Introduction

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During the past decade, out of hours services have been the object of attention in many countries. In Denmark more and more general practitioners became dissatisfied with the workload during out of hours periods. As a result the whole system was reformed on 1 January 1992. The new agreement was part of a reform that aimed to transfer both costs and working hours from out of hours periods to daytime.

Apart from the out of hours service provided by the general practitioners, casualty departments run accident and emergency services in most hospitals. There is an ongoing debate about how to integrate the two services.

The principles of the reform have been detailed elsewhere.¹ We report the main points of the reform and describe the effects on number of out of hours services, workload for general practitioners, the cost of the service, and patient satisfaction.

The change
Before 1992, there were three main types of out of hours service in Denmark. For many years the patients' own general practitioners provided most of the out of hours services. Later it became common for several practitioners in an area to join a rota system to run the service. In most of the larger towns there was a deputising service, in which a non-medical person answered the telephone and almost all the patients received home visits.

	Methods

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Data were collected by searching the national and international literature for articles concerning out of hours services, and our own earlier studies were also used.² The Danish national health statistics contributed data on economic aspects and the number of services used by the population. These data are highly valid because they are based on accounting figures. The Danish trade union for general practitioners makes regular questionnaire surveys of general practitioners on different aspects of their work (income, workload, etc). The response rates are typically 90%, and the surveys are considered very valid. Many counties in Denmark have surveyed patient satisfaction since the reform, and some of them have comparable studies before the reform in 1992. We report the results of the largest and methodologically best studies.

	Results

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Distribution of services
Figure 1 shows the distribution of the three types of servicea home visit, a consultation at the out of hours consultation room, and advice over the telephone. The reform resulted in a remarkable change in service distribution: home visits dropped from 46% to 18%, telephone consultations almost doubled to 48%, and surgery consultations were relatively unchanged (24% to 33%). The total number of services decreased by 11% just after the reform, but has now reached a level slightly (1%) higher than before the reform.

View larger version (29K): [in this window] [in a new window]   Fig 1.   Out of hours services in Denmark, 1990-65

Economic aspects
The rearrangement of the out of hours service was part of a comprehensive reform in primary health care, which also included an increase in fees for daytime services. Overall, the reform increased the income of almost every general practitioner, and general practitioners now earn a larger part of their salary on their daytime work. Though 9.6% of the general practitioners received more than a third of their salary from out of hours work in 1990, the proportion had fallen to 3.5% in 1993 and 1.8% in 1995. ^{3 4} The expenses for all out of hours services for the whole country decreased by 16% between 1991 and 1992. However, they have now reached a level very close to that of 1991.⁵

Workload
Figure 2 shows that general practitioners' out of hours workload has decreased since the introduction of the reform.³ If some general practitioners in a county like to do more than their share of the out of hours work, some of their colleagues can be let off. The proportion of general practitioners doing no out of hours work rose from 23% in 1990-1 to 36% in 1993-5 (44% of singlehanded practitioners in 1995). ^{3 4}

View larger version (16K): [in this window] [in a new window]   Fig 2.   Out of hours workload of general practitioners, Denmark, 1987-93 3 4

Patient satisfaction
The proportion of satisfied or partly satisfied patients was higher in 1991 than in 1992. Table 1 shows figures from one of the big counties (n=460 000).⁶ Patient satisfaction began to increase again as people got used to the service. In 1995 only 19% were not satisfied, but this is still significantly more than in 1991 (<0.0001). Table 2 shows the distribution of satisfaction for patients attending the out of hours service in 1995 in the county of Vejle (n=330 000).⁷ The patients who did not get the type of service they expected mainly received telephone advice, when they typically expected a home visit. Overall, 72% were satisfied.

	Discussion

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Medical outcome
We could not find any Danish data that compared health status before and after the out of hours reform, but we have no reason to suspect that the reform has changed medical outcomes. A study from Leicester, England, comparing out of hours care provided by patients' own general practitioners and commercial deputising services did not find any differences relating to health status.⁸ It also showed no significant differences in the number of follow up visits, prescriptions, or hospital admissions between patients treated by practice doctors and patients treated by deputising doctors, but an earlier study showed a higher (but non-significant) admission rate when out of hours services were provided by general practitioners from a nearby practice compared with doctors from the patients' own practice.⁹

Distribution of services
The increase in demand for out of hours services is mainly due to an increase in telephone consultations. As well, many calls that previously would have required home visits are now dealt with over the telephone or through consultations. Replacing a high proportion of out of hours contacts with daytime contacts has been shown to be medically safe.^12-14 A study in England found that practice doctors were more likely to give telephone advice than deputising doctors.¹⁵ Other studies have found nearly the same overall visiting rate for doctors from the practice and doctors from a practice nearby.⁹ To give proper telephone advice, it is crucial that experienced general practitioners undertake the telephone triage.

Workload
The workload for individual general practitioners has decreased considerably. The finding that about a third of all general practitioners have no out of hours work at all will probably remain constant, reflecting the difference between young general practitioners, who would like to do more out of hours work to earn more money, and older ones, who prefer more spare time. In addition, many general practitioners express their satisfaction with the new type of contact with their colleagues. In the United Kingdom in 1989-90, general practitioners had an average of 26 hours on call, but nearly a third of the general practitioners had no regular out of hours work.¹⁶

Patient satisfaction
The decrease in patient satisfaction is disappointing, but satisfaction is now rising again. Part of the explanation could be that the population has been given far too little information about the background for the reform, and also that politicians failed to tell the public about the intentions of the new arrangement. As one might predict, most of the unsatisfied patients did not have their expectations fulfilled. In time, when people have expectations that match reality better, overall satisfaction will probably be even higher. Nevertheless, patients adjusted quite easily to the changes, and patients' evaluation is acceptable, with 72% satisfied. The Leicester study showed an overall satisfaction score for practice doctors of 71% and for deputising doctors of 62%.⁸ Comparisons should be made between care provided by different types of out of hours services. We are planning to compare Denmark and Britain by using a Danish version of a new English questionnaire that measures patient satisfaction with out of hours primary medical care.¹⁷