Family Practice Vol. 17, No. 4, 340-347
© Oxford University Press 2000
Review |
The demand for out-of-hours care from GPs: a review
Division of Primary Health Care, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.
Salisbury C. The demand for out-of-hours care from GPs: a review. Family Practice 2000; 17: 340–347.
Received 22 December 1999; Accepted 13 March 2000.
Abstract
Background. The perception of a relentless increase in demand for out-of-hours care has led to the development of new models of organization. A comprehensive review of the evidence about the demand for out-of-hours care has, however, been lacking.
Objective. The aim of this study was to review all published work relating to out-of-hours care in UK general practice which included data about the demand for care, and the variation in demand.
Methods. Searches were conducted in MEDLINE (1966–December 1999) and EMBASE (1988– October 1999). Further references were identified from those cited in papers, and by use of the Science Citation Index to extract articles which cited key papers. Information about night visit fee claims was also obtained from the NHS performance indicators. The review was restricted to research in the UK published since 1959.
Results and Conclusions. The activity of GPs has been used as a proxy indicator for the demand for out-of-hours primary care. Most research has been based on claims for night visit fees, which reflect only a small proportion of all out-of-hours care. Night visit rates vary widely between areas, practices and individual doctors, for reasons which remain largely unexplained. There is evidence that levels of provision of out-of-hours care have risen considerably, but the wide variation between areas, and differences between studies in terms of definition and methodology, make it difficult to confirm this finding. The recent use of electronic call management systems by general practice co-operatives allows an accurate assessment to be made from routinely collected data of the total demand for out-of-hours care. This information will make it possible to assess the impact on general practice of new models of service provision, such as NHS Direct and primary care walk-in centres.
Keywords. Family practice, house calls, night care, primary health care, time factors.
Introduction
The organization of primary care services when GPs' surgeries are closed has undergone revolutionary change in the UK in recent years, and this process will continue with the expansion of NHS Direct and the establishment of primary care walk-in centres. These changes have occurred partly because of a perception of a relentless increase in patient demand. The increasing unwillingness of GPs to meet this demand led to contractual changes and the exploration of new models of care.1
However, the evidence that demand is actually rising is unclear. In her influential review of primary care outside normal surgery hours, published in 1994, Hallam noted the absence of reliable data on this topic.2 This review therefore sought to identify all published research which enabled an estimation of the demand for out-of-hours care from GPs.
Method
The initial literature searches were conducted in MEDLINE (1966–October 1999) and EMBASE (1988– August 1999) using combinations of the terms primary health care, family practice, house calls, night care, time factors and the text words out of hours, deputizing, co-operative and [(night or late) and (visit or call)]. Studying the reference lists of retrieved papers led to the identification of further articles. A limit to this process was made by not retrieving any papers published earlier than 1959. A review of articles published before 1959 is provided by Clyne.3 Studies were also identified by using the Science Citation Index to extract articles which cited key papers. The review was restricted to research in the UK.
The review of paper-based publications was supplemented by information about night visit fee claims obtained from the NHS performance indicators, published until 1995 on computer disc. These show the total cost of night visit fees in England and Wales, and the total population.4 The number of night visits can be calculated by dividing the total sum paid in fees by the fee payable at the time. After 1990, a higher rate was paid for visits carried out by GPs working in rotas of <11 doctors, and a lower rate for visits carried out by deputizing services or doctors in larger rotas. The calculation therefore needed to be made separately for high and low rate fees and then totalled to calculate the total number of visits. The differential fee also enabled a calculation of the proportion of visits carried out by deputies (or in rotas of >10 doctors).
Operationalizing the concept of patient demand
The concept of demand generally has been equated with measures of the activity of GPs, deputizing services and co-operatives. This assumes that patient demand always results in contact with a doctor, and ignores the possibility of ‘frustrated demand’ if patients are unable to access care. In an interview study involving 1897 respondents in Manchester in 1982, 23% of those who had tried to contact a GP at night or weekends found it difficult,5 and a more recent study using a ‘rapid appraisal’ technique in London identified widespread difficulties.6 Apparent increases in demand as measured by doctor– patient contacts may reflect improved accessibility, for example as more people have access to telephones in their homes.
Secondly, GPs may alter their behaviour and activity in response to the same level of patient demand. For example, doctors may be more likely to offer home visits instead of telephone advice over a period of time because of medico-legal considerations. These issues have been neglected in the published research, which has focused almost entirely on measures of activity.
A large number of studies have sought to measure the demand for out-of-hours primary care, but there are considerable difficulties in evaluating the findings. The research has been carried out in different settings, over different time scales and using different methods. The results are also presented in various ways. In some cases, contact rates per 1000 registered patients per annum are quoted, in other cases these have been derived for this review in order to produce comparative data. Some studies have been based on periods of <1 year, in which case annual rates have been calculated assuming that demand is spread evenly throughout the year.
Night visits and all out-of-hours visits
Many studies have used night visit claim rates as a proxy indicator of demand, since these data are available nationally, and clearly defined. However, this gives insufficient attention to the fact that contacts at night are far fewer than calls during evenings, weekends and bank holidays, and that visits only represent a proportion of calls from patients at night (as many patients are advised by telephone).7 Night visit rates can therefore be used to compare different practices, areas or years, but not as a proxy for total out-of-hours demand.
The definition of a night visit has changed several times. Between 1967 and 1972, a fee was paid for visits requested and made between midnight and 07.00, which changed to 23.00–07.00 from August 1972 to April 1990, and to 22.00–08.00 from 1990 onwards. Reports based on night visit fee claims also discount the possibility of underclaiming of fees. Where studies have not been restricted to night visits, the definition of the out-of-hours period has varied.
Out-of-hours visits and all out-of-hours contacts
Although many early studies of out-of-hours care only recorded visits, others have recorded all contacts with a doctor, such as telephone calls, and attendance at the surgery or the doctor's home. A few reports have also included out-of-hours contacts at rural casualty departments, manned by GPs.
Studies which use visit rates as a measure of demand do not take account of the effect of varying rates of telephone advice. In studies of GPs providing care personally (rather than via a deputizing service or co-operative), there are major differences between contact and visit rates, with some doctors visiting >80% of callers,8–10 but others visiting <50%.11–13
Uncertainty about the denominator
The denominator for rate calculations is the patient population covered by the practice or service concerned. In some studies, this is based on the registered list of patients, but in other studies the patient population has been estimated with few details given about the basis for the estimation. Allowance has rarely been made for list inflation, which varies widely between areas and over time. Sensitivity analysis could be performed to show how rates of demand vary if different assumptions are made to estimate patient list sizes, but this has rarely been done.
Practical difficulties in the assessment of demand for out-of-hours care
Before the advent of electronic call management systems, there were considerable difficulties involved in determining the true total number of out-of-hours calls, including those leading to telephone advice and those visits which did not attract night visit fees. Studies depended on accurate data collection by GPs, usually working from their homes. Studies in one practice have limited generalizability, but multipractice studies require a large number of doctors to take part, who will have varying commitment to the study. Under-recording should be anticipated, particularly of telephone calls for advice, and it is very difficult to assess the extent to which this may have occurred.14 Studies of deputizing services are likely to present more reliable data, but such studies rarely acknowledge the fact that many doctors only use deputizing services for some of the time.15
An accurate measure of demand would record all out-of-hours contacts (including visits, telephone advice and consultations at the surgery or doctor's home), and would include all calls received from patients outside normal surgery hours. In order to calculate a rate, it is important to have accurate information about the denominator, which is the practice population covered. Few studies provide all of this information.
What is the demand for out-of-hours care from GPs?
Table 1
details the information about patient demand which could be obtained from all identified studies. The studies are listed in chronological order according to when the research was carried out, not by publication date.
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The table of data obtained from a range of studies presents an initially confusing picture, reinforced by the different time periods included in different studies. Research carried out in individual practices shows enormous variation in demand, but more recent studies across larger districts, and which include all types of out-of-hours contact, continue to show considerable variation between areas. Many of the individual practices report higher levels of demand than the district-wide studies, and it may be that these authors choose to audit and report their out-of-hours work because they are conscious of the high level of demand in their practice, as illustrated by the letters from Main and Main9 and Robinson.42
Characteristics of demand
Many of the descriptive studies provide useful data about the pattern of patients using out-of-hours services, and several consistent findings emerge. There are a disproportionate number of calls from parents of children aged under 5 years of age, representing up to a quarter of all out-of-hours calls.10,12,19,28,33,35,40,53–55 These calls are most frequent in the evenings.17,53,54 Call rates are lowest for older children and young adults, and steadily rise with increasing age.10,19,28,35,40,55 Calls about children more often result in telephone advice, whereas elderly patients are more likely to be visited.12,53,54,56 More calls are received about female than male patients,17,19,29 although some reports suggest that calls about young children more often involve boys than girls.19,53,55 In studies which categorized presenting complaints into diagnostic categories, the most common reasons for calling were upper respiratory tract infections, diarrhoea and vomiting, childhood fevers and minor injuries.10,12,16,19,28,29,33
Times at which calls are made also show a consistent pattern, with more than half of all night calls occurring before 1 a.m.16,17,19,41,53,55 Call rates are higher on weekend nights than on weekdays.28,34,39 Reports about a seasonal variation in calls are surprisingly contradictory.10,16,17,53,55 This may be because no studies presented monthly rates of calls over more than one year.
Variation in night visit rates
Comparisons between areas
The wide variation in night visit rates demonstrated in Table 1
has long been recognized, and research to describe and examine this phenomenon falls into two main groups. Some studies have used routinely available data and regression analysis to identify factors which appear to explain variations in the night visit rate. Other studies have been carried out at local level, and these describe variations between different doctors in the same practice or different practices in the same health centre.
The first of the large-scale national studies was carried out by Buxton et al.,21 who showed that the number of estimated visits per 1000 patients increased from 4.3 in 1967 to 10.1 in 1975–1976. Within these national averages, there were large differences between areas, with a range in 1973–1974 from 17.0 per 1000 in Tynemouth to 3.8 per 1000 in Northampton. The highest rates generally occurred in northern industrial cities. Regression analysis was used to assess the effect of supply factors (e.g. average list size, proportion of single-handed practices, use of deputizing services, proportion of GPs aged >50 years) and demand factors (e.g. the proportion of young and elderly patients in the population, infant mortality, birth and death rates, social class, one-person households) on night visit rates. It was found that the most important factors were the proportion of GPs with permission to use deputizing services, and the proportion of the population in social class V. Generally, supply factors had more impact on night visit rates than demand factors, but all variables in the model only explained 43% of the variation.
A similar study was carried out to explore variation in night visit rates between all 148 practices responsible to Nottingham Family Practitioner Committee.30 Practices were classified according to the type of area, use made of deputizing services, number of partners and practice list size. These variables only accounted for 16% of the total variance, with use of deputizing services accounting for 12% of the variance. Although this study is widely quoted to support the view that use of deputizing services is the main factor leading to higher night visit rates, an alternative interpretation would be that deputizing use appears to have only a minor impact, and that other so far unexplained factors are more important.
Since 1990, three further studies have used the wider range of information now routinely available about individual practices and have carried out multiple regression analyses to attempt to explain the observed variation in night visit rates.43,45,57 Although the details of the studies vary, the important factors appear to include the population standardized mortality ratio,57 unemployment rates43 and other indicators of deprivation,45 average practice list sizes,43,57 the proportion of GPs aged >65 years,57 the proportion of the population aged under 5 years45 or recorded as having a limiting long-term illness,45 and practice list inflation.43,45
It is noteworthy that none of these studies found any association between night visit rates and permission to use a deputizing service, and all found that the Underprivileged Area Score did not contribute to the equation significantly, even though it was designed as an indicator of general practice workload.58
In contrast to the above studies based on night visit claim rates, a recent study has carried out a similar analysis but using all out-of-hours contacts as the dependent variable.49 This study suggested that several indicators of deprivation (areas with overcrowding, unemployment, more non-owner-occupied housing, low car ownership, increased ethnicity and more single parents) were associated individually with higher rates of out-of-hours contacts with GPs. The Underprivileged Area Score explained 58% of the variation in rates between 23 different electoral wards.49
Comparisons between doctors or local practices
An alternative approach to understanding the issue of the variation in out-of-hours calls rates is to consider activity in one practice or centre. These studies have supported the finding that patients living in deprived areas place considerably greater demands on out-of-hours services.24,40 Carlisle et al. compared the night visit rates of patients from the same practice in different electoral wards in Nottinghamshire,40 and found that the Townsend score59 (a measure of deprivation) and the unemployment rate explained 49 and 31% of the variation, respectively.
Finally, Usherwood et al. compared night visit rates in 10 group practices sharing the same health centre, taking patients from the same geographical area and sharing the same out-of-hours call rota.31 They found a 2-fold difference in night visit rates between the practices, which was not accounted for by different age distributions of patients, practice size or chance. This suggests that differences in practice organization may contribute to the variation in the out-of-hours demand.
Although there are important differences between the above studies, several conclusions can be drawn. Night visit rates are generally increased in areas with high levels of illness (evidenced, for example, by high standardized mortality ratios or numbers of patients with a chronic illness) and social deprivation, and in populations with a high proportion of young children (although not all studies support this).40,53 Areas with high list inflation not surprisingly have lower night visit rates. The importance of deputizing services is small but statistically significant according to some studies, but insignificant in others. Other factors in practice organization may be important. All studies show very wide variation both between different practices in an area and between different areas, and much of this variation remains unexplained. Similar findings have been reported when all home visits (including those in normal hours) are studied.60
Many authors have suggested a wide range of factors about which information is not routinely available, which might have an important bearing on out-of-hours call rates. These include cultural expectations of different populations, local social support networks, other local sources of help [particularly hospital accident and emergency (A&E) departments], the availability and accessibility of doctors in normal working hours, GPs consultation skills and organizational arrangements such as the use of appointment systems.9,10,37,39,61,62 Little or no evidence is available to support these opinions.
What proportion of out-of-hours primary care is provided by general practice?
It is important to note that the use of activity data from general practice underestimates the true level of patient demand for primary care when doctors' surgeries are closed. A proportion of patients may contact A&E departments directly, and this proportion may vary in different parts of the country. Dixon and Williams studied GPs, deputizing services and hospital A&E departments in four urban areas in England in 1984.63 They suggested that 45.2% of patient encounters for primary care in the out-of-hours period occurred in A&E, 27.5% with doctors in a practice rota and 27.2% with a deputizing service or a co-operative. There are a number of problems with this study, including the definitions used for ‘hospital’ and ‘primary care’ cases, and the likely under-recording of telephone consultations by GPs.
More recently, Brogan et al. attempted to map all organizations providing out-of-hours medical and social care across Buckinghamshire, including GPs, A&E departments, ambulance, nursing and social services.14,64 This ambitious study attempted to record all out-of-hours contacts in March and April 1995. The authors concluded that GPs were the main providers of care, being involved in 45% of contacts, followed by A&E departments who dealt with 27% of contacts. This conclusion is broadly supported by a study which analysed out-of-hours contacts with GPs and the A&E department made by patients from six practices in Nottingham.49 Almost two-thirds of contacts (64%) were with GPs, and 36% were with the A&E department.
A study of out-of-hours contacts in London suggests that the balance between calls to GPs or the A&E department is related to the age of the patient and the time.65 The majority of out-of-hours calls about children under the age of 10 years were made to GPs, but young adults were more likely to contact A&E. In the early hours of the morning, most out-of-hours calls were made to A&E, but during the day at weekends most callers contacted GPs.
Is demand rising?
The data shown in Table 1 suggest that out-of-hours contact rates have been rising, although the variation recorded in different studies, the changing time period attracting night visit fees and the different methodologies used make this unclear. The only study to analyse night visit rates in one area over several years suggested a consistent rise in night visits over one decade.41 This is supported by the data derived from the health service indicators, shown in Figure 1.
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Conclusion
The activity of GPs has been used as a proxy indicator for the demand for out-of-hours primary care. The only reliable data historically come from studies of night visit rates which represent only a small proportion of all out-of-hours visits, and a smaller proportion of out-of-hours calls due to the use of telephone advice. Night visit rates vary widely between areas, practices and individual doctors. The reasons for this variation remain largely unexplained but may be related to areas having higher levels of illness and deprivation, differences in the age profile of populations and the use of deputizing services. There is some evidence from the literature and from NHS payment data that levels of out-of-hours care are rising, but the wide variation between areas, and differences between studies in terms of definition and methodology, make it difficult to corroborate this finding.
The recent use of electronic call management systems, and the widespread development of co-operatives which take all out-of-hours calls on behalf of large numbers of general practices, makes it now possible to obtain accurate data about the total demand for out-of-hours care.53 Using this information, it will be possible to assess the impact on general practice of changes in the provision of out-of-hours services, such as the telephone helpline NHS Direct, and walk-in primary care centres which are open during the evenings and at weekends.
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