Home > Information for doctors >Tutorials > Out of Hours

Francisco Machado 1997

Index

Why was a change needed in the delivery of out of hours care?
BJGP June 1993 24-Hour cover: time for reappraisal

What did the new out of hours agreement mean?
Changes to Out of Hours Terms of service for GPs

How do co-operatives manage their patients?
BMJ 314 Jan 1997 A survey of GP cooperatives

How does a deputising service compare with GPs seeing their own patients?
BMJ 314 Jan 1997 Comparison of OOH care provided by patient's own GPs and commercial deputising services: a randomised control trial.

How do co-operatives and deputising compare?
BMJ 314 Jan 1997 Observational Study of a GP out of hours cooperative: measures of activity Salisbury

What makes a doctor visit?
BMJ 312 June 1996 Responding to OOH requests for visits: a survey of GP opinion

Can nurses reduce the number of patient contacts
BMJ 314 Jan 1987 Nurse telephone triage in OOH primary care: a pilot study

Will patients attend primary care centres?
BMJ 309 Dec 1994 Out of Hours primary care centres: charateristic of those attending and declining to attend.

BJGP June 1993 24-Hour cover: time for reappraisal Toby

• GMSC special report "Your Choices" indicated that a large number if GPs wanted to opt out of 24 cover for patients.
• Salisbury identified a perception of an increase in the demand of patients out of hours
• New GP contract in 1990 increased GP workload
• Concern about recruitment to general practice
• Out of hours cover is a source of stress:
  1. Cooper had identified a deterioration in mental health
  2. Just being on call even if not called out is stressful
  3. Fear of exposure to violence
• Advantages of providing 24 hr care:
  • satisfaction of providing personal service
  • increased self confidence which may derive from close supervision of treatment
  • the educational benefits of observing outcomes in patient care
  • financial reward
• Suggest that there should be greater flexibility in how GPs can arrange for 24 hr cover and where this cover should take place.

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Changes to Out of Hours Terms of service for GPs

• a development fund of approx 45 million per year to be shared between Gps equally for development of OOH service
• one night visit fee irrespective of who did the visit and where ever it occurred.
• GPs could continue to do their own calls, form co-ops of greater than 10 doctors or use commercial deputising services
• Gps should decide where the patient should be seen, and if felt that hospital admission was necessary could do this without visiting the patient.

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BMJ 314 Jan 1997 Observational Study of a GP out of hours cooperative: measures of activity Salisbury

Observational study comparing an OOH CO-OP with a deputising service.

CO-OP in Kensington and Chelsea, Deputising in Brent and Harrow

          Patients   Telephone   Primary    Patient's  Patients   Response    
          visited    advice      Care       prescribed admitted   times       
          at home                Centre                                       
                                            treatment                         

CO-OP     32%        57.8%       7.1%       37.6%      8.7%       75 minutes  

Deputisin 76.3%      19.3%       0%         51.7%      6.8%       65          
g                                                                             

3920 calls to co-op and 1892 calls to HC, despite similar numbers of GP subscribers in each group, mainly due to HC either screening their calls or taking their calls up until midnight.

• HC had no treatment centre
• there was a large difference in the age of the patients that contacted each service, patients were younger for HC, also more likely to be of Asian or African origin.
• Telephone advice:
  • difference may have been due to HC vetting calls
  • HC was bound by Code 1984 for deputising services which required a visit to be made to any patient who requested one, so that subscribing doctor did not face an allegation of failure to visit.
  • other studies have shown a variation of telephone advise between GPs covering their own patient's and different co-operatives in the country.
  • The impact of a high rate of out of hours telephone advice on health outcomes should be a priority for future research
• Out of Hours Primary Care Centres
  • only 7% of co-op patients were seen in the treatment centre
  • HC centres around Britain quote a figure of 22% of callers being persuaded into attending the emergency treatment centre
  • several co-op have quoted figures of up to 30% attending treatment centres
  • In areas where a large number of patients attend A/E departments with primary care problems e.g. it is difficult to persuade the patient to attend an emergency treatment centre
  • In some areas GPs work in A/A departments instead of developing Emergency treatment centres.
• Prescribing differences
  • Difficult to explain

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BMJ 314 Jan 1997 Comparison of OOH care provided by patient's own GPs and commercial deputising services: a randomised control trial.

The process of care

Duty periods for OOH care were randomly allocated to either patient's own GP or Deputising service., in four urban areas, Manchester, Salford, Stockport, and Leicester.

Results

• Practice doctors are more likely to give advice over the phone 20%. In this study HC only gave advice in 1% of patients
• When practice doctors visit at home they get there sooner
• Practice doctors give fewer, cheaper , and more generic prescriptions and prescribe less antibiotics.
• no difference in admission rates

The outcome of care

• between 24 and 120 hours after a request for out of hours care patients cared for by deputising services and practice doctors show no difference in health status
• no difference in health service use between the two groups in the two weeks after a request for out of hours care
• patients were more satisfied with the out of hours care provided by their own doctors in terms of :
  • communication
  • attitude of the doctor
  • delay in visit
  • overall satisfaction

Final conclusion of the study was that in light of the cost to GPs of providing personal out of hours a care, the advantages of practice doctors continuing to provide out of hours care are small in the context of these difficulties.

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BMJ 314 Jan 1987 Nurse telephone triage in OOH primary care: a pilot study

Study took place in two practices in Salisbury covering 10 000 patients.

18 4 hour sessions (14 evening and 4 weekend)

In coming calls were diverted to an experienced practice nurse aided by TAS, Telephone Advise System, a computer based primary care call management system. A printed summary of each assessment was faxed to the GP

56 calls were handled by the nurse.

• No deaths, no hospital admissions, no ambulance calls
• 38% of patients were managed by the nurse without patient/nurse contact with the doctor.
• No triage decision was changed by the doctor
• About a half of calls passed onto the doctor resulted in a house call, one third were dealt with over phone, the rest were seen at the emergency treatment centre
• The majority of patients were satisfied with the system and those who had received advice from the nurse did not express a desire to have spoken to a doctor.

Implications

• ? substitute nurses for doctors in the initial assessment.
• cut down the number of patient contacts with the on call doctor.

Future long-term study under way.

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BMJ 312 June 1996 Responding to OOH requests for visits: a survey of GP opinion

Patient related factors that make visit more likely

• patient says call is urgent
• patient demands a visit
• patient says unfit to travel
• patient has no ready available transport

Patient related factors that make visit less likely

• patient has access to a phone
• patient has a history of inappropriate use of OOH services

Factors relating to GP that make a visit more likely

• not wanting to miss an urgent condition
• wanting to avoid complaints
• wanting to avoid confrontation

GP factors felt no to be relevant to whether a visit is made

• worrying about coping the next day
• worrying about continuity of care
• being concerned about personal safety

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BMJ 314 Jan 1997 A survey of GP cooperatives

124 GP cooperatives were registered with the National Association of GP Co-ops

A postal survey was made of these, 67 replied

Estimated proportion of patient contacts reported as managed by telephone advice, base visit or home visit

Type of service         Range                    Median                   

Telephone advice        10-65%                   38%                      

Base visit              5-70%                    30%                      

Home visit              10-80%                   33%                      

• 91% employed non-medical managers and drivers
• 28% employed nurses
• 57% measured service quality
• 49% had made contact with local CHC
• None had patient participation groups

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BMJ 309 Dec 1994 Out of Hours primary care centres: charateristic of those attending and declining to attend. Cragg et al

• Study of 1000 attenders and 1000 non attenders at 5 PCCs.
• the attendance rate varied from 8.9% to 52% mean 22%
• of non attenders 40% had no transport, 34% said they were too ill to travel
• the number of attenders and non attenders given prescriptions and admitted was equal
• Those who attended were seen quicker and were very satisfied with the service.
• " a substantial cultural change will be necessary before centres can be widely adopted"

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