Out of hours primary care

Variable service provision means inequalities in access and care

The six papers on out of hours care published in this week's BMJ highlight the increasing variability in primary care services available to patients outside normal surgery hours. Variations in the quality and acceptability of care provided by deputising services and general practitioner rotas have long caused concern,1 but a third provider group has now entered the arena. General practitioner cooperatives have mushroomed, fuelled by general practitioners' dissatisfaction with rota commitments and financial support from the government.2 3 Unlike commercial services,4 5 6 cooperatives do not face external controls and, as Jessopp and colleagues point out (p 199),7 they vary widely in their composition and patterns of service delivery.

Giving telephone advice alone is increasingly common. Cragg and colleagues' data from 1994-5 (p 187) show that less than 1% of callers to four deputising services and 20% of callers to general practitioner rotas received telephone advice,8 which contrasts sharply with Salisbury's data for 1996, with rates of 19% for deputising service contacts and 58% for a general practitioner cooperative (p 182).9 While it would be unwise to place too much reliance on figures from one metropolitan cooperative, Jessopp and colleagues report rates of telephone advice between 10% and 65% across 67 cooperatives, with a median of 38%.7

Is this a cause for concern? It is clear that clinical criteria alone do not govern the nature of the response to patients' calls and that widely differing standards of access to a doctor now obtain. In 1987, when Marsh and colleagues reported handling 59% of out of hours calls to their own practice rota by telephone advice alone,10 this was considered sufficiently alarming to generate columns of correspondence in subsequent issues of the BMJ, questioning the safety and standard of care provided. In a 1992 survey of telephone use in general practice, a substantial proportion of general practitioners expressed personal disquiet with this form of care, particularly when they did not know the patient.11 Yet telephone advice is now being offered increasingly often by deputising services and by large groups of general practitioners in cooperatives with consequently less personal knowledge of the patients they are advising and the communities in which they are working. Previously expressed concerns seem to have evaporated, and the potential role of practice nurses in providing telephone triage is now being studied (p 198).12

A new and reliable measure of patient satisfaction with out of hours care, developed by McKinley and colleagues (p 193),13 has shown higher levels of dissatisfaction than ever previously reported (p 190).14 The authors are right to point out that direct comparisons between these findings and those of earlier studies using less well designed and tested measures are not possible, but the levels are striking in themselves, and once again deputising services score less well than general practitioner rotas. Patient satisfaction has been shown in the past to be related to speed of response,15 16 and this remains the aspect of care with which patients are least satisfied. Yet response times are slowing generally and seem to be poorest in the cooperative studied by Salisbury.9 Cragg et al's median response times of 35 minutes for rota general practitioners and 52 minutes for deputising doctors8 contrast with Salisbury's 65 minutes for deputising doctors and 75 minutes for the cooperative.9

More research is needed on the ability of cooperatives to respond rapidly in cases of urgent need. Many rural cooperatives cover large geographical areas. Outside the periods of peak demand a single general practitioner may be responsible for providing telephone advice, centre based consultations, and home visits. In some cases, call handling services introduce an added delay between patients' calls and a general practitioner's response. This issue does not simply relate to patient satisfaction but also to patient safety.

In 1992 a stage had been reached at which the demands and expectations of patients for out of hours care had outstripped general practitioners' willingness and ability to meet them. Increased reliance on deputising services and the growth of the cooperatives has averted an immediate crisis. However, out of hours services are now more variable, and it is by no means clear to what extent that variability represents inequality in access, quality of care, and hence satisfaction with services. McKinley and colleagues' measure of patient satisfaction will be a valuable tool in assessing the impact of new methods of organising and delivering services on patient satisfaction.12

We have not yet accumulated a sufficient body of evidence to judge the quality of services offered by cooperatives. As Jessopp and colleagues show,7 their enthusiasm for centre based care (5-70% of contacts) in preference to home visiting is as variable as their reliance on telephone advice and equally unevaluated. The benefits they offer their general practitioner members have been widely quoted,17 but they have spread without reference to patients' views, with no attempt to involve users in their planning and operation, and with limited efforts to assess patient satisfaction. Without evidence to support a need for uniform standards of service and care, and without a clear idea of what those standards should be, they are likely to maintain their independence of action, as practice rotas have always done.

Uniformity is not necessarily a virtue in circumstances where needs and demands for care differ. The importance of flexibility in order to address local needs and circumstances, particularly where services are poor, lies at the heart of the recent government white paper on primary care.18 However, equality of access to uniformly high standards of care is an important goal for primary health care, and increasing variability in the organisation and delivery of out of hours services should not lead to increasing inequality.