Characteristics of service users and provider organisations associated with experience of out of hours general practitioner care in England: population based cross sectional postal questionnaire surveyBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2040 (Published 29 April 2015) Cite this as: BMJ 2015;350:h2040
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Warren and colleagues highlight the importance of timely care in the out-of-hours setting. Poor timeliness of care was also a leading reported cause of harm in the out-of-hours setting in our analysis of patient safety incidents from primary care in the England and Wales National Reporting and Learning System (2003-2013).
Out-of-hours services see patients who present with acute illnesses and are unable to wait until in-hours primary care services are open. From our work to date, over 300 incidents report harm to patients related to out-of-hours care. Harm to children is described in 33 reports, and of those, 18 report a delay in referral to appropriate services such as emergency or secondary care. Insufficient assessment of patients preceded most delays too, most notably during a telephone triage process, and included failures to recognise children with acute, serious conditions.
The use of telephone triage in primary care is efficient, but its safety has been questioned. Training is required to increase the detection rate of low incidence, high-risk children who require emergency care or those who are at risk of sudden deterioration. The UK Royal College of Paediatrics and Child Health recommends that GPs have access to immediate consultant paediatric advice when managing acutely unwell children  and good communication between services could vastly improve patient safety. Improvement efforts must seek to build systems between primary and secondary care services with resilience to mitigate sources of harmful events to children. Regularly interrogating incident reporting systems locally would be a suitable means of identifying such insights, and our own work indicates this is a feasible and rich source of learning to mitigate future events. However, until a blame-free reporting culture exists, and frontline healthcare professionals reliably provide details about care failures, this opportunity will be limited.
1. Warren FC, Abel G, Lyratzopoulos G, et al. Characteristics of service users and provider organisations associated with experience of out of hours general practitioner care in England: population based cross sectional postal questionnaire survey. BMJ 2015;350:h2040.
2. National Institute for Health Research. Characterising the nature of primary care patient safety incident reports in England and Wales: mixed methods study. Available from: http://www.nets.nihr.ac.uk/projects/hsdr/1264118.
3. Giesen P, Ferwerda R, Tijssen R, et al. Safety of telephone triage in general practitioner cooperatives: do triage nurses correctly estimate urgency? Qual Saf Health Care 2007;16(3):181-84.
4. Royal College of Paediatrics and Child Health. Facing the Future: Together for Child Health [Internet]. 2015 [cited 10th May 2015]. Available from: http://www.rcpch.ac.uk/sites/default/files/page/Facing%20the%20Future%20...
5. Rees P, Edwards A, Panesar S, et al. Safety Incidents in the Primary Care Office Setting. Pediatrics. Published Online First: 4 May 2015. doi:10.1542/peds.2014-3259.
Correspondence to: Andrew Carson-Stevens, 3rd Floor Neuadd Meirionnydd, Division of Population Medicine, School of Medicine, Cardiff University email@example.com
Competing interests: AC-S and AE are co-chief investigators of a National Institute for Health Research Health Services and Delivery Research grant to characterise patient safety incident reports in primary care (12/64/118). PR is a research assistant employed to work on the study. PJE, HW, HPE, AB have no conflicts of interest. The views expressed herein are those of the authors and do not necessarily reflect those of the UK Health Services and Delivery Research programme, NIHR, NHS, or the Department of Health.
Warren et. al. report the observation that patients from minority backgrounds report poorer out of hour care, and that ethnic minority patients are clustered in lower scoring providers. (1)
In a response to the article by Mead and Roland on how ethnic minorities experience primary care, Morgan suggested that a possible confounder, physician characteristics, was not taken into account. (2) (3)
In addition to the hypotheses of the authors, it is possible that the lower scoring providers or private providers are using more foreign medical graduates, which may explain lower ratings in satisfaction surveys.
(1) Warren F, Abel G, Lyratzopoulos G, Elliott M N, Richards S, Barry H E, Roland M, and Campbell J L. Characteristics of service users and provider organisations associated with experience of out of hours general practitioner care in England: population based cross sectional postal questionnaire survey. BMJ 2015;350:h2040. http://www.bmj.com/content/350/bmj.h2040
(2) Mead N and Roland M. Understanding why some ethnic minority patients evaluate medical care more negatively than white patients. BMJ 2009;339:b3450. http://www.bmj.com/cgi/content/full/339/sep16_3/b3450
(3) Morgan C L. Physician factors. BMJ, 2009, 01 October. http://www.bmj.com/rapid-response/2011/11/02/physician-factors
Competing interests: No competing interests
Re: Characteristics of service users and provider organisations associated with experience of out of hours general practitioner care in England: population based cross sectional postal questionnaire survey
Following publication of our paper, we have received a number of enquiries regarding the scores associated with each of the three aspects of out of hours care we examined. Marginal mean scores (indicating the expected score for each provider type with adjustment for individual service user characteristics) were calculated for each outcome, based on model C, set out below and in the attached pdf file.
Marginal mean score (95% confidence interval)
Overall experience of care
Not for profit: 72.1 (71.1 to 73.1)
NHS: 73.2 (71.7 to 74.7)
Commercial: 69.0 (67.5 to 70.5)
Timeliness of out of hours GP care
Not for profit: 68.4 (66.8 to 70.1)
NHS: 69.7 (67.3 to 72.1)
Commercial: 64.9 (62.6 to 67.3)
Confidence and trust in out of hours clinician
Not for profit: 66.2 (65.2 to 67.2)
NHS: 67.2 (65.7 to 68.7)
Commercial: 63.0 (61.5 to 64.4)
These scores reiterate the observed tendency for commercial providers to receive poorer reports of experience of care, compared with not for profit providers or NHS providers.
Competing interests: No competing interests