Health: Doctors on call - at the surgery: Nicholas Timmins talks to GPs and patients at a centre where they are cutting back on out-of-hours home visits

When Susan Reed called her doctor one evening early last week about the cough and a half that her nine-year-old daughter, Helen, had developed, she found herself talking to Dr Kalyani Ghosh from Meddoc - Medway Doctors on Call.

Dr Ghosh gave her some advice and said if things didn't improve, she should call back in an hour. When she did, she was told she could take Helen to see Dr Ghosh at Meddoc's base. At 9.35pm on a dark though not cold night, they found themselves in the old admiral's surgery in Chatham dockyard being prescribed antibiotics.

This is the shape of general practice to come. Out of hours - that is after 7pm and at weekends - patients increasingly are likely to be asked to go to the doctor, rather than the doctor, as is traditional, visiting the patient.

The centres they will visit, however, may well not be the local GP's surgery, but either a designated primary-care emergency centre, or a surgery appreciably further away than their local one.

At Medway they have been doing this for five years. All 160 doctors in an area covering 300,000 patients take part in the non-profit-making co-operative. It covers the towns of Strood, Rochester, Gillingham, Chatham and Sittingbourne, plus a swathe of surrounding countryside which, at its extreme, is 20 miles away from the dockyard base.

Instead of perhaps 20 or 30 doctors, plus a deputising service, being on call at nights and weekends, Meddoc manages with just two local GPs out in cars and one at the centre dispensing advice and consultations - although a tier of further back-ups is available. On the weekend of a flu epidemic, for example, up to nine doctors have been out at once.

'Our aim is to get more and more patients to accept advice to get them through to the next morning, when they can see their own GPs,' says Dr John Grace, co-founder of the co-operative. 'Eighty per cent of calls can be dealt with perfectly safely by advice, although we only get about 40 per cent of patients to accept that. The next stage is to invite people to come to the base for a consultation - we average about 18 per cent, but have occasionally got it up to 25 to 30 per cent, never above that. The third level is for a visit.'

The difference this arrangement makes for the doctors is spectacular. Dr Grace says: 'Instead of being on call at night once or even twice a week and having to work normally the next day, and then being on call for the whole of every third or fourth weekend, I now do four sessions a month, which pays for my use of the service the rest of the time.

'The alternative would be to use one of the commercial deputising services - which don't have the best of reputations and over which I have very little quality or financial control. It also means doctors and their families can plan their lives and know when they will have time off.'

It replaces, he argues, an inefficient system - where the doctor might or might not get called out - with one where they work hard but less frequently and can then take time off to recover.

For the patient, the request to visit the base surgery until as late as midnight can come as a surprise. Some, the doctors say, resent it. But many, perhaps surprisingly, do not. Mrs Reed, as she took Helen home not long before 10pm, said: 'It's a good idea. Before this service was available, when the children were babies and you worry more, I've had to wait for an hour or two, even longer, for a doctor to visit. With this, I could come straight down here - and for someone who couldn't come in I may have made it easier for the doctors to get out to them. I didn't think this was severe enough to call a doctor out, but it meant I could see one without feeling that they might be needed out on a more major problem.'

The point is well made. As Dr Ghosh was seeing Helen Reed, her two colleagues were out dealing with a hallucinating young man, who had earlier attempted to slash his wrists, and an elderly lady with chest pain. Dr Grace says there will always be patients who cannot be asked to travel - the frail elderly, those without access to a car, the single mother with no one to look after the other children - but they are the minority.

It isn't, however, just the less serious cases that get invited in. In the past, patients have been sent on to hospital from the base surgery with suspected appendicitis or chest pains. However, both the local patients' watchdog, the Community Health Council, and the Family Health Services Authority, which is responsible for GP services, say that they are pleased with the system.

'We used to get complaints about the deputising service, but complaints about out-of-hours service are now rare,' says Graham Hills, the CHC's chief officer. And the health authority is pleased that all the doctors involved are fully- trained local GPs who are directly answerable to it if anything goes wrong - not deputising doctors, who may not even live in the area.

Even champions of out-of-hours surgeries doubt they will ever go 24-hour

FIVE days ago the Department of Health announced a new deal for family doctors. Patients can expect to receive fewer home visits at night while groups of GPs will be encouraged to set up out-of-hours emergency centres, to which patients may be asked to travel. The deal may make a big difference to the numbers of patients visiting a surgery during the evening and at weekends, Dr John Grace, a pioneer of a doctors' co-operatives believes. But simple economics make it unlikely many patients will be asked to turn out to all-night surgeries, he says. In his practice in the Medway area of Kent patients are asked to the base surgery up to midnight, but not after.

'Between 1am and 7am we average eight calls a night and that is on a population of 300,000. Given that some people will need a home visit, we can't do away with having a doctor out in the car,' he said.

'If we have to have a doctor out there visiting, it doesn't make economic sense to have another sat at an emergency base when most nights there will be very few patients to see. It is during the evenings and weekends that having the emergency surgery available makes a real difference.'

He also suspects that some of the enthusiasm of doctors' negotiators for primary-care emergency centres is based on a misunderstanding. 'I told a reporter that 15 per cent of our patients on average visit the base surgery and that was misheard and reported as 50 per cent - since when some people have been saying half our out-of-hours calls end up as visits to the base surgery. That's not the case, and I would be surprised if that could be achieved without a great deal of antagonism between patients and doctors. What is needed is an educational process which changes attitudes and stops patients abusing the service by calling GPs out unnecessarily. We have to persuade them to accept advice and come into the centre when it's appropriate.'

(Photograph omitted)