By Nick Triggle
BBC News Online health staff
The majority of GPs will have stopped providing out-of-hours service come December. But with primary care trusts struggling to pay for the cover, there are concerns some health services may be cut? BBC News Online investigates.
Most GPs are handing over out-of-hours service to PCTs
After decades of providing out-of-hours cover, many feel GPs are entitled to relinquish responsibility for tending to all those night-time ailments.
After all, who really wants bleary-eyed GPs seeing scores of patients during surgery opening hours?
But one consequence of the opt-out, which was part of the new GP contract which came into effect in April, is that the overwhelming majority of England's 298 primary care trusts have been left with a huge gap in their budgets as they take on the burden of out-of-hour service.
The cut-off point for PCTs to take on responsibility for the service is December.
Two-thirds of trusts already have their arrangements in place and the average shortfall is expected to be as high as £200,000.
Finance officers are now facing tricky questions over how to make the books balance with the spectre of service cuts beginning to be raised.
PCTs are at the forefront of the NHS, having responsibility for spending 75% of the NHS budget - some £49bn this year - to provide primary and community care and commission hospital services.
In public, most trusts say they are optimistic they will manage to make savings without cutting back on services.
But one person who works with PCTs, who did not want to be named, told BBC News Online that services such as district nurses and physiotherapy could be the first to feel the pinch.
A recent survey by the NHS Alliance, which represents PCTs, found that nine out of 10 trusts anticipated the new service costing more than the previous GP cover.
The study of 94 PCTs, a third of the total in England, also revealed half would be delaying investment in new services, while one in four was proposing to take money out of existing services.
South West and South East Oxfordshire PCTs are facing a joint £500,000 deficit and Bath and North East Somerset (Banes) PCT has a £300,000 shortfall.
But both told BBC News Online they were confident the money could be found once the new systems had bedded in.
NHS Alliance chairman Dr Michael Dixon said trusts had a tough task.
"It is inevitable that PCTs will have to record a deficit or find the money from elsewhere," he said.
"The natural course of events will be that trusts will have to slow down investment. PCTs are there to be bold and radical but that may not always be possible now."
Could physiotherapy be the first service to be hit?
He said the situation had arisen because GPs were not being paid at the market rate in the previous system.
"GPs were really forced to do the service before and it is only now we are realising what the true market rate for the out-of-hours service is."
But Dr Dixon remains realistic about the prospect of more funding.
"In an ideal world we would get more money, but the government has made the allocations and that is all we are going to get."
More than 90% of GPs have opted out of providing the services but, according to NHS Alliance figures, the majority of services will still be provided by GPs often working in partnership with other health staff.
A third of PCTs with arrangements in place are using a GP co-operative and a quarter a mutual organisation, involving GPs, nurses and paramedics.
Another quarter are providing the service in house, often using a mixture of nurses and GPs, and one in 10 PCTs have hired private agencies.
Dr Dixon said: "We are just going to have to live with it and adapt. The problem is that we just don't know how the service is going to be provided yet, so most trusts are stocking up on GP cover.
"In time we will be able to use nurses and paramedics more and bring down costs, but that is going to take two or three years to stabilise."
However, the plight of PCTs has received little sympathy elsewhere.
The government has provided more than £300m for out-of-hours services, an extra £50m for IT upgrades and £1.2bn for PCT premises.
The Department of Health said the extra money, coupled with the 33% increase in PCT funding from 2002-3 to 2005-6, was enough to provide the out-of-hours cover.
And Michael Summers, the chairman of the Patients Association, said local health officials should be able to balance the books without cutting services.
"They have been provided with funding so it really is a question of financial management.
"If they can't do that it reflects poorly on them, we certainly don't want to see services cut," he said.
But despite the difficulties, PCTs remain pragmatic about the task ahead.
Chris Jenkins, the out-of-hours development manager for Newcastle PCT, which is facing a £41,000 budget shortfall, said: "The truth is that the service being provided will have to change. I think everyone realises this."
The PCT, in conjunction with neighbouring trusts, is using a not-for-profit group of GPs, nurses and emergency care staff.
"At the moment we are probably top heavy with GPs. As the service settles down we are going to have to look at whether we need so many on call," Mr Jenkins said.
"It may be that we will have one GP supported by a team of nurses at certain times."