Family Practice Vol. 16, No. 1, 23-27
© Oxford University Press 1999
Responding to out-of-hours demand: the extent and nature of urgent need
LSL Out-of-hours Project, Department of General Practice and Primary Care, King's College School of Medicine and Dentistry and
a Professor of Primary Care, School of Postgraduate Medicine, University of Warwick, Coventry, UK.
Cathy Shipman, Department of Palliative Care and Policy, King's College School of Medicine and Dentistry, Bessemer Road, London SE5 9PJ, UK.
Shipman C and Dale J. Responding to out-of-hours demand: the extent and nature of urgent need. Family Practice 1999; 16: 23–27.
Received 19 May 1998; Accepted 7 October 1998.
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Abstract |
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Background. Little research has been undertaken concerning GPs' perceptions about urgent or ‘appropriate’ out-of-hours demand.
Objective. We aimed to measure GPs' perceptions about patients' need for urgent out-of-hours general medical help according to indicators of physical, psychological/emotional and social need, and the medical necessity of a home visit.
Methods. Twenty-five practices participated in an audit and research study whereby GPs completed an audit form for all contacts during November/December 1995 and February/March 1996. Each contact was assessed according to the indicators of urgent need and GPs commented on reasons for making such assessments.
Results. Audit forms were completed on 1862 patients, and GPs considered that 66.6% (1027) of contacts had either a physically, psychologically/emotionally or socially urgent need for help and were uncertain about a further 10.7% (165). Over half (53.0%) were considered to have an urgent physical need, almost one-third (31.0%) to have an urgent psychological/emotional need and 10.1% (119) to have an urgent social need for help. Over half (55.2%) of visits were considered to be medically necessary, the majority of which (89.9%) were assessed as having an urgent physical need for help.
Conclusions. The findings raise questions about the strategic direction of newer forms of service delivery (GP Co-operatives) and suggest the need for further research to inform the strategic reduction in home visiting, particularly in inner-city areas where many residents have little access to transport out-of-hours to enable them to attend a primary care centre. GP co-operatives are, however, well placed to improve interagency working and cross-referral to other health and social service personnel, and respond more ‘appropriately’ to some psychological/emotional and social problems.
Keywords. Appropriateness, out-of-hours, service development..
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Introduction |
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‘Appropriateness’ in using and providing out-of-hours general medical services is a central and contentious issue in primary care. Demand continues to rise, and new solutions to service provision are being sought,1,2 but little is known about the nature and extent of overall patterns of demand. Perceptions of extensive ‘inappropriate’ or unnecessary demand remain a concern of both GPs and Health Authorities, reflected in patient education measures that have attempted to reduce non-emergency demand.3
GPs' perceptions of ‘appropriate’ out-of-hours calls vary substantially. One review of studies found that between 41–60% of contacts were considered unnecessary, although only 0–8% of night calls were felt to be inappropriate.2 More recently, an audit of eight Mid-Lothian practices found 61% of calls to be classified as necessary and 29% unnecessary, while GPs were unsure about 9%; 61% of patient visits and 55% of telephone consultations were assessed as necessary.4 In a study of out-of-hours contacts in Buckinghamshire, GPs found 5% to be urgent, 55% necessary, 26% to be able to wait until the next morning and 14% unnecessary.5 An earlier study asking GPs to rank factors influencing decision making identified the patients' definition of urgency, demand for a visit or patients' difficulties in travelling to surgeries as major issues. Factors leading to a home visit from the GP's perspective included the need to exclude urgent cases, and to avoid confrontation and complaints.6 ‘Inappropriate’ calls included requests concerning minor illness, repeat prescriptions and chronic complaints that GPs thought could have waited until the next surgery.7 Inability to time the call for help appropriately (whether too soon in the course of the illness or too late in the day if help had not been sought earlier) has also been considered significant.7
This paper describes a study undertaken as part of an out-of-hours audit with a group of practices in south-east London.8 The aims were to understand more about the nature and urgency of out-of-hours demand and GPs' perceptions of appropriateness. It was undertaken in an inner-city area characterized by many indicators of social deprivation including street homelessness, a high percentage of lone parent families and a high proportion of the population, 26%, being from minority ethnic groups, many of whom experience language differences.1
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Methods |
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Practices in the vicinity of King's College Hospital and Lewisham Hospital were invited to participate and collect data on all their out-of-hours contacts for periods of up to 6 weeks during November/December 1995 and February/March 1996. Two different sample periods were used to reflect seasonal variation in out-of-hours demand. Twenty-five practices participated, 15 in the first audit phase and 17 in the second, seven of which were involved in both. The first phase included 61 GPs and the second 66. The practices were recruited to reflect a range of partnership sizes, and in total their registered populations were 135 000 patients for the first phase and 148 640 for the second phase of the study.
Out-of-hours working during the week was defined as the period between evening and morning surgery, and over the weekend, between Saturday morning surgery and Monday morning surgery.
Audit packs and recording forms were devised to assist data collection. The recording forms were used to collect GP assessments of the urgency/medical necessity of contacts, with more qualitative open-ended questions concerning reasons for the decision to visit and contextual information about the contact. Full details of the process and average GP non-completion rate (26.5%) have been reported elsewhere.8 We present here data for 7 weeks over both phases when completion was more comprehensive and when 21 practices were fully involved.
We had originally intended to investigate criteria and perceptions of ‘appropriateness’ from the GP's perspective, but after consideration of findings from other research, we concluded that this was subjective, context-dependent and possibly difficult for GPs to make. We therefore decided to use the indicators of perceived physical, psychological/emotional or socially urgent need for help, and assessments of whether visits were considered to be medically necessary to provide more meaningful and comparable results. Perceived urgency was also indicated by the decision to provide telephone advice or a home visit.
Analysis of quantitative results was undertaken using SPSSpc and chi-square tests of significance. Thematic analysis of open-ended responses was undertaken qualitatively, using the framework approach.9
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Results |
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Out-of-hours demand
In all, 1862 patients were recorded to have made out-of-hours contacts over the 7-week period, of which 58.3% were female. Children under 5 years formed the greatest category of age-related demand (33.5%), disproportionate to their prevalence in the Lambeth, Southwark and Lewisham population (7.6%). Patients aged 5–19 years comprised 17.6% of overall demand and those aged 20–64 years comprised 35.5%. Contacts with patients aged 65 or over were 11.5%, less than expected, given their prevalence within the local population (13.6%) and potential for increased morbidity. The main presenting complaints fell within digestive (29.6%), respiratory (24.4%) and general/viral (34.5%) recording categories.10
Home visits and telephone consultations
GPs visited 60.7% (1130) of patients at home, and provided telephone consultations to 36.9% (688), although there was considerable variability between practices (15.7–69.4%); 2.4% (45) were invited to attend surgery. GPs' comments on their reasons for deciding to visit or to give telephone advice reflected criteria that included the following.
Social categories:
- Age—particularly under 6 months, or the elderly where there may have been confusion or multiple problems.
- Where it was impossible to assess adequately patients over the phone, e.g. language differences, deafness, no telephone or wrong telephone number.
Medical categories:
- Where there was a need to assess the severity of symptoms to exclude a serious condition, where the condition was worsening or where an odd combination of symptoms was reported.
- Where there was a previous history of severe pathology.
Assessments of urgent need could involve a complex number of interrelated factors, for example:
"Mum with twins of one month who lost a toddler to sudden infant death syndrome soon after birth of the twins. This probably affected request and response."
Assessment of lack of urgent need for a visit could be complicated by perceptions of extraneous factors, for example the insistence of the caller:
"Was fairly clear from the telephone conversation that he should have been seen in normal hours. He remained unconvinced and I visited to ensure clinical correctness—very unsatisfactory use of service."
or the need for medication:
"Avoidable if mother had kept stock of usual inhaler."
Other criteria that influenced the decision to visit included where the GP was in the locality, where she/he was uncertain about home circumstances and where contacts had to mind younger children.
Indicators of urgent need and ‘appropriate’ contact
Just over half (53.0%, 791) of patients were considered to have an urgent physical need for help, with almost a third (31.0%, 391) having an urgent psychological/ emotional need; 10.1% (119) were assessed as having a socially urgent need for help. Table 1 indicates that perceptions of urgent physical need for help formed a significantly smaller percentage of contacts who received telephone advice.
No significant difference was noted between those receiving telephone advice or visiting in terms of perceptions of urgent need for psychological or emotional help, although responses were lower for these groups. There was, however, considerable variation in responses between practices (e.g. 17.3–32.8% for urgent psychological/ emotional needs). This may reflect different case mixes as well as differences in perceptions of urgency. Age was a factor significantly associated with assessment of physical need, as 64% (73) of those aged over 65 years were considered to have a physically urgent need in comparison to 47.6% (234) of those aged under 5 years; 50.4% (129) of those aged 5–19 years and 55.6% (266) of those aged 20–64 years (chi-square = 19.81, d.f. = 6, P = 0.003). More families with under fives who received telephone consultations (38.7%, 65) were assessed as having urgent psychological/emotional need, in comparison to those aged 5–19 years (26.7%, 24), 20–64 years (31.4%, 54) and over 65 years (25.7%, 9), (chi-square = 14.84, d.f. = 6, P = 0.022).
Of the total sample, 20.7% (319) were considered to have no physical, psychological or socially urgent need for help. Of those contacts assessed as not having a physically urgent need, 28.1% (146) were assessed as having an urgent psychological/emotional need and 7.4% (34) as having an urgent social need for help.
We asked GPs to indicate whether they considered that home visits had been medically necessary, and responders agreed for over half of contacts (55.2%, 487, range 41.7–81.6%), were uncertain about 16.4% (133) and assessed 26.3% (213) as having no urgent need. Almost all (89.9%) visits classified as medically necessary were assessed as having an urgent physical need for help (Table 2) , but there was no significance difference for assessment of psychological/emotional or socially urgent need.
In total, 6.5% (31) of medically necessary visits were not assessed as having an urgent physical need for help. Seven of these patients were assessed as having a psychologically/emotionally urgent need and two a socially urgent need.
Just over a quarter of patients received prescriptions and 16.8% were advised to see their GP the next day (Table 3). Few were referred directly to hospital, indicating that most contacts are not emergency cases in terms of perceived need for secondary care. Advice and reassurance was a major outcome for contacts (50.6%).
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Discussion |
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GPs participating in this study considered that most (66.6%) out-of-hours contacts had an urgent either physical, psychological/emotional or social need, and the majority (53.0%) were considered to have an urgent need for physical help. This finding is similar to estimates from other recent studies.4,5 Under a quarter (20.7%) of contacts were considered not to have been urgent, and only just over a quarter of home visits (26.3%) were considered not to have been medically necessary. Few (6.8%) patients were referred to hospital at the time of contact, indicating that GPs did not consider a need for secondary care to be the urgency threshold for seeking out-of-hours help.
Just over a quarter (28.1%) of those considered not to have an urgent physical need were assessed as having an urgent psychological/emotional need. This may indicate the prevalence of psychological problems in the population, the extent of anxiety that accompanies illness at a time when usual sources of help and support may be less accessible and the impact that this may have on the ability to cope with physical symptoms. A smaller proportion of contacts (10.1%) were assessed as having a socially urgent need for help, including 7.4% of those with no physically urgent need. These assessments do indicate that certain groups of patients may contact the GP, but require mental health and/or social service support out-of-hours.
Physically urgent need was identified in a higher percentage of elderly patients, and this group was more likely to be visited at home. Psychological/emotional need was identified more often for parents calling out-of-hours for children under 5 years, which may reflect anxiety and concerns about caring for sick children.11
The proportion of cases for whom the GP recorded uncertainty about the urgency of the need for help may in part reflect the methodology of the study, which required participating GPs to respond at the time of the contact rather than complete a questionnaire about past or hypothetical contacts. It is possible that reflection on the spur of the moment raises a wider range of contingency factors that need to be taken into account. Uncertainty about misdiagnosing potentially serious conditions is likely to be a particular feature of out-of-hours working, where most patients access care by telephone and are less likely to be known to the doctor, and the amount and timing of demand are unpredictable. This has been identified as a significant stressor for GPs, and the Chief Medical Officer has highlighted the difficulty of establishing certainty with other than hindsight.12
Although the sample of participating practices was clustered around only two south London A&E Departments8 which might limit the generalizability of the findings, it did comprise a mixture of partnership sizes and arrangements. While on average 26.5% of audit forms were not completed during the total data collection period (a component of gathering data in the out-of-hours period rarely commented on in other studies), the data presented here are from a 7-week period when completion was more comprehensive. It is possible that some missing data may have reflected cases that GPs found particularly difficult to assess, but this is unlikely to have significantly affected the nature of the findings. Duplication of findings at two points in time, despite some differences in the particular practices that were participating in the study, underpins the validity of the data.
The reorganization of out-of-hours care within GP co-operatives has led to a change in form of service delivery, with home visits on average being reduced from 32–23%13 and an increase in telephone and primary care centre consultations. The study was undertaken shortly before a GP co-operative became operational, when 60.7% of contacts receiving home visits and responding GPs considered that over half of these visits were medically necessary. It will be important that comparative research be undertaken within this new form of service delivery, in order to understand the extent to which the form of organization can shape perceptions of urgent need and the extent to which patient needs are being met. Our results raise questions about the strategic shift away from home visiting reported by many GP co-operatives, particularly in inner-city areas where public transport can be severely limited out-of-hours and where only 50% of the population might own a car. The findings also support the need to demonstrate that telephone advice and base consultation are effective alternatives.1,14
While GPs identified a substrata of psychological/ emotional and socially urgent need, this did not appear to be the main criterion for indicating a medically necessary visit. It appears that out-of-hours there may be a more reductionist focus to the consultation than the more contextual and biographical form of medicine which has developed in within-hours general practice,15,16 probably shaped by limitations in time and resources. However, this more reductionist focus on physically urgent need may leave other psychological, emotional or socially urgent needs unmet. The move towards greater interagency working out-of-hours13 should be prioritized, as this may enable greater referral of patients to other services, for example mental health and social services, and this may allow more sensitive and ‘appropriate’ responses to patients' needs.
In conclusion, GPs working out-of-hours have historically worked in isolation both from the primary health care team and from other community health and social service colleagues. This is likely to have shaped the way that they work and their experience of out-of-hours demand. The advent of GP co-operatives and other new out-of-hours arrangements is creating opportunities to consider more broadly the remit of out-of-hours general medical services and strategies of service delivery, but this needs to be informed by a strong research base sharply focused on improved interagency and referral arrangements. Rethinking a strategic and a more-sensitive response to patient demand is a challenge that GP co-operatives are well placed to meet.
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Acknowledgments |
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This study took place within the Lambeth, Southwark and Lewisham Out-of-hours Project. It received additional funding from the Clinical Audit Area Steering Committee and the Medical Audit Advisory Group. Susan Longhurst was the Audit Officer and Florian Hollenbach the Research Assistant. We thank those practices who participated, the patients who agreed to be interviewed, and June Gorman and Steve Smith for their support. Finally we are grateful to the Out-ofhours Project Team for their support, particularly Lynda Jessopp and Fiona Payne.
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References |
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8
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11
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16 Dowrick C. Rethinking the doctor–patient relationship in general practice. Health Social Care Comm 1997; 5(1): 11–14.
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