Responding to out of hours requests for visits: a survey of general practitioner opinionBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7043.1401 (Published 01 June 1996) Cite this as: BMJ 1996;312:1401
- B V Court, senior registrarac,
- C P Bradley, senior clinical lecturerb,
- K K Cheng, professor of epidemiologya,
- R J Lancashire, computer officera,
- R J Lancashire, computer officer
- a Department of Public Health and Epidemiology, Medical School, University of Birmingham, Birmingham B15 2TT
- b Department of General Practice, University of Birmingham
- c Correspondence to: Dr
- Accepted 6 February 1996
In response to the mounting pressure of out of hours care, the terms of service for general practitioners in the NHS have been modified to emphasise that professional judgment should guide whether a consultation is required (based on the patient's medical condition) and if so, when and where the consultation should take place.1 Comprehensive searches of four literature databases revealed little about the nature and relative importance of factors which influence practitioners' judgments when responding to out of hours requests for visits. One small study found that a potentially serious diagnosis was the most common reason for out of hours visits but that in less clearcut cases the expectations and non-medical needs of patients also played a part.2 The objectives of our study were to identify the main factors which influence general practitioner principals when making decisions about requests for out of hours visits and to find out whether they would welcome guidelines.3
Subjects, methods, and results
Eligible subjects were 720 general practitioners who were listed as providing general medical services in the three health authority areas of Coventry, South Staffordshire, and Shropshire and 16 general practitioner registrars in these areas.
Focus groups were used to identify a preliminary set of 13 factors that might influence the decision to visit. These were incorporated in a questionnaire, pilot versions of which were modified after a trial.4 Practitioners were asked whether guidelines would help them in making decisions about out of hours visits and whether each of the 13 factors would tend to make a visit more likely or less likely or was not relevant. They were then asked to rank up to five factors in order of importance in terms of influencing their decisions.
Data were analysed with SPSS-PC. Characteristics of respondents were compared with data for England and Wales where available, using hypothesis tests for single proportions.
In response to the two mailings in May 1995, 72% (532/736) of questionnaires were returned. Nineteen questionnaires were discarded: the practitioners stated that they had made no out of hours visiting decisions during the past year or that they were retired. Significantly more of the respondents were trainers (21%) than in data for England and Wales (12%), and 37% defined out of hours in accordance with the official definition (from 7 pm to 8 am weekdays and from 1 pm Saturday to 8 am Monday). Only 38% of respondents thought guidelines would be helpful.
Table 1 summarises how respondents thought each of the 13 factors would affect out of hours visiting decisions. Ranking of up to five factors revealed that the most important factor to influence decision making was “if the patient (or someone on their behalf) says that it is urgent,” closely followed by the practitioner “not wanting to miss an urgent condition.” Demands for a visit were ranked third, followed by the “patient (or someone on their behalf) saying that the patient is unfit to travel.” The fifth most important factor was “wanting to avoid complaints.”
Our findings suggest that factors other than purely medical ones influence practitioners in making decisions about out of hours visits. The fact that guidelines on visiting are not generally welcomed may reflect the difficulty of producing comprehensive advice which incorporates such additional factors. Although the two most important factors relate to the concept of urgency, general practitioners and patients may have different perceptions about what constitutes “urgency” and whether a patient is thought to be fit to travel. Visiting policies that are uncritically demand led are a source of excessive workload.5 Inappropriate fear of complaint is likely to potentiate inappropriate demand for out of hours visits. Further research might usefully explore how such defensive medical practice can be modified to benefit both patient and practitioner.
We thank all the general practitioners who participated in the study, Pam Bojczuk for help with data handling, and Dr J Walsworth-Bell for advice and support.
Funding South Staffordshire Health Authority. Conflict of interest: None.