Warning over 'out-of-hours' care

The new contract was introduced in 2004

Serious illnesses in feverish children may be being missed because of the lack of face-to-face care outside of GP surgery hours, an expert has warned.

Oxford University's Dr Anthony Harnden voiced concern at the heavy reliance on phone consultation and the skills mix in out-of-hours care.

Research suggested half of children with meningococcal disease were sent home after first consultation, he said.

The government said there was no evidence patients were at risk.

Out-of-hours GP care changed with the introduction of a new contract in 2004.

The deal allowed family doctors to opt out of providing evening and weekend care.

To improve the care of children with feverish illness in primary care, we should be offering less telephone advice and more opportunities for a prompt clinical assessment Dr Anthony Harnden, lecturer in general practice at Oxford University

Nine in 10 took up the option, leaving it to local health bosses to make alternative arrangements.

Many have relied on co-operatives of doctors, nurses and paramedics. But as they tend to cover large areas, many rely on telephone consultations to assess patients.

The public also leans heavily on NHS Direct, the 24-hour phone advice service.

But, writing in the British Medical Journal, Dr Harnden, who is a lecturer in general practice, said: "Changes in NHS policy have led to the primary care of febrile (feverish) children presenting outside office hours being delivered by an increasing number of professional groups.

"Doctors, nurses, staff working for the telephone helpline NHS Direct, out-of-hours centres and accident and emergency departments may all have different levels of skill and experience.

"This is a major concern because the most solid evidence for recognising clinical severity in febrile children in primary care is a global assessment by an experienced clinician.

"The global assessment involves eliciting a clear history and careful observation of signs, including alertness, activity, colour and respiratory effort."

Assessing

His criticisms come after the NHS drugs adviser, the National Institute for Health and Clinical Excellence, published guidelines in May on assessing and providing care for young children with feverish illness.

Up to 40% of parents report a feverish illness in their child each year and it is the second most reported symptom in accident and emergency departments.

Doctors were issued with a "traffic light" system to help them spot serious illnesses.

Symptoms listed under "red" and needing immediate action include a very high temperature or mottled skin.

Meanwhile, symptoms under "amber", requiring monitoring, include skin pallor or fever lasting more than five days and those under "green", requiring no immediate action, include mild symptoms but breathing and crying that was normal.

Dr Harnden said GPs must not disregard their intuition because of the NICE guidelines.

And he added: "To improve the care of children with feverish illness in primary care, we should be offering less telephone advice and more opportunities for a prompt clinical assessment."

A Department of Health spokeswoman said: "Through both our out-of-hours service and NHS Direct, patients have access to skilled GPs at all times.

"It is important to remember that in the comprehensive independent national review of out-of-hours care conducted by the National Audit Office two years ago, there was no evidence of patients being put at risk."