Out-of-hours visits in a group practice

Out-of-hours utilization in primary and secondary care. A favourable experience in a Finnish health centre

OBJECTIVE

To clarify whether out-of-hours health centre visits and referrals to hospital are equally distributed in the three different duty models being used for health care in southwestern Finland.

DESIGN

A medical audit of 2926 health centre visits and 223 referrals to hospitals by general practitioners (GPs) on duty. The duty models were formed on the basis of a possibility to utilize a local health centre during nights and weekends. Two-month follow-up period.

SETTING

Primary health care. Population 46438.

MAIN OUTCOME MEASURES

Out-of-hours visits to health centres and referrals to hospital, and the effect of age and duty model on referrals and visits.

RESULTS

Patients over 64 years of age received most of the referrals although they visited the health care centre less frequently than the 0-14 year-olds (p < 0.001). The people who had an opportunity to utilize their local health centres visited more during out-of-hours than those who did not have this opportunity (p < 0.001).

CONCLUSIONS

The health centre visits were not equally distributed in the three examined duty models. The over 64 year-olds in particular had the least visits and the most referrals.

Annual night visiting rates in 129 general practices in one family health services authority: association with patient and general practice characteristics

BACKGROUND

Rates of night visiting by general practitioners have increased steadily over the last 30 years and vary widely between general practices.

AIM

An ecological study was carried out to examine night visiting rates by general practices in one family health services authority, and to determine the extent to which differences in night visiting rates between practices could be explained by patient and practice characteristics.

METHOD

The study examined the variation in annual night visiting rates, based on night visit fees claimed between April 1993 and March 1994, among 129 general practices in Merton, Sutton and Wandsworth Family Health Services Authority, London.

RESULTS

Practices' annual night visiting rates varied from three per 1000 to 75 per 1000 patients. The percentages of the practice population aged under five years and aged five to 14 years were both positively correlated with night visiting rates (r = 0.38 and r = 0.35, respectively), as were variables associated with social deprivation such as the estimated percentage of the practice population living in one-parent households (r = 0.24) and in households where the head of household was classified as unskilled (r = 0.20). The percentage of the practice population reporting chronic illness was also positively associated with night visiting rates (r = 0.26). The percentages of the practice population aged 35 to 44 years and 45 to 54 years were both negatively associated with night visiting rates (r = -0.34 and r = -0.31, respectively) as was the estimated list inflation for a practice (r = -0.31). There was no significant correlation between night visiting rates and the distance of the main practice surgery from the nearest hospital accident and emergency department. There was also no association between night visiting rates and permission to use a deputizing service. In a stepwise multiple regression model, the multiple correlation coefficient was 0.56 with four factors (percentage of the practice population aged under five years, percentage aged 35-44 years, percentage who were chronically ill and estimated list inflation) explaining 32% of the variation in night visiting rates.

CONCLUSION

Only about one third of the variation in night visiting rates between practices could be explained by patient and practice variables derived from routine data. Population-based research using data collected on individual patients and practices is required to improve current understanding of the patient and practice characteristics that influence the demand for night visits and of why night visiting rates vary so widely between practices.

Primary medical care outside normal working hours: review of published work

Fundamental changes in the delivery of primary medical care outside normal surgery hours are under consideration in Great Britain. Published research into the provision and utilisation of out of hours services shows long term trends towards decreasing personal commitment among general practitioners and rising demand from patients for primary and hospital accident and emergency department care. Wide variations exist regionally, locally, and between practices. Previous studies, however, have been limited in scope and provide an inadequate basis for assessing the potential impact of change. The overall demand for care across all sources of provision cannot be measured: there is a lack of data on costs, and evaluative studies comparing alternative patterns of service delivery have rarely been undertaken. A period of experimentation and evaluation of a range of options should precede the wider adoption of any particular models.

Daily home visiting in one general practice: a longitudinal study of patient-initiated workload

New requests for home visits performed by one general practitioner were recorded every weekday over 13 years from 1977 to 1989. Overall, a steady reduction in patient-initiated demand for visits was seen. However, longitudinal analysis by age showed that this was statistically significant only in patients aged under 65 years, for whom there was a 71% decrease. There was no significant change in the rates of visits requested for elderly (65-74 years old) and very elderly (75 years and over) patients. In the last year of the study 75% of daily visiting was requested by 18% of the patients, that is by the elderly and very elderly, a sector of the population which is increasing. The findings challenge the prediction that home visits will decline until they eventually disappear. General practitioners in the UK still need to maintain a domiciliary service to their elderly patients.

Out of hours workload of a suburban general practice: deprivation or expectation

The out of hours workload of a training practice in a suburban and semirural area on the south coast of England was studied for one year. An overall rate of contact of 273/1000 patients was found, which indicated a workload greater than that reported in most other studies. The duty doctor received over 35 telephone calls from patients during some Saturdays (1200 Saturday to 0800 Sunday) and Sundays (0800 to 0800 Monday), up to five being between 2300 and 0700. Of the patients who contacted a general practitioner, 44% were given advice by telephone and 4.9% were admitted to hospital. The admission rate was lower than that given in other studies. A considerable proportion of the workload arose from doctors covering the casualty department of a cottage hospital. Patients having a high expectation of 24 hour care by general practitioners in an area of comparative affluence (Jarman indices -13.8 to 1.7) may account for this aspect of the workload.

Twenty four hour care in inner cities: two years' out of hours workload in east London general practice

Two inner city general practices in east London jointly provide care outside normal working hours without using deputising services for about 14,000 patients. The statistics on workload were reviewed for 1987 and 1988. An overall rate of face to face consultations of 4.1 per patient per year was recorded, there being 115,965 consultations over two years for a mean list size of 14,174 patients. Four per cent (4737) of such consultations were outside normal working hours. The annual rate of visiting outside normal hours was 128.1 per 1000 patients in 1987 (1793 visits) and 131.5 per 1000 in 1988 (1888 visits). The rates of night visiting were 18.8 (262 visits) and 18.9 (271 visits) per 1000 patients in 1987 and 1988 respectively. Only 24% of all the requests for medical help out of hours (1483/6220) were dealt with by advice given on the telephone. The high rates of consultation outside normal working hours with only a small proportion being dealt with on the telephone alone may be explained by indices of deprivation. Local rotas for out of hours work are a good compromise between meeting the needs of patients and doctors in deprived areas, but there are financial implications for inner cities.

A study of telephone advice in managing out-of-hours calls

Two doctors in a five-partner urban practice recorded details of their out-of-hours telephone calls for a year. No caller was refused a visit, but 474 of the 809 incoming calls (59%) were managed by telephone advice, an unexpectedly high proportion. Although these callers were instructed to telephone again if still worried, only 40 did so during the same duty period, and only 55% of a smaller sample of patients receiving telephone advice only consulted again within a week. No evident detriment to patients' health was observed. Thirty nine (5%) of the 809 incoming calls were managed by an out-of-hours surgery attendance and 296(37%) by a home visit. The urgency of the visits made was categorized retrospectively as high (34% of visits), medium (39%) and low (27%). It is hoped that this descriptive account will foster discussion of the value and implications of telephone advice in managing out-of-hours calls.

Wide variations in the night visiting rate

The night visit record of an out-of-hours rota service of a large health centre which includes 10 group practices was examined. The mean annual night visiting rate for the health centre was 35.2 per 1000 patients, ranging from 25.8 to 43.5 between individual practices. The organization of medical care at night was the same for all the practices, and no major demographic differences between practices were identified. It is argued that the doctor-patient relationship may have an influence on differences in night visiting rates.

Night calls: an Irish dimension

Night calls made by 17 general practitioners in Cork in the Republic of Ireland in 1980 were analysed and compared with similar studies in the UK. There were 323 night calls: 11 per cent were classified as irresponsible, 59 per cent of which involved patients in social classes IV and V who make up 26.5 per cent of the population of Cork. Young children and the elderly had more calls than expected, and significant sex differences emerged in all age groups apart from the 45-65 age group. The incidence of night calls done comes towards the lower range of studies in the UK.

The doctor's deputizing service in a single-handed practice

The out-of-hours calls received by a doctor's deputizing service on behalf of a single-handed general practitioner were studied over the course of one year.It was found that the overall rate of call (66.3 per 1,000 patients per year) and the rate of night call (10 per 1,000 patients per year) differed little from the rates found by general practitioners who did their own out-of-hours calls. The main users of the service were children under five and women. The time when the service was used least was between 23.00 and 07.00.It is concluded that employing a deputizing service did not necessarily increase the rate of out-of-hours calls, but that the rate was influenced by the age/sex structure of the practice list. The most economical time to employ the service was found to be from 23.00 to 07.00.