Summary of main findings and comparison with existing literature
This study estimated that around 2% of calls to the out-of-hours service are by patients with cancer, of which around a half (56%) have advanced cancer and/or palliative care needs. This figure is conservative, as 15% of cancer calls could not be classified due to a lack of information on cancer staging. Electronic searches will also have missed around 1.3% of all calls in cases where the patients had died and where death was expected, but where the cause of death was not recorded. National (English) data suggest that around one-quarter of these calls might be attributable to cancer.17 The figures in the present study are broadly comparable to those of a previous study of out-of-hours cooperatives, which identified that 2.1% of all calls were for palliative care patients (any cause).18
The out-of-hours service experienced a substantial increase in call rates after the implementation of the new contract, although the proportion of cancer-related calls remained constant. The increased demand is probably attributable to the standardisation of the working hours around the time of handover between in-hours and out-of-hours services, combined with the loss of Saturday morning clinics provided by general practices.
Contrary to widespread concerns expressed among the primary care community,2,9,10 while the introduction of the contract may be associated with increased demand for out-of-hours care, there is no conclusive evidence that the demand from patients with complex needs altered disproportionately; rather it is likely that these patients were simply seeking help from the primary care service available to them at the time at which their needs arose (for example, on a Saturday morning).
Statistically significant changes in the proportions of callers receiving different management and follow-up options were observed, although care must be taken when interpreting the clinical significance of these changes, given the large sample available for analysis. Stability of the proportions of callers who received a home visit or who were admitted to hospital suggests that, although the service has experienced increased demand (all causes), this did not result in negative sequelae such as spiralling hospital admission rates or greater difficulties in accessing a home visit for callers with cancer.
Changes in some outcomes, such as the decline in out-of-hours clinicians who definitively resolved the care episode, could be consistent with reduced quality of care. However, an alternative explanation is more credible for some of these changes, namely that clinicians have simply altered their use of certain categories across time (for example, ‘refer to in-hours GP for follow-up’ is increasingly used now in preference to ‘patient definitively managed by out-of-hours service’). The latter explanation cannot, however, account fully for the reduction (absolute decrease of 3.1%) in the proportion of calls where the out-of-hours clinician issued a special message direct to the in-hours team to alert them to important clinical information. In the absence of reliable data on case-mix severity, it is impossible to interpret these changes more fully. Notwithstanding this, the observed decrease in inter-agency communication is likely to be detrimental to the continuity of patient care.
Perhaps the most conclusive evidence that the implementation of the contract may have detrimentally had an impact on patient care for individuals with complex care needs, was the observed increase in the time taken to start of triage. Unfortunately, data were not available for all patients (any cause) to explore if this pattern was specific to patients with complex needs, or simply reflecting more widespread changes. Although patients with cancer had to wait longer until the start of triage, once the clinical care had commenced there was no change in the length of time taken to resolve the care episode. Difficulties in some providers meeting the national quality requirement response times have recently been highlighted.3 This finding is particularly interesting given that Devon Doctors was one of the minority of providers nationally that satisfied this requirement, whereby over 95% of all calls were triaged within 60 minutes (Avery S, personal communication, 2007).
Strengths and limitations of the study
This study explored changes in the use of out-of-hours primary care services before and after the implementation of the new contract, for patients with cancer. This group was selected as a proxy for the wider population of patients with complex needs, who may be most at risk under the new arrangements.10 Working with a large, not-for-profit provider, the researchers had access to a large, relatively stable population of urban and rural areas composed of socioeconomically diverse communities, although with limited ethnic minority representation.
There are several limitations to this study design. First, the observational design does not allow testing of hypotheses or establishment of causal relationships between the implementation of the new contract and changes in service usage. This issue is common to any study seeking to understand the impact of major policy initiatives on the organisation and delivery of healthcare services, which, by the nature and complexity of the policy implementation, are not readily amenable to more controlled empirical designs. Second, the study restricted its cohort to patients with cancer as at the time of sampling, and the information system (Adastra software) used here (and by more than 95% of English out-of-hours providers) only recorded case-mix data through text fields, with each call treated separately and no electronic linkage by patient.
Implications for clinical practice
Due to the observational nature of this study, it is only possible to speculate on the explanations for the complex changes observed. The magnitude of the increased demand (all causes) at follow-up is unlikely to be replicated in subsequent years as the rationalisation of service operating hours is complete. Despite this, the study found evidence that quality of care for patients with cancer had been adversely influenced under the new arrangements.
Out-of-hours providers face substantial, practical difficulties in identifying patients with complex needs, and particularly those with palliative care needs (in part, due to the inherent challenge in documenting when curative treatment finishes and palliative care begins).19 It is vital that the software evolves to allow audit and possible targeting and monitoring of vulnerable groups if key goals, such as ‘around the clock’ effective inter-agency communication10,18 embedded within NHS primary care policy and practice, are to be realised. Software has recently been developed to support clinicians by automatically linking the current call to details of previous contacts made by the patient. However, increased use of electronic coding (such as Read codes) by health professionals entering clinical data would simplify the process of identifying patients with specific morbidities.
In-hours primary care services also have an important role. Systems already exist to allow special alerts to be sent to out-of-hours services, providing them with vital information to support patients with complex care packages,20 although previous research has identified that they remain under-used.18 New incentives outlined in the Quality and Outcomes Framework (2006),19 including the identification of patients suitable for inclusion on a palliative care register,21 and regular multidisciplinary team meetings to review such patients, provide an ideal mechanism to facilitate greater use of special alerts to out-of-hours services.9
