Impact of the 1990 contract for general practitioners on night visiting.

Abstract

The 1990 contract for general practitioners extended the hours of eligibility for night visiting claims by 25% and introduced financial incentives to discourage the use of deputizing services. This study set out to examine the impact of these contract changes on the rate and pattern of night visiting. Family health services authority data were used to compare trends in night visiting before and after the introduction of the new contract. Rates were calculated separately for those authorities which might be expected to have a high rate of visiting because of their demographic structure and those that might be expected to have a high rate because of their socioeconomic composition, thus separating out these two sets of factors combined in the Jarman index. Rates of night visiting increased by 33% between 1989 and 1990 while the proportion of visits made by deputies fell by 19%. These changes could not simply be explained either by the extension of eligible hours or the success of financial incentives in changing behaviour in the appropriate direction. It was found that the effect of the new contract was to increase visiting most in family health services authorities with a high proportion of elderly people living alone, that is, where demand would be expected to be higher. In previous years there had been little variation in visiting rates between authorities with a high proportion of those aged 65 years and over living alone and those with a low proportion. The effect of the contract was also to increase rates of visiting most in affluent authorities, that is, where demand would be predicted to be lower. This again marked a sharp break with trends in previous years in that the gap between the high rates in the deprived family health services authorities and lower rates in the most affluent authorities narrowed. The 1990 contract achieved the government's policy aims of promoting night visiting by principals and discouraging the use of deputies in its first year. However, the finding that doctors responded more to demand from elderly people and affluent people than from deprived people presents a challenge both for analysis and for policy. It underlines the importance of disaggregating the Jarman index when examining the impact of policy change on local populations and suggests that general practitioners in the most deprived family health services authorities may lack the capacity or the incentive to respond to the changes introduced in the 1990 contract.