Primary medical care outside normal working hours: review of published work

Abstract

General practitioners' out of hours arrangements Time spent on call is a shrinking component of general practitioners' workload. Between 1964 and 1977 the proportion of general practitioners on call five or more nights each week fell from 39% to 9%1. By 1991 < 4% were on call 16 or more nights during the week or every weekend over a period of four weeks.2 Time on call between 7 pm and 8 am weekdays and between 1 pm Saturday and 8 am Monday fell to an average of 26 hours a week in 1989-90, nearly four hours < in 1985-6.3 In a 1989 national survey nearly a third of general practitioners reported no regular personal commitment to their practice's night cover.4 Wide regional variations in on call commitments largely reflect the availability of commercial deputising services.4 In the late 1960s these services began to expand to cover most large cities in Great Britain. In 1964 only 9% of general practitioners sometimes used such services.1 Between 1971 and 1976 the number of general practitioners subscribing to them doubled from 4000 to 80005 and the number of patients having contacts with deputies increased by nearly 50%6; by 1977, 42% of general practitioners were using deputising services (26% regularly).1 Studies suggest that the overall proportion of users has remained between 38% and 45% but that the proportion of regular users has risen.*RF 2-4,7,8* In 1989 deputies carried out 46% of night visits.9 Although 45% of general practitioners do not have access to deputising services,2 changes in the structure of general practice have facilitated the growth of practice rotas, an alternative means of reducing personal commitment. The proportion of general practitioners working single handedly fell from 43% in 1952 to 11% in 1989; the proportion in groups of four or more rose from 9% to 55%.10,11 Two thirds of general practitioners now use a practice rota for some or all duty periods, and up to 30% use a rota in collaboration with other practices at least some of the time.2,4 The case for larger, cooperative rotas in which several practices provide a service in an area was argued as early as 1984,12 and this movement has recently gathered momentum.13 Few criticisms have been levelled at practice rota systems. Suggestions that lack of personal knowledge of individual callers may present a problem for general practitioners on a rota are not supported in published works.*RF 14-18* General practitioners believe that rotas are an effective means of balancing their own and their patients' needs.12,19,20 Patients' satisfaction is reportedly high.21,22 No systematic evaluation of cooperatives has so far been undertaken. Commercial deputising services have provoked considerably greater controversy. It has been argued both that they provide essential relief for general practitioners and that they undermine the principle of continuing personal care.*RF 20,23-30* Although general practitioners are satisfied with the standard of particular services,31 questions have been raised about deputies' qualifications, the quality of care provided, and the impact of such services on demand.*RF 32-37* Visits by deputies have been linked to significantly lower patient satisfaction.*RF 38-40* Guidelines on restricting the use and controlling the standard of commercial services apparently have not been consistently applied.41,42 but little research into deputising services has been conducted recently. Despite a reduction in the volume of out of hours care provided by individual general practitioners this aspect of their workload contributes disproportionately to feelings of stress, fatigue, and fear of violence.*RF 25,26,43-48* In an extensive recent survey 57% of general practitioners believed that 24 hour responsibility was outdated; 82% agreed that it should be possible to opt out and 73% said that they would like to do so.2 Around two thirds supported limiting their commitment to between 8 am and 7 pm and nearly a quarter would not be prepared to participate in any alternative arrangement for providing out of hours care. Support for ending 24 hour responsibility has come from both the General Medical Services Committee and the annual conference of local medical committees.49,50 None the less, some studies of general practitioners show a professional commitment to providing care at all times and a disquiet with the perceived consequences of becoming a 9 to 5 service.*RF 20,28,29,51-53* The Royal College of General Practitioners has questioned the very term out of hours, asking what a doctor's hours are.43