By Hannah Goff BBC News Health Reporter

When the local primary care trust took over the running of out-of-hours services in East Lincolnshire in January 2005 it was not long before concerns were raised.

Patients were left waiting longer than they should have been for responses to their calls and many saw even longer waits at hospital emergency departments, and local GPs warned patient safety was being put at risk.

The health watchdog the Independent Healthcare Commission was called into investigate.

Many patients were left waiting too long for out of ours care

The situation arose because all the GPs in East Lincolnshire had exercised their right to opt out of providing out of hours medical cover by January 2005, and an alternative model was put in place.

This was formed of visiting emergency care practitioners, call handling and nurse triage, the local accident and emergency department and the continuation of a contract for a visiting GP service - the North Yorkshire Emergency Doctors (NYED).

But not long after the handover, NYED collapsed and the primary care trust was forced to "backstop" with the ambulance service personnel, the local A&E department and local GPs.

Although a group of GPs worked out of a local hospital, doctors' home visits were largely replaced by responses from paramedics.

Paul Miller, director of neighbouring West Lincolnshire primary care trust, says that with so many different providers, the East Lincolnshire service was perhaps more fragmented than the in-house service developed in the west of the county.

Local doctors claimed the new service was set up with very little involvement from the people who had provided it before and so what emerged was patchy and lacked cohesion.

'Dedication'

Boston GP Dr Richard Gent, one of the doctors who raised the alarm, said there was "a bit of a muddle as to who was supposed to do what".

"If it hadn't been for the dedication of the staff doing the job - it just would not have worked."

The argument was that much of the out of hours work carried out under the old system did not need to be done by a GP.

Dr Gent says: "That may well be true but would you want to fly with a pilot who could only land 90% of the time?"

"There was an enormous underestimation of quite what was happening in out of hours before hand.

"It is a service that just doesn't lend itself to fragmenting into little boxes."

This is denied by the PCT, which also insists GPs were fully involved in planning the service, but they do admit that there were "some difficulties" with the service in the early stages of development.

East Lincolnshire PCT said: "Over time the service has developed and improved, and this has been fully acknowledged by the Healthcare Commission in its last review of the service.

"The number of complaints has decreased significantly since the service was established and the results of patient surveys have, in the main, been positive."

On call

"As with all our services we continue to make improvements and evaluate what action we can take to make things work better.

"The costs of the services have halved during the period that the service has been running."

But a few weeks ago, the East Lincolnshire service was subsumed into a county-wide in-house service ran by Mr Miller and modelled on the earlier West Lincolnshire service.

Patients are given one number to call.

Emergency patients are filtered out by the ambulance service, with the rest being directed to an assessment centre for further assessment of need and risk.

Half of calls are dealt with through telephone advice - such as coughs and sneezes and the mild temperatures.

Skill mix

But there are always GPs, nurse practitioners and emergency care practitioners on call and ready to make home visits.

Mr Miller says: "If a GP needs to go then that's what happens.

"The overall aim is to provide care for patients but we have to do it cost effectively, getting the right skill mix - it's just like anything else there has to be a balance.

"But there should always be a GP in the system.