After 90 per cent of GPs in England gave up 24-hour responsibility in 2004, out-of-hours services were in and out of the headlines. Tales of highly-paid European doctors flown in and paid several thousand pounds for a weekend's work surfaced as PCTs struggled to cope.
The scandal involving German locum Dr Daniel Ubani, who killed a patient on his first shift in the UK, then put out-of-hours squarely in the spotlight.
The case sparked a debate about whether doctors unfamiliar with local health systems should be involved in out-of-hours care. The East of England SHA, among other NHS organisations, ruled that only local doctors should provide the service.
A flurry of reports after the case highlighted the need for tighter regulation and checks.
As these began to be implemented, out-of-hours providers faced rising costs. Providers also report staff costs have risen and demand is high. Meanwhile, flatlining GP income in recent years has meant out-of-hours opt-out money levied from practices has not increased in line with the rising costs.
So, as GP consortia prepare to inherit responsibility for commissioning out-of-hours in 2013, what state is the service in?
Dr Fay Wilson, chairwoman of Birmingham out-of-hours co-op BADGER, says GP out-of-hours providers' costs are 'not going down anywhere'. She says part of this is due to the 'Ubani effect'.
'There is a lot more administration going on, we do a lot of training and audits and provide more patient information. (But) everything you do has a cost to it,' she says.
Dr Wilson warned that with the advent of the Care Quality Commission, audits and administrative workload will continue to grow. She says the rising costs of providing out-of-hours services meant the co-op had been 'eating into reserves in the past year or two'.
Patient Care 24, an out-of-hours provider in south-west London, says cost pressures in providing the service have been an issue 'for some time' but are now something it is 'increasingly concerned about'.
The not-for-profit organisation, formerly a GP co-op known as Croydoc, is now at a crossroads. About half of GPs in the area opted to retain 24-hour responsibility in 2004, with Patient Care 24 now providing the service on their behalf.
But some GPs now feel they can no longer afford to stay opted in, after Patient Care 24 announced that cost pressures meant it would have to hike fees from £3.64 to £5 per patient.
Dr Ian Harper, chairman of Merton, Sutton and Wandsworth LMC, says most practices in the area will not be able to afford the extra cost.
With a crisis brewing, the local PCT has stepped in to offer GPs a second chance to opt out.
Dr Harper says it is likely that most GPs will take up the offer. 'For most practices it is untenable to stay opted in,' he says.
Meanwhile, David Stout, director of the NHS Confederation's PCT Network says the increase in out-of-hours provider costs has not presented too much of a problem for PCTs. 'The cost of out-of-hours care in the context of a multi-million-pound budget is not the biggest of their pressures,' he says.
But GPC deputy chairman Dr Richard Vautrey says more out-of-hours funding would be available if general practice had been adequately resourced.
But because GP income has been flat, the out-of-hours levy they pay has been flat too. This has restricted PCT funding for out-of-hours, but has been a particular problem for opted-in GPs, who do not enjoy access to the wider budget PCTs can call upon.
'We would be concerned that the necessary resources aren't there to support decisions made in good faith,' Dr Vautrey says.
When consortia take responsibility for commissioning out-of-hours, Dr Vautrey says some GPs are concerned they will inherit a pared-down out-of-hours service where PCTs have tried to make cost savings.
He says that the challenge for GPs as commissioners of out-of-hours care will be how to provide a high-quality service within the available resources.
As GPs look to balance the lack of resources with their expectations of quality, new models of out-of-hours provision may begin to emerge.
What GPs will be keen to demonstrate to; patients is that good-quality out-of-hours does not depend on their taking back 24-hour responsibility.