The use of out of hours health services: a cross sectional surveyBMJ 1998; 316 doi: http://dx.doi.org/10.1136/bmj.316.7130.524 (Published 14 February 1998) Cite this as: BMJ 1998;316:524
- Catherine Brogan, Consultant in public health medicinea,
- Diane Pickard, research and development specialist nurseb,
- Alastair Gray, directorc,
- Steve Fairman, information managerb,
- Alison Hill, director of public healthb
- a Anglia and Oxford Regional Office NHS Executive, Linford Wood, Milton Keynes MK14 6QP
- b Buckinghamshire Health Authority, Verney House, Aylesbury HP19 3ET
- c Health Economics Research Centre, University of Oxford, Institute of Health Sciences, Oxford OX3 7LF
- Correspondence to: Dr Brogan
- Accepted 22 October 1997
Objectives: To determine the use and costs of the principal out of hours health services in Buckinghamshire.
Design: Prospective cross sectional survey and cost description of patient contacts with out of hours services.
Setting: Buckinghamshire during March and April 1995.
Subjects: General practices, accident and emergency departments, ambulance services, and community nursing services.
Main outcome measure: Contacts with patients and cost of out of hours services.
Results: 438 patient contacts/1000 population/year were recorded at an annual incremental cost of between £4.6m and £7.2m (depending on the costing of general practitioner services), for a population of 660 000. Of these contacts, 21 649 (45%) were with general practitioners. Night time contacts with all services diminished sharply after 10 pm. General practitioners considered that 40% of contacts were unnecessary or could have waited until morning. Over 70% of contacts were for upper respiratory tract infections, earache, gastroenteritis, and other minor ailments. Nursing care was predominantly for elderly people, and 33% of nursing contacts were to supervise medication. Accident and emergency care was predominately for young adults, especially men, and 41% of attendances were for medical conditions.
Conclusions: New models such as multidisciplinary primary care centres with telephone advice lines and triaging are required to ensure high quality, cost effective care that is responsive to the needs of both consumers and professionals.
We studied the out of hours activity of six general practices and the local accident and emergency department in Nottingham for six months
There were wide variations between electoral wards in both general practice and accident and emergency events
Deprivation scores explained more than half of the variation, with out of hours activity being highest in deprived inner city areas
Highly deprived areas close to the accident and emergency department generated high levels of work for both general practice and accident and emergency services, with no evidence of one service substituting for the other
British general practitioners' contracts give them 24 hour responsibility for their patients. The component of total remuneration related to out of hours work has never been made explicit, but such work has increasingly been seen as an important source of stress and low morale among general practitioners,1 2 leading to demands that pay for out of hours work should be explicitly stated and negotiated. This dispute has stimulated interest in the volume, patterns, use, and costs of out of hours health services. Previous studies have documented the increasing demand for general practitioners' services,3 audited the demand for deputising services4 and rates of payments for night visits,5 and drawn attention to the costs of out of hours hospital services such as surgical procedures.6 7
Our study was undertaken to inform debate and future policy in this area by recording the volume and characteristics of all out of hours demands for a broad range of health services and to assess the incremental costs associated with providing such out of hours care.
We contacted all general practices, cooperatives, deputising services, accident and emergency departments, ambulance services, and evening nursing services in Buckinghamshire and invited them to participate in the study: 84% of general practices and 100% of other service providers agreed to participate. The participating general practices were representative in terms of location, size, and other known characteristics, and we adjusted the contacts with general practitioners recorded in the survey by a factor of 1.19 to compensate for the incomplete participation of general practitioners in the county.
We used routine data collection sources and specially prepared data collection sheets to obtain information from each service provider on all out of hours contacts from 1 March to 30 April 1995. The out of hours periods were defined as 7 pm to 8 am on weekdays, weekends (8 am Saturday to 8 am Monday), and bank holidays (8 am to 8 am the next day). We estimated annual rates by calculating the average number of contacts over the study during each weekday night, and during each 24 hour period of weekends and bank holidays, and multiplying by 251 weekday nights and by 114 weekend or bank holiday 24 hour periods.
We estimated incremental costs of out of hours services by identifying the additional or incremental resources required by each group of service providers to provide their services. We attached unit costs to these resources. Thus the items of cost included varied with different service providers, making direct comparison difficult. We calculated unit costs of staff time by using mid-points of salary scales prevailing in April 1995, including all employers' costs. We costed non-staff resources such as transport and accommodation as opportunity costs, using accounting and cost information within each service area. Prices were expressed in 1995 terms.
A total of 47 828 patient contacts were recorded from 1 March to 30 April 1995 during the defined out of hours periods (table 1): 21 649 (45%) were with general practitioners, 12 908 (27%) with accident and emergency departments, 11 318 (24%) with home nursing services, and 1953 (4%) with ambulance services.
Table 2 shows the broad pattern of contacts by out of hours period. For most service providers, over half of weekday evening contacts occurred between 7 pm and 10 pm—that is, before payments for night visits begin (fees can be claimed for visits between 10 pm and 8 am). However, contacts with ambulance services were more evenly spread throughout the evening and night.
Table 3 shows contact rates by patients' age and service provider. Overall, the recorded contact rate was equivalent to 438 contacts/1000 population/year. The contact rates with general practitioners and accident and emergency departments were broadly U shaped with respect to patients' age, while the contact rate with home nursing services rose steadily with age.
Of the 92 general practices in the county, 77 (84%) recorded 18 193 out of hours contacts with patients: after adjustment for non-participation, this was equivalent to 21 649 contacts for the county as a whole. Of the recorded contacts, 7577 (35%) were home visits, 8010 (37%) were surgery visits, and 6062 (28%) were telephone advice. A total of 2963 fees for night visits were paid across the county. On weekdays the number of contacts was highest during 7 pm-10 pm (on average, 51% of contacts occurred during this period). The number of contacts then fell sharply until midnight and remained low until about 6 am.
In the survey we asked general practitioners to classify all contacts, using a four point scale, according to their perceived urgency. Overall, 1082 (5%) contacts were classified as urgent, 11 907 (55%) were considered necessary, 5629 (26%) could have waited until the next morning, and 3031 (14%) were unnecessary.
Diagnostic information was available for 13 555 (75%) of these contacts, and there was no evidence that these were unrepresentative of all contacts. The main diagnostic areas were upper respiratory tract infection (3130, 23%), diarrhoea and vomiting (1646, 12%), ear infections (1051, 8%), chest infections (959, 7%), abdominal pains (641, 5%), skin complaints (611, 5%), injuries (592, 4%), medications (592, 4%), and urinary tract infections (506, 4%).
Accident and emergency services
During the study, 12 908 patients attended the three accident and emergency departments in Buckinghamshire for out of hours care. Detailed information on the source and reason for referral, and mode of transport, was available from the departments for 4651 (37%) of contacts. Of the records that were valid, 79% (3620/4576) were self referred, and the main reasons for attending were injuries (29%, 1325/4651), lacerations (11%, 501/4651), fractures (5%, 225/4651), and foreign bodies (3%, 137/4651). However, the third largest category of referral types (9%, 422/4576) were patients referred by a general practitioner to another specialty, such as medicine or neurology. For these patients, the accident and emergency department was primarily a gatekeeper to the hospital.
A negligible proportion of all patients came via public transport, with 77% (3585/4651) arriving by private transport, 21% (959) by ambulance, and 2% (81) walking. As with general practitioner contacts, just over half (55%) of weekday evening contacts were between 7 pm and 10 pm.
Eight ambulance sites across Buckinghamshire provide out of hours services. During the study, these recorded 1953 out of hours contacts: 1523 (78%) were emergency (“999”) calls, and 430 (22%) were “urgent” calls requested by a doctor. A total of 1523 (78%) patients were transported to hospital, while the rest did not require hospitalisation.
The distribution of ambulance contacts over time was less skewed towards the 7 pm-10 pm period than was the case with general practitioner and accident and emergency contacts: 859 (44%) of the contacts occurred between 7 pm and 10 pm, while 1094 (56%) occurred during 10 pm-8 am.
Three hospital trusts provided out of hours nursing services, from early evening to midnight. The nurses had no formal response role and essentially provided home visits that had been prearranged. Of the total of 11 318 contacts recorded during the study, only 792 (7%) were with new patients while 10 526 (93%) were follow up calls.
Each trust maintained a slightly different classification system for recording information about diagnosis and category of care. However, 3056 (27%) of all visits were for ongoing nursing assessment, advice, and support; 2490 (22%) were related to the control and administration of drugs; 2037 (18%) were for the care of dressings and leg ulcers; 1019 (9%) were for administering eye drops; 792 (7%) were related to palliative care; and 453 (4%) were concerned with continence, bladder, and bowel care.
Table 4 summarises the estimated costs of providing out of hours services during the study and the estimated yearly cost per 1000 patients.
General practice—This was the most difficult service to cost because only a fraction of it is covered directly by fees. The payments for night visits made during the study totalled £145 000, equivalent to £1317/1000 population/year. However, we also made an alternative estimate of cost by calculating the actual fixed and variable running costs of a cooperative providing services in part of the county and then estimating the costs of extending this service across the county. Fixed costs were those for premises, radio, overhead staff, and computing, while fully variable costs were those for cars, drivers, fuel, stationery, and general practitioner session fees. If this service model had been used to provide all general practice services the total cost during the study would have been £587 000, equivalent to £5190/1000 population/year.
Accident and emergency services—Costs were defined in terms of staff employed during the relevant periods. The total cost of medical, nursing, and receptionist staff during the study was £255 000, equivalent to £2290/1000 population/year.
Ambulance service—The total cost, based on staffing costs and variable operating costs during out of hours periods, was £232 000 during the study, equivalent to £2080/1000 population/year.
Nursing services—We identified the costs as those of the staff plus transport and other expenses directly associated with out of hours calls. These totalled £147 000 over the study, equivalent to £1306/1000 population/year.
In total, therefore, the cost of all out of hours health services was equivalent to between £6990 and £10 870/1000 population/year, or a total annual cost of between £4.6m and £7.2m across Buckinghamshire. Although most contacts during weekday evenings occurred during 7 pm-10 pm, only 15% of out of hours resources were devoted to this period compared with 24% allocated to the period 10 pm-8 am.
Table 5 shows the cost per contact by out of hours period and service provider. The highest cost per contact was for the ambulance service, at £119 per patient contact. For general practitioners, the cost based on the general practitioner cooperative model was £27.12 per contact, whereas the cost based on payments for night visits was £6.68 per contact. Accident and emergency and home nursing services had costs per contact of £20 and £13 respectively.
Out of hours health services have developed with little planning or coordination, and the resulting pattern of provision is unsatisfactory to providers such as general practitioners and may not be the most appropriate use of resources. The results of this comprehensive survey of out of hours services give a reasonably accurate quantitative estimate of the numbers, types, and costs of contacts with different services in Buckinghamshire. It provides a basis for considering options for change.
We did not measure cross boundary flows and assumed that the flows in and out were roughly equal. The pattern of local services, cross boundary flows, and seasonal variations should be considered before generalising these findings elsewhere.
Costs of general practitioner services
About a half of all out of hours contacts were with general practitioners, but this service was particularly difficult to cost. Payments for night visits totalled £145 000 during the study, but only 39% of the home visits were made during the defined out of hours periods, and only 14% of all recorded contacts were reimbursed via the system of night visit fees. Hence, many of the costs of out of hours services provided by general practitioners are currently not reflected in night visit fees.
If all the general practitioner services had been provided by means of the model of a local cooperative the cost would have been about £587 000, roughly four times the level of night visit fees. To the extent that cooperative costs are funded by general practitioners from their capitation budgets, this may not be a net cost to the NHS. In practice, extending the cooperative model might be possible only by paying higher general practitioner session fees than those agreed between the general practitioners in the cooperative, in turn increasing the costs of this mode of service delivery.
Our results therefore highlight the need for more detailed assessment of the range of general practitioner cooperatives now in existence. To date, only one evaluation of a general practice out of hours cooperative has been published, and this did not give any information about costs.8 The running costs of the cooperative in our study were at the upper end of the range of development funding requirements reported in a recent brief survey of 36 cooperatives,9 but the comparability of these figures with our study is uncertain. We emphasise that the cost data presented here may not be representative of other cooperative models elsewhere in Britain.
Appropriateness of patient contacts
The general practitioners considered many patient contacts to be fairly trivial. They felt that better information could improve the appropriateness of out of hours contacts: possible channels for communication included media campaigns, handbooks, telephone help lines for all out of hours calls answered by trained staff using protocols to triage patients, recorded advice, and health pages on the internet. Insufficient resources were available to include pharmacists in our survey, but their role in providing advice could also be expanded. Patients could be taught specific skills such as instilling their own eye drops with dropper aids.
Integration of services
Our study raises the issue of skill mix. For example, cooperatives or primary care centres could be multidisciplinary and could triage telephone calls, give advice, and deal with minor injuries. Ambulance workers could be integrated more closely with accident and emergency departments when not responding to emergency calls. Indeed, accident and emergency departments could become the site of primary care centres and use a variety of carers, such as nurse practitioners or paramedics, to deliver appropriate care. Practice nurses could deal with a proportion of calls to general practitioners.10 Many of these models are already being developed and evaluated. The settlement reached on out of hours care during 1996 may be dependent on finding sustainable, alternative patterns of organisation.11
We are grateful to numerous people in Buckinghamshire for their cooperation and assistance in undertaking the survey. Members of the steering group provided valuable advice and comments; in particular, we acknowledge the support of David Olney, accident and emergency consultant, who died suddenly during the study.
Funding: Buckinghamshire Health Authority; Anglia and Oxford NHS Executive Locally Organised Research programme.
Conflict of interest: None.
Contributors: CB initiated and coordinated formulation of the cross sectional survey, discussed core ideas, designed the protocol and data analysis, and coordinated interpretation of data and writing of the paper. DP coordinated the study; discussed core ideas; participated in protocol design and collection, interpretation, and analysis of data; and participated in writing of the paper. AG designed and conducted the economic evaluation, discussed core ideas, collected and analysed costing data, and participated in analysis and writing of the paper. SF designed the database, collated data from various sources, organised the data analysis, and participated in interpretation of data and editing of the paper. AH initiated formulation of the cross sectional survey, discussed core ideas, chaired the steering group, and participated in interpretation of data and editing of the paper. David Eveling participated in design of the database, collated data from various sources, and participated in analysis and interpretation of data. Penny Drewett provided administrative support and entered the data. CB, DP, and AG are guarantors for the paper.