Changing the pattern out of hours: a survey of general practice cooperativesBMJ 1997; 314 doi: http://dx.doi.org/10.1136/bmj.314.7075.199 (Published 18 January 1997) Cite this as: BMJ 1997;314:199
- Lynda Jessopp, Project managera,
- Imogen Beck, project officera,
- Lisa Hollins, service development managera,
- Cathy Shipman, research fellowa,
- Mark Reynolds, secretaryb,
- Jeremy Dale, project leadera
- a Lambeth, Southwark and Lewisham Out of Hours Project Department of General Practice and Primary Care King's College School of Medicine and Dentistry London SE5 9PJ
- b National Association of General Practice Co-operatives c/o Maiddoc Royal British Legion Village Aylesford Kent ME20 7SE
- Correspondence to: Ms Jessopp
- Accepted 22 November 1996
Since early 1995 substantial changes have been taking place in general medical services provided out of hours. A package of revisions to terms and conditions have been agreed, including reimbursing night visits uniformly wherever they occur, permitting transfer of responsibility to another principal, and providing a development fund.1 The number of out of hours cooperatives registered with the National Association of General Practice Co-operatives rose from six in 1990 to 124 in October 1996. Cooperatives are “non-profit making organisations entirely owned, and medically staffed by, the general practitioner principals of the area in which they operate.”2 We surveyed registered cooperatives to investigate the extent of change and likely future directions.
Methods and results
In May 1996 a postal questionnaire was devised after an initial telephone survey of 20 cooperatives and sent to all 98 organisations then registered with the national association. Sixty seven responses (68%) were received after two reminders. There was a slight bias towards smaller and newer cooperatives. Respondents represented 5476 general practitioners covering 11 462 500 patients.
Fifty two (78%) cooperatives were established during 1995-6 and 19 (28%) had been operational for under three months. General practitioner membership in each ranged from 20 to 256 (mean 82; median 67), most cooperatives (47; 70%) having under 100 members. Sixty one cooperatives (91%) reported support from out of hours development funds in 1995-6. The average received was £108 399 (range £10 000 to £400 000).
Home visits were provided by all cooperatives, 63 out of 64 (98%) offering telephone advice and 62 of 64 (97%) offering base consultations also. Table 1) gives the proportion of calls estimated as dealt with by home and base visits or telephone advice. Five cooperatives (8%) reported over half of calls as resulting in a base consultation. Fifty three (83%) estimated that under half resulted in a home visit.
Of all 67 respondents, 61 (91%) employed non-medical managers, administrators, and drivers whereas only 19 (28%) reported employing nurses or nurse practitioners. Thirty eight cooperatives (57%) reported measuring service quality but only 23 (34%) had agreed quality monitoring standards with their health authority. Almost half of the cooperatives (33; 49%) had contact with community health councils but none reported patient participation in cooperative development.
Thirty six (54%) cooperatives anticipated needing between £16 000 and £489 000 (mean £152 644) of development funding in 1997-8. Plans included extending the scope of services, training for members, introducing protocols, employing nurses, establishing interagency links, and tackling access issues by the provision of patient transport. Development funding would also support core costs, subsidise salaries, and maintain low fees.
Out of hours cooperatives have nearly tripled in number since 1995. Almost all provide telephone advice, base consultations, and home visits but they differ in size, staffing, and levels of funding. Many cooperatives are very new and some differences may be attributed to stages of development.
The survey raises key issues about future directions. It suggests that a substantial shift is occurring away from home visiting and towards increased telephone advice and base consultations. Attendance at cooperative bases may be higher than previously reported.3 Patients may be more willing and able to travel than expected, a cultural shift in public attitudes may be occurring, or there may be a combination of the two.4 We found high levels of commitment to ensuring user feedback and quality monitoring. Cooperatives have the potential to become important stakeholders in negotiating funding, location, and type of service delivery and may appreciably alter the balance of power at local and national levels. Therefore, it seems crucial that there should be national public debate to examine appropriate standards, levels of telephone advice, and base visits as well as to consider ethical issues in defining “need” and “urgency.”5
Funding: The out of hours project is funded by Lambeth, Southwark, and Lewisham Health Authority.
Conflict of interest: None.