How to cure this lethal shambles: Concluding our major investigation, Mail doctor Martin Scurr prescribes a surprisingly simple plan of action By Dr Martin Scurr When your child falls ill in the middle of the night or your elderly parent develops chest pains at the weekend, what you need is the reassurance of good medical advice and care. But as the Mail investigation this week has highlighted, too many patients are being failed dismally by out-of-hours services. And the continuing crisis is having a knock-on effect on patient confidence - as a result, many are simply going straight to A&E, which is buckling under the pressure. The root of the problem is that patients are confused and anxious about where to get help if they are ill outside business hours The root of the problem is that patients are confused and anxious about where to get help if they are ill outside business hours. Until 2004, they would have simply contacted their GP. When I became a GP in the Seventies, we expected to provide our patients with out-of-hours care. That could mean between ten and 15 home visits in a weekend. Of course, we grumbled - GPs aren't saints - but the patients were so grateful it made you feel like a hero. But the new GP contract changed all that: family doctors were able to opt out of providing out-of-hours care - and they did so in droves. The Royal College of GPs insists its members are not at fault, but many of us beg to differ. What replaced the old system was a patchwork of services offering woefully inconsistent care. This has only been made worse by the recent introduction of the NHS 111 helpline, which was supposed to help rationalise out-of-hours care, but has been marred by reports of unanswered calls from critically ill patients and possibly fatal delays and mistakes. As a result of all this, A&E departments - already under pressure from an ageing population and a shortage of staff and beds - are becoming a "war zone," as one leading Casualty doctor has put it. We've heard the horror stories and everyone agrees that something must be done, but what? Here is my ten-point manifesto for tackling the crisis: GPs should take responsibility for commissioning out-of-hours care and keep a close eye on how it¿s being run and who is running it There is no doubt that a GP who knows you, and your medical history, is the best person to see if you have a non-emergency health problem. It's called continuity of care and it's been shown to make patients happy - and keep them out of hospital. But if GPs won't provide out-of-hours care (that genie is long out of the bottle), then they owe it to their patients to ensure the service is fit for purpose. GPs should take responsibility for commissioning out-of-hours care and keep a close eye on how it's being run and who is running it. Of course, employing a locum GP is not as good as treating your own patients, but if it's a locum with local knowledge, they will have an understanding of the needs of patients in that area - whether it's a seaside town with a higher percentage of the elderly or a suburb with lots of young families - and of the services that are available. This would also avoid the kinds of stories we've heard of patients calling NHS 111 and being sent to GP clinics 30 miles from their homes because call centre workers have no knowledge of the local area. There should also be greater encouragement for doctors who want to set up out-of-hours co-operatives, which are not-for-profit services run by the GPs themselves. These score the highest ratings for patient satisfaction, compared with private contractors and NHS services such as walk-in clinics and minor injury units. Our GPs aren't there to deal with emergencies, but to take the preventative steps to stop a condition developing into a crisis. If a patient has a urinary tract infection, for instance, treatment that is given in time can so often prevent it escalating into pyelonephritis, a serious kidney infection that may require hospital admission and intravenous antibiotics. Once a patient ends up in A&E, even with a simple urinary tract infection, this sets off a cascade of tests and investigations that may not be safe or good (a kidney X-ray, for example, exposes the patient to radiation), with cost implications. Treatment by a familiar GP avoids such dangers. For this reason, surgeries should open on weekends and bank holidays on a rota basis with other local GP practices. Surgeries should open on weekends and bank holidays on a rota basis with other local GP practices The introduction of this new national helpline has been marred by horror stories. Patients can't feel anything but an enormous lack of confidence in the service. I think GPs should run their own out-of-hours emergency lines, as the GP co-ops do - these are manned by call handlers employed by the GP. Then a GP, possibly even a GP you know, calls you back. However, if NHS 111 is to be retained - and many still feel that in principle it is a good idea - then it needs to be managed properly. In some areas, the NHS 111 helpline is run by medically trained staff, such as doctors, nurses or paramedics. But in many others it's operated by call handlers who have had a few weeks" training and rely on a checklist to work out if the caller needs urgent help. It's difficult enough for a doctor or nurse to work out what's wrong with someone over the phone - you need to see the rash or look at a child with a high temperature. But if it's hard for medics, it's simply impossible if you have no medical training and are relying on "protocols" - a list of questions that eventually steer you to a medical conclusion. As a result of protocols, callers to NHS 111 are being sent by ambulance to A&E for a sore throat, as the Mail revealed earlier this week, because the call handler can't distinguish between a minor infection and a possibly fatal allergic reaction. Home visits should be regarded as an integral part of out-of-hours care, and certainly not reduced. If you are housebound, a home visit is not a luxury, it is a necessity. The alternative is to go by ambulance to A&E, which is absurd. Research shows that patients seen by GPs working in A&E have fewer clinical tests and are less likely to be admitted overnight In any event, home visits are a core part of GP work - seeing the home environment is an important part of treating the patient. It is not unusual on a house call to realise that an elderly patient is not keeping themselves warm or eating a cooked meal every day. Home visits provide us with many such insights about social circumstances that are relevant to health. Yet I fear that, particularly with the elderly, this safety net is disappearing. There should be a national standard for the ratio of doctors/nurses to patients for out-of-hours care to prevent the scandal of just one healthcare professional having responsibility for hundreds of thousands of patients at night. A whistleblower recently revealed to the Mail that Harmoni, Britain's biggest out-of-hours care provider, had just one advanced nurse practitioner working overnight to cover all of north Somerset, an area with 250,000 patients. Private contractors that have allowed this to happen should lose their contract. There are schemes around the country where GP annexes are set up in A&E to deal with patients who don't need emergency care (see right). The experience of senior doctors is vital for making sure that those who need urgent treatment are admitted, reducing unnecessary admissions and A&E overload GPs assess patients who have walked into Casualty under their own steam. Research shows that patients seen by GPs working in A&E have fewer clinical tests and are less likely to be admitted overnight, but fare just the same in the long run as those seen by A&E doctors. Of course, these annexes need to be run by experienced GPs - it's no good junior GPs being shoved in simply to make up the numbers. I understand from talking to some A&E doctors that the tendency is for inexperienced GPs simply to refer the patient directly to Casualty because they lack confidence in their own knowledge. People don't just get ill during business hours, yet outside these times it's often junior doctors who are left making the decisions - one in five A&E units don't have experienced doctors at night. The experience of senior doctors is vital for making sure that those who need urgent treatment are admitted, reducing unnecessary admissions and A&E overload. This will mean employing more A&E staff - unfortunately, many trainees are reportedly giving up because of the pressure in A&E. But unless we have more staff and reduce the pressure, patients will suffer. Specialists, scanning facilities and blood tests should be available round the clock, seven days a week, so beds aren't blocked by out-of-hours patients waiting for diagnosis or assessment. More and more of us - from airline pilots to pizza delivery boys - work all hours, and it should not be considered beneath specialist medics to do the same. Hospital managers can't stick their heads in the sand. Many hospital staff recognise this, but the specialist services need to follow suit. One of the great pressures on A&E is that once patients have been admitted, they have to wait, often for hours, for a bed on a ward. It's been reported that 50 hospital beds have been axed every week since the General Election in May 2010. The number of general and acute beds available overnight on hospital wards has fallen by more than 6,500, or 6 per cent. So where are patients admitted to A&E meant to go? A&E is the pinchpoint of the NHS and there's only so much pinching it can take. Dr Scurr writes the Ask The Doctor column in the Mail's weekly Good Health section. Parachute GPs into the A&E war zone Could employing GPs in A&E help tackle the crisis in out-of-hours care? As well as cutting the burden in A&E, research shows that patients seen by these GPs do just as well long-term as those seen by Casualty doctors. Among these pioneering GPs is Dr Jane Weatherstone. In January, she began a new post that involves her working at least two shifts a week in the A&E unit at North Tyneside General Hospital. "On a shift in A&E, my work covers everything from minor illness and injury to major crises such as heart attacks," she says. Lewisham hospital, in South-East London, has just this month begun a trial using two GPs in A&E I don't wait for patients to be referred to me. Instead, I keep an eye on everyone who comes in and look for the patients who can best benefit from my skills. I take the pressure off consultants, who are free to deal with the seriously ill. People find it comforting to be treated by a GP in Casualty because it's familiar to them. And as I've been a local GP for 22 years, we often know each other already. Much of the time, she finds herself providing care and support to elderly patients. Often frail, older people come into A&E who are medically OK, but need a bit more help at home. I have the knowledge and networks to make that happen. This can prove crucial in reducing the load on A&E. A patient who gets the right health support at home from community staff is far less likely to return to Casualty within the following weeks. When a GP sees patients, their instinct is to see if they can be cared for outside the hospital, which reduces the risk of them picking up infections in a ward or becoming sucked into the care system Other hospitals are trying this scheme. At London's Charing Cross Hospital, GPs assess patients when they walk into Casualty. And Lewisham hospital, in South-East London, has just this month begun a trial using two GPs in A&E. Diana Princess of Wales Hospital in Grimsby has spent the past year running a GP pilot scheme in Casualty. Two family doctors screen as many patients as possible to see if they can be offered care that does not involve them going through A&E. But the health service's tangled financial systems can complicate matters. For while it seems logical to ensure patients don't fill beds needlessly, a hospital's income is based on the number of its in-patients. So, employing GPs in Casualty may, ironically, reduce their funding. "There is also a question of where we would get extra GPs," says Andrew Ombler, who is responsible for piloting the Grimsby scheme. After all, the major complaint about out-of-hours GP services is that patients find they are being seen by doctors who aren't local. "Ideally, we'd get a local GP co-operative to provide the doctors," says Mr Ombler. Despite such problems, the idea has won support from one of the country's leading experts in Casualty care. Matthew Cooke is professor of emergency medicine at the University of Warwick and an A&E consultant. When a GP sees patients, their instinct is to see if they can be cared for outside the hospital, which reduces the risk of them picking up infections in a ward or becoming sucked into the care system. Indeed, research by Jeremy Dale, professor of primary care at Warwick University, has shown GPs working in Casualty subject patients to fewer clinical tests and admit fewer patients to hospital than A&E doctors - but they fare just as well in the long run. "We have spent years trying to change people's habits of coming into A&E when they might be better off seeing their GP," says Professor Cooke. But our efforts do not seem to have worked. So having GPs in A&E instead is a really good way forward.