Family Practice Advance Access published May 18, 2011 Family Practice 2011; 0:1 6 doi:10.1093/fampra/cmr029 Ó The Author 2011. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. Management of out-of-hours calls by a general practice cooperative: a geographical analysis of telephone access and consultation Joanne Turnbull a, *, Catherine Pope a, David Martin b and Valerie Lattimer c a Organisation and Delivery of Care Group, Faculty of Health Sciences, b School of Geography, Faculty of Social and Human Sciences, University of Southampton, Highfield, Southampton, UK and c School of Nursing and Midwifery, Faculty of Health, University of East Anglia, Norwich, UK. *Correspondence to Joanne Turnbull, Organisation and Delivery of Care Group, Faculty of Health Sciences, University of Southampton, Highfield, Southampton SO17, UK; E-mail: j.c.turnbull@soton.ac.uk Received 12 January 2011; Revised 15 April 2011; Accepted 20 April 2011. Background. Centralization of urgent care services may reduce access for patients living further away from primary care centres (PCCs). Telephone-based access is often proposed to remedy this. Objective. To examine the effect of distance and rurality on the doctor s decision to manage the call by telephone or face-to-face. Methods. Geographical analysis of routine data on calls to an out-of-hours cooperative, including logistic regression to examine the effects of distance and rurality on triage decisions. Results. For distances >6 km, the likelihood of receiving telephone advice only increased progressively with increasing distance from the PCC (Model 1). However, for those patients seen face-to-face, overall, there was increased likelihood of receiving a home visit (compared with PCC attendance) with increasing distance (Model 2). Conclusions. Patients experience differences in how their call to out-of-hours services is managed depending on where they live. Telephone access and consultation can be used to overcome geographical barriers but do not necessarily make access geographically equitable. Those who live furthest away are more likely to receive telephone advice rather than being seen face-to-face, but paradoxically, those who do get a home visit are more likely to live at a greater distance from the PCC. These findings present important challenges to proposals to integrate urgent care services and increase telephone-based provision and suggest that attention should be given to configuring services to ensure geographical equity of access, regardless of how far away people live from health services. Keywords. Consultation, family medicine, health service management, telemedicine. Introduction Despite continual National Health Service (NHS) reform of the GP contract and with it changes to out-of-hours care provision, the use of deputizing services and GP-led cooperative services remains the standard model for providing primary care outside usual office hours in much of the UK. 1 Typically, out-of-hours services are run from primary care centres (PCCs) where up to half of the workload is managed by telephone 2 4 rather than face-to-face consultation. Most patients who contact urgent care services by telephone are subsequently asked to travel to a PCC to be seen, and some receive visits from a care provider in their own home. In the UK, GP out-of-hours care is provided free of charge for patients, regardless of how and where they are seen. As provision of services by cooperatives became more commonplace, concerns were raised about patients dissatisfaction with receiving telephone advice (rather than being seen face-to-face) 5 and the apparently poorer access to face-to-face consultations for patients living further away. 6,7 Research conducted in Northern Ireland 6 reported that the likelihood of receiving only telephone advice was positively correlatedwithboththedistanceandtheestimatedtravel time to the PCC, and further work in the North West of England found that the likelihood of being seen Page 1 of 6
Page 2 of 6 Family Practice an international journal fell progressively with increasing distance after adjustment for age, sex, deprivation, rurality and day and time of call. 7 While improving patient access to primary care continues to be a priority for the UK government 8,9 trends towards centralizing and integrating urgent and out-of-hours care mean that patients live further away from these services. Telephone-based services have continued to be championed as a solution to the problem of geographical access, notably for providing care to rural or sparsely distributed populations. In the UK, this push towards telephone services has culminated in the recent announcement of a new national 111 telephone number to access urgent (non-emergency) care. The English NHS provides a wide range of urgent care services that are free at the point of use, including out-of-hours services, minor injuries units, NHS walk-in centres and the telephone service, NHS Direct. The proposed 111 telephone number aims to provide a single point of access to these diverse urgent care services in order to reduce public confusion about where to seek help, thereby improving access to urgent care and the coordination and integration of services. 9 These developments complement the existing 999 emergency. 10 This shift, towards using a telephone service as the first point of contact for urgent care, is a significant change to service provision, but the impact on equity and on primary care practice of making the telephone the principal mode of access is poorly understood. This paper updates an earlier analysis presented by Munro et al. 7 and uses newer measures of rurality and deprivation based on 2001 geographical census areas (rather than 1991 geographical census areas) to examine the effect of distance and rurality on GPs decisions about whether to manage the call by telephone or face-to-face. Our data were collected prior to the introduction of the 2004 General Medical Services contract where some reorganization of services followed, but nonetheless, the features of out-of-hours services described above remain. Our research examines the relationship between telephone and geographical access to out-of-hours services and sheds light on policies which promote or increase the reliance on telephone-based services, such as the new 111 service. Methods Design and setting Our analysis is based on routinely collected data on telephone calls to an out-of-hours cooperative in Devon, UK. The setting and the data are described in detail elsewhere. 11 Briefly, quantitativedatawere collected in 2003 when a GP-led cooperative comprised >500 GP members providing out-of-hours care covering 81% of the area s population (in total 928 725 registered patients) (19% were covered by a different deputizing service or GPs operating their own out-of-hours arrangements). It operated 19 PCCs in urban and more rural locations across the county (9 opened during weekdays and weekends and a further 10 only on weekends). Calls were initially answered by call operators who took basic demographic call details. An out-of-hours GP based at a PCC telephoned the caller back to triage the call. Calls were primarily managed by asking patients to attend the PCC, providing GP telephone advice or by home visit. Patients are typically deterred from dropping in at a PCC without telephoning first for an appointment, although in practice, it is difficult to turn people away. Data The study is based on all routinely logged calls to the cooperative in June and December 2003 (n = 34 229 calls) and includes data about the patient s age and sex, date and time of call and postcode and the initial GP triage decision (the dataset contained no details about the presenting medical problem). Measures of deprivation, distance and rurality were matched to patient call data where patient s postcode was complete. The Index of Multiple Deprivation 2004 of Super Output Areas (SOAs) 12 was used to derive quintiles of deprivation by dividing the population of SOAs in Devon (not national quintiles). Straight line distance from the patient s address to their nearest open PCC (based on time and day of call) was calculated. Rurality was measured by the ONS Rural and Urban Area Classification for England and Wales (2004) of Output Areas (OA). Analysis Data were analysed using SPSS v14. Logistic regression analyses were undertaken to examine the effects of distance and rurality on the GP s initial triage decision. The analysis aimed to closely reproduce the methods used in an earlier study 7 which presented two logistic regression models to predict the effects of distance on: the likelihood of being seen face-to-face by a GP (either a home visit or a PCC attendance) or receiving telephone advice only (Model 1); the likelihood of being seen at a PCC or receiving a home visit (this model is a subset and includes only patients that were seen face-to-face) (Model 2). Binary outcomes were adjusted for the effects of age (0 4 years and then 5-year age bands), deprivation quintile, sex, rurality (urban, town/fringe, village and hamlet/isolated dwelling), time of day (00:00 to <08:00, 08:00 to <18:00 and 18:00 to <00:00) and day of week (weekday and weekend). The variables used here are the same as those presented by Munro et al. 7 but different measures of rurality and deprivation are used. Since
Management of out-of-hours calls by a general practice cooperative Page 3 of 6 this analysis aimed to reproduce the methods used in a previous study the Enter method was chosen in preference to Stepwise models. Since most patients only made one call during the months of June and December [24 017 calls with complete data were made by 23 624 patients; 20 369 (86%) called the service once], we did not attempt to account for clustering within the data where the service received more than one call for a patient. Results Of 34 226 calls (call management information missing for three calls), 14 575 (42.6%) were managed by GP telephone advice, 8891 (26%) were invited to attend a PCC and 5628 (16.4%) received a GP home visit (Table 1). An ambulance was called by the out-of-hours service for 1.3% of calls and a small proportion of calls were referred to other services including district nursing services, NHS walk-in centres and dental services. A number of patients did not attend (DNA) when invited to the PCC or cancelled the call (1.9%). Of the calls, 72 were classified as walk-ins i.e. the patient did not make prior telephone contact with the service (Table 1). Of 29 094 calls that received telephone advice, a home visit or were seen at the PCC, 5077 (17%) had missing age, sex and/or postcode data. The logistic regression analysis is based on 24 017 calls with complete data. Model 1 (face-to-face or telephone advice) showed that the likelihood of a patient being seen face-to-face was similar for distances <6 km (Table 2). However, for distances of >6 km, the likelihood of face-to-face consultation fell progressively with increasing distance from the PCC, odds ratio (OR) of 0.86 [95% confidence interval (CI) 0.76 0.96) for distances of 6 to <8 km to an OR of 0.36 (95% CI 0.30 0.43) for distances of 16+ km (compared to baseline category of <2 km). Rurality had only a negligible TABLE 1 Call management Number (percentage) of how the calls were managed N (%) calls GP telephone advice 14 575 (42.6) Patient attended a PCC 8891 (26.0) Received a GP home visit 5628 (16.4) Ambulance called 433 (1.3) Referral to other services a 1062 (3.1) Message handling calls 2906 (8.5) Patient DNA or cancelled call 657 (1.9) Other b 74 (0.2) Total 34 226 Call management information missing for three calls. a Dental advice, district nurse, NHS walk-in centre and community paramedic services. b 72 patients dropped in to PCC without prior telephone contact and 2 patients transferred from the ED. effect on the likelihood of being seen face-to-face, with no difference for urban, town and village OAs. Populations from hamlet and isolated dwelling OAs were more likely to be seen face-to-face, OR 1.12 (95% CI 0.99 1.27) but this finding was not significant (baseline category is urban). Deprivation did not strongly predict the likelihood of receiving a face-to-face consultation, although there was an increased likelihood of being seen face-to-face for patients in Quintile 5 (least deprived). Males and older adults were more likely to be seen face-to-face. Patients calling overnight (00:00 to <08:00) were less likely to be seen in person than those calling at other times. The likelihood of being seen face-to-face was higher for weekends than weekday callers (likely to be the result of the increased number of PCC attendances at weekends). ORs for decision to see the patient face-to-face (primary care centre or home visit) versus giving telephone advice for the management of out-of-hours calls TABLE 2 Model 1 Patients seen face-to-face All calls OR (95% CI) Distance (km) <2 4007 7392 1.00 2 to <4 2871 5237 1.05 (0.98 1.13) 4 to <6 2041 3916 0.99 (0.91 1.07) 6 to <8 827 1667 0.86 (0.76 0.96) 8 to <10 696 1476 0.78 (0.68 0.89) 10 to <12 604 1363 0.72 (0.64 0.82) 12 to <14 600 1416 0.71 (0.63 0.80) 14 to <16 255 765 0.46 (0.39 0.54) 16+ 225 785 0.36 (0.30 0.43) Deprivation 1 (most deprived) 2947 5753 1.0 2 2451 4851 1.06 (0.98 1.15) 3 2211 4489 1.07 (0.98 1.16) 4 2150 4398 1.01 (0.93 1.11) 5 (least deprived) 2367 4526 1.14 (1.05 1.24) Gender Male 5262 10 161 1.0 Female 6864 13856 0.94 (0.89 0.99) Rurality Urban 8795 16 862 1.0 Town and fringe 1641 3566 0.94 (0.86 1.03) Village 1015 2186 1.06 (0.95 1.19) Hamlet/isolated dwelling 675 1403 1.12 (0.99 1.27) Time of day 18:00 to <00:00 4348 9446 1.0 00:00 to <08:00 1359 3243 0.89 (0.82 0.97) 08:00 to <18:00 6419 11 328 1.27 (1.19 1.37) Day of week Weekday 3603 8490 1.0 Weekend 8523 15 527 1.30 (1.21 1.39) Total 12 126 24 017 ORs are the odds for the decision to see the patient face-to-face (PCC or home visit) relative to advice calls. Logistic regression model included distance, deprivation, age, sex, rurality, time of day and day of week. Age is not presented in the table due to large number of age bands in the analysis.
Page 4 of 6 Family Practice an international journal Model 2 (home visit or PCC appointment) showed that overall, there was a pattern of increasing likelihood of receiving a home visit with increasing distance, likelihood peaking at 12 14 km (then slightly decreasing again for those >14 km) (Table 3). There was no difference in the likelihood of a home visit for distances <4 km, OR 1.11 (95% CI 0.97 1.27), but for distances >4 km, there was a significant increase in the likelihood of being seen at home. From this, it might be assumed that increased rurality would predict greater likelihood of a home visit, but this was not so. Urban and town/fringe areas were similar to each other, but those living in villages and hamlets were less likely to receive a home visit. This might suggest that distance and rurality should not necessarily be used as a proxy for each other. The likelihood of a home visit decreased for the least deprived TABLE 3 ORs for decision to see the patient at home versus PCC attendance for out-of-hours management of calls Model 2 GP home visit All calls to be seen OR (95% CI) Distance (km) <2 1291 4007 1.0 2 to <4 1010 2871 1.11 (0.97 1.27) 4 to <6 800 2041 1.38 (1.19 1.60) 6 to <8 321 827 1.51 (1.21 1.87) 8 to <10 299 696 1.56 (1.22 2.00) 10 to <12 267 604 1.51 (1.18 1.94) 12 to <14 300 600 1.80 (1.42 2.29) 14 to <16 110 255 1.69 (1.19 2.40) 16+ 99 225 1.61 (1.09 2.36) Deprivation 1 (most deprived) 1072 2947 1.0 2 929 2451 0.94 (0.81 1.08) 3 820 2211 0.79 (0.67 0.92) 4 778 2150 0.74 (0.63 0.87) 5 (least deprived) 898 2367 0.66 (0.56 0.77) Gender Male 1905 5262 1.0 Female 2592 6864 0.98 (0.88 1.08) Rurality Urban 3153 8795 1.0 Town and fringe 697 1641 1.03 (0.87 1.22) Village 396 1015 0.75 (0.61 0.93) Hamlet/isolated dwelling 251 675 0.76 (0.60 0.97) Time of day 18:00 to <00:00 1779 4348 1.0 00:00 to <08:00 874 1359 2.63 (2.25 3.07) 08:00 to <18:00 1844 6419 0.44 (0.38 0.50) Day of week Weekday 1773 3603 1.0 Weekend 2724 8523 0.64 (0.56 0.73) Total 4497 12126 ORs are the odds for the decision to see the patient face-to-face (PCC or home visit) relative to advice calls. Logistic regression model included distance, deprivation, age, sex, rurality, time of day and day of week. Age is not presented in the table due to large number of age bands in the analysis. quintiles. Gender had no significant effect on whether to see the patient at home or at the PCC. For adults aged >20 years, the odds of receiving home visit rose consistently and steeply with age but gender had no significant effect. The likelihood of receiving a home visit was twice as likely overnight (00:00 to <08:00) compared to evenings and was more likely on a weekday. Discussion Geographical variation in patients use of services 7,11,13 appears to be amplified by geographical variation in the way that the out-of-hours services manage telephone calls. Overall, our Model 1 findings were consistent with those of Munro et al. 7 Deprivation did not affect the likelihood of being seen face-to-face (except for the least deprived SOAs) suggesting that call management decisions are not being unduly influenced by socio-economic factors. We found that patients living at the greatest distance from the PCC were less likely to be seen face-to-face and tended instead to receive telephone advice. But paradoxically, for those patients who were seen face-to-face (Model 2), patients living at greater distances were more likely to receive a home visit. This finding contradicts from the earlier study by Munro et al. 7 which reported that distance appeared to have little effect on where patients were seen. The explanation for this finding is not clear. Elsewhere, we have reported that the outof-hours consultation is a negotiated encounter, in which the caller/patient has opportunities to influence the decision by the GP about where they are seen. 14 It is possible that local GPs, cognizant of the local geography and transport difficulties may be more sympathetic to those patients who live further away. They may factor in this geographical awareness with other patient characteristics, such as age or coexisting health problems, in their decisions about whether to undertake a home visit. In the UK, there are a number of health services that patients can use free of charge as an alternative to out-of-hours services. These include emergency (999) ambulance services and NHS Direct (both accessible by telephone), emergency departments (ED), minor injuries units (MIUs) and NHS walk-in centres. Services provided face-to-face (ED, MIU and walk-in centre) are located in major towns and cities and there are likely to be similar geographical barriers to patients wishing to use these services. However, transport routes and access to private vehicles may mean that patients living more remotely use these services, perhaps as a way of bypassing the need to telephone the out-of-hours service before being seen. Providing home visits for those living furthest away runs counter to policies of service centralization and
Management of out-of-hours calls by a general practice cooperative Page 5 of 6 there are likely to be significant opportunity costs associated with deploying resources, notably GP time and transportation costs, in this way. Our findings also challenge the assumption that patients living furthest away and patients living in rural areas face the same barriers to accessing services. Distance and rurality are not synonymous; while the relationship with rurality and mode of consultation was less consistent, those living in rural villages and hamlets were less likely to receive a home visit. This cautions us against assuming that measures of distance can be used as a proxy measure for rurality or vice versa. Policy and practice deliberations about service provisions need to recognize this important distinction. Limitations of the study The limitations of the data have been described elsewhere 11 but it is worth reiterating that straight line distance and the rural/urban area classification are two of a number of measures that could be used for this type of analysis. Straight line distance does not take into account variations in transport network density, but it has been shown to correlate well to more complex measures such as travel time 14 (and Munro et al. 7 reported that straight line distance and road travel distance gave similar results in their analysis). This study focuses on geographical and service use data. We were not able to examine objective or subjective perceptions of the severity of the presenting medical problem. It may be that severity influences willingness to travel or the perceived need for face-to-face contact and thus affects GP and patient decisions about how care is provided (by telephone or face-to-face). Implications for service delivery and organization Patients have identified difficulties in accessing services and in particular face-to-face consultations. 13 Furthermore, patients prefer face-to-face contact over telephone advice when offered a choice. 15,16 A postal survey showed that while 40.9% of respondents sought telephone advice, 35.7% wanted to be seen at a PCC and 23.4% requested a home visit. 17 Providing telephone consultations may overcome barriers of distance but is only a viable alternative if patients/callers find it acceptable. Current provision of out-of-hours services combines provision of telephone consultation with telephone call management where the telephone service is simply used as the gate to face-to-face consultation in the form of a home visit by a health provider or a patient visit to a PCC. Neither telephone consultations nor telephone-based call management appears to mitigate the effects of geographical inequalities. The proposals for a national 111 urgent care telephone service seek to simplify access to urgent care. 10 Our work suggests that it should not be automatically assumed that this kind of service will make access equitable. Further work is needed to assess how such initiatives will really affect different geographical populations and in particular how they impact on different types of rural populations. In developing more integrated urgent care services and embracing technologies such as telephone (and potentially internet based) services, attention should be given to configuring these to avoid disadvantaging those who live furthest away. The telephone is not, on its own, the solution to geographical disadvantage. Tackling these complex inequalities is likely to involve consideration of how health care is provided and tackling the wider issues of access associated with transport. Acknowledgements Our thanks go to the out-of-hours service for providing us with data and for their support. Declaration Funding: University of Southampton PhD studentship. Ethical approval: Devon and Torbay Research Ethics Committee (07/Q2102/7). Conflict of interest: none. References 1 Huibers L, Giesen P, Wensing M, Grol R. Out-of-hours care in western countries: assessment of different organizational models. BMC Health Serv Res 2009; 23: 105. 2 Lattimer V, George S, Thompson F et al. Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial. The South Wiltshire Out of Hours Project (SWOOP) Group. BMJ 1998; 317: 1054 9. 3 Leibowitz R, Day S, Dunt D. A systematic review of the effect of different models of after-hours primary medical care services on clinical outcome, medical workload, and patient and GP satisfaction. Fam Pract 2003; 20: 311 7. 4 Salisbury C, Trivella M, Bruster S. Demand for and supply of out of hours care from general practitioners in England and Scotland: observational study based on routinely collected data. 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