, we all had lower expectations of life and of medical care. The industry of Joe Duffy, law and litigation had not reached its present-day heights. GPs had a more central role, often running hospitals and cottage hospitals, big and small. They delivered babies and did surgery. Even today, this tradition continues in rural Australia, where GPs do surgery, trauma and anaesthetics. Even this is under attack and will result in fewer doctors in those rural communities. Death will be the result. Death of communities. All these pressures are shrinking what doctors can safely do. The patients suffer.
So life has evolved and a GP’s work is now relatively less important, but more pivotal.
The three cancers of bureaucracy, litigation and protocols interfere with good medicine, while trying to give the impression of helping. Medicine as a professional ‘calling’ seems ludicrous. You get punished for caring and more and more doors are put in your way. Common sense is rare. Doing something that actually makes a difference is becoming more difficult.
I asked a GP for her views of OOH. She talked of her increasing frustration that her genuinely sick patients are finding it more difficult to be seen in the madness and volumes of after-hours care for minor illnesses that should be dealt with at home. The power of sensible doctors to triage the really sick from the moderately sick is being steadily undermined by corporate thinking and the love of protocols. “If we only had all the perfect algorithms,” they surmise, “then all would be well.” The opposite is actually happening. More and more medical common sense, experience and nuance are being lost at the altar of centralised control.
So the future of OOH is that patients will be seen in increasing volumes, and for shorter visits, with a doctor who does not know them. Referrals to emergency departments will continue to increase because it will be too risky to make a commonsense decision in OOH. Expensive tests will continue to rise in the absence of time for history or examination. And it will continue to get more difficult to get doctors of ability and experience to work in these dangerous work situations.
Will a solution be found?
The basics for OOH are: Make OOH optional for GPs. Make the work reasonable, attractive and safe for doctors to work in. Pay the medical indemnity for GPs. Support medical care during working hours so that GPs can prioritise their sickest patients, rather than trying to cope with ALL the increasing demands on their time.
Finally, reduce bureaucratic enslavement and waste. The Government has many opportunities to let us get on with the actual work of medicine and get out of our way.