In many developed countries, the delivery of primary care medical services has gradually evolved into two apparently distinct types of service; in-hours and out-of-hours (OOH). In-hours care has often been equated to routine GP care during the working week, whereas OOH care has traditionally been regarded as that provided by GPs for acute problems and emergencies, often by home visiting.
However, the nature of primary medical care provision has also changed in many other ways in the last 20 years. Now primary care providers work in teams and offer a wide range of nursing and medical services, preventive health care, and screening as well as acute care, from increasingly sophisticated clinic premises.
Many primary care service providers, including GPs, offer their routine services for extended hours over and above traditional Monday to Friday clinic times, effectively working shifts to increase patient accessibility to both routine and acute care. Acute care in this setting may well include both unscheduled clinic appointments and home visiting, and it is this type of ‘in-hours’ same day care that is investigated in the paper by Edwards et al,1 examining a successful change in skill mix by expanding the role of the nurse practitioner.
It is useful to consider in-hours care as full-service (routine and acute) primary care, and OOH care as restricted-service (acute only) primary care, regardless of whether the OOH care is provided by home visiting, at a clinic, or via a telephone advice service.
In the UK, since the introduction of the 2004 GMS contract, when responsibility for OOH care passed to primary care trusts, GPs have been able to opt out of providing this type of care for their patients. Many have, and results from Geue et al's paper suggest that those most likely to re-provide OOH care are most often younger male GPs with dependent families, for whom the desire to raise additional income is attractive.2
The prospect of additional income may be one reason to choose to be a re-provider of OOH care, but there are many factors that make OOH care different from full service in-hours care. For doctors already working full time, especially if also working into the evening to cover extended hours of opening, the prospect of yet more hours holds little attraction. For those with competing demands from family responsibilities (more likely, but not exclusively, for female GPs) OOH care is an added burden that can now be alleviated by opting out of re-provision.
More important than the number of hours worked is the differing nature of the work. When dealing with acutely ill patients in usual in-hours clinic circumstances, the support provided by a competent team in familiar surroundings cannot be underestimated. Not only is the patient likely to be known to the practice, but triage, emergency treatment, and further diagnostic assessment can also be arranged most effectively with the backup of a fully staffed clinic.
In the OOH situation, however, particularly if a home visit or accident scene is involved, the GP must deal with many of these aspects of management alone. The ability to deal with more than one patient at a time is limited, inevitably creating unacceptable waiting times. While there are obvious limitations to OOH service evaluations that rely heavily on patients' perceptions about waiting times, as reported later in this issue,3 they provide an indicator of accessibility and timeliness of treatment. In OOH situations, clinical decision making is inherently more difficult because patients are much less likely to be known, and options for adequate diagnosis and subsequent patient care are more limited. In rural practice, although patients and their social situation may be more known than in urban areas, travelling distances may be substantial and challenging. In either situation, personal safety may be compromised. On-call work in rural areas may well wear GPs down over time. A recent study investigating male GPs' attitudes to rural general practice in New Zealand suggests that, while the challenge and variety of on-call work may appeal to younger GPs, older GPs, despite being more experienced, describe increasing resentment about the continued need to undertake stressful on-call work.4
As Ingram et al describe in their paper in this issue,5 GPs vary considerably in their attitude to risk taking, and this affects OOH referral rates. Variability in risk aversion is also likely to affect GPs' willingness, or otherwise, to tolerate the increased clinical and/or personal risk inherent in OOH work.
Other factors that influence GPs' hospital referral rates in OOH situations include time of day and the site where the patient was seen, with patients seen on home visits and between 11pm and 7am more likely to be admitted.6
In urban areas, the increasing provision of OOH services from dedicated clinics goes some way to alleviating these difficulties, providing a collegial work environment and extra support when needed. However, the clinical risk is still higher than for in-hours care: almost every consultation is with a new patient, previous patient notes are usually not available, and medication and other errors are more easily made. For risk averse GPs who are given a choice, this is a potentially stressful situation best avoided.7
OOH care remains an essential component of primary medical care, regardless of how it is delivered or who delivers it. Acknowledgement that OOH care is different from in-hours care is an important first step; however, simply paying more money to those who provide such care is not the whole answer. Structured support in the way of a clinic base, support staff, ability to discuss problems with others, and provision of intermediate levels of care where appropriate, are all factors that will not only improve outcomes for patients but also enhance job satisfaction for the health professionals who deliver the care.
Now that responsibility for OOH care in the UK resides with primary care trusts, there are new and improved opportunities for better provision of safe and effective OOH care for patients and health professionals alike. OOH care that mitigates both clinical and personal risks as far as possible is best achieved with a well-structured, well-supported, and adequately resourced approach to acute primary medical care.
- © British Journal of General Practice, 2009.