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Out-of-Hours Primary Medical Care - 2004. Revised 2016

The provision of out-of-hours care is a key part of general practice. The AMA Out-of-Hours Primary Medical Care 2016 position statement has been developed to guide the design of these services, outlining the essential feature of a successful model of out-of-hours primary medical care.

11 Nov 2011

1. Introduction

Out-of-hours primary medical care (or out-of-hours care) refers to medical care provided outside normal general practice surgery hours. It is a central tenant of a high quality health care system.[1] The Royal Australian College of General Practitioners (RACGP) Standards for General Practices includes the practice’s responsibility ‘to ensure reasonable arrangements for medical care for patients of the practice outside its normal opening hours’.[2]

The AMA has determined that any period outside 8:00am until 6:00pm on weekdays as out-of-hours. The Commonwealth Department of Health defines out-of-hours as those hours outside 8:00am to 6:00pm weeknights; outside 8:00am to 12:00pm Saturdays; and all day Sundays and public holidays.[3]

This position statement outlines the broad criteria for the provision of out-of-hours care that the AMA believes will deliver quality out-of-hours services. It complements the AMA position statement Out-of-Hours Criteria for Medical Deputising Services 2002. Revised 2014.

2. Arrangements for out-of-hours care

The delivery of out-of-hours care has traditionally relied on individual GPs providing care to their own patients. However, over recent decades, there have been significant changes in the GP workforce, demographics and work practices, which have affected the way GPs provide out-of-hours care for their patients. The most recent data show that the majority of GPs are now providing between 21 to 40 hours a week of direct patient care hours, are shifting away from solo practice, and are increasingly using medical deputising services to provide out-of-hours medical care. This is particularly true for metropolitan areas. [4],[5]

In rural areas, however, GPs are more likely to provide out-of-hours services themselves, have cooperative on call roster arrangements with other local practices, or provide out-of-hours services at the local hospital.[6]

In some jurisdictions, GPs use a phone triage and support service (GP Assist in Tasmania is one example) where the general practice rosters a GP to remain on call and available should phone triage deem a face-to-face consultation with the GP is necessary. This arrangement enables continuity of patient care and safer working hours for the GP.

General practices have further adapted to increasing demand and consumer expectations for access to general practice outside traditional weekday hours by offering extended weekday and Saturday and Sunday surgeries. These extended hours of operation have blurred the boundaries between normal general practice “in hours” and out-of-hours services.

3. Key issues

Across the country availability and access to out-of-hours services varies considerably.[7] There are a number of challenges to providing efficient, accessible and appropriate out-of-hours services for all Australians.

The AMA has identified the following barriers to the provision of out-of-hours care:

  • an under supply of GPs in rural and remote areas;
  • excessive workload and working hours to meet the demands of in hours services;
  • safety risks for GPs attending unfamiliar situations and patients alone, particularly late at night and early in the morning;
  • extremely limited or no access to locums;
  • inadequate financial support for existing out-of-hours GP arrangements;
  • reduced access to out-of-hours care in rural and remote Australia due to geography/demography together with downgrading and closure of local hospitals and facilities;
  • inadequate on call allowances for most rural GPs servicing state hospitals;
  • insufficient hospital facilities available for primary out-of-hours medical care as triage and assessment centres and bases for visiting doctors;
  • poor patient awareness of available GP services;
  • lack of emergency respite care;
  • other health services inappropriately deferring responsibility for level 4/5 triage patients; and
  • insufficient patient education, which contributes to:
    • increased patient expectation that the service will be timely, free and convenient, though not necessarily appropriate; and
    • lack of patient awareness of other available services that may be more appropriate in emergency situations, such as ambulance in cases of severe asthma or chest pain.

The AMA believes that any strategy that seeks to improve the provision of, and access to, 24 hour care for patients must, at a minimum, address the barriers outlined above and consider responding to the following critical underlying problems:

  • the overall increase in patient-driven demand for extended hours services;
  • changing workplaces with more GPs now working part-time and the need to ensure safe working hours and a safe work environment;
  • the increased burden of early discharge and the increased complexity of out-of-hours patient care related, but not limited to, community care of chronic conditions, palliative care, care of the elderly and those with psychiatric illness at home;
  • the need to maintain state rural (community) hospitals with adequate resources including appropriate remuneration of the visiting medical officer (VMO) GP workforce;
  • the need for the expansion of the role and use of Telehealth medical services, particularly for rural and remote communities, with better remuneration for GPs providing these services; and
  • a lack of access to hospital support for urban GPs.

4. AMA position

The AMA adopts the following criteria for out-of-hours primary care services:

4.1 Essential criteria

The model must:

  • ensure patient access is clinically required;
  • acknowledge and incorporate GP expertise in its design, governance and implementation;
  • ensure continuity of care by notifying the patient’s usual GP the next working day of any significant change in their medical status and treatment;
  • be locally appropriate;
  • reflect clear and sustainable collaboration between GPs, hospital(s), triage and deputising services and the community;
  • collect adequate data as the basis to undertake credible evaluation;
  • include community education, especially for raising awareness of available services and their appropriate use;
  • conform to agreed standards related to the protection and safety of doctors and staff;
  • have clearly defined and transparent clinical objectives;
  • demonstrate that its establishment is based on credible evidence that it is best able to fulfil the proven need and stated objectives;
  • have the demonstrated support of local GPs and community;
  • conform to appropriate professional standards;
  • incorporate a defined quality improvement cycle;
  • incorporate processes and procedures that ensure continuity of care for patients, for example, the provision of an out-of-hours number to a certified pathology provider;
  • comply with agreed standards for safe working hours for doctors;
  • be supported by appropriate remuneration of GPs that reflects the real value of the service provided; 
  • incorporate adequate and defined funding for infrastructure, including information technology management and communication systems;
  • meet workplace health and safety (WHS) standards; and
  • be subjected to the same Medicare auditing as in-hours medical services.

4.2 Desirable criteria

Desirablecriteria for any model of out-of-hours primary care service include:

  • home visits are provided on the basis of need;
  • the model should complement and augment existing GP services;
  • the model should integrate the whole spectrum of GP care, such as access to out-of-hours pharmacy; 
  • fee for service should be the basis for remuneration; and
  • a medical deputising service should be accredited to the relevant RACGP Standards for General Practice, including RACGP criteria for out-of-hours services and is accredited to confirm it meets all the additional criteria set out by the National Association for Medical Deputising Service (NAMDS).

4.3 Unacceptable criteria

A model of out-of-hours primary care service is unacceptable to the AMA if it incorporates any of the following elements:

  • a compulsion to bulk bill is imposed on GPs who participate in the service;
  • cashing out of MBS out-of-hours funding is a feature of the financial model for the service;
  • funding of the model involves any form of budget capping;
  • the establishment of the service imposes a perceived or actual compulsion on GPs to participate in the service;
  • a Government funded or controlled service that competes unfairly with local GPs through an inequitable funding model;
  • the service acts in any way as a barrier to patients’ access to GP services; 
  • it acts as a means of substitution for GP care; and

direct advertising by exclusively out-of-hours medical deputising service providers that encourages patients to use their services for routine or convenience purposes.


 

[2] Royal Australian College of General Practitioners Standards for general practices: 4th Edition, Standard 1.1, Criterion 1.1.4.

[3] Department of Health (2015), After hours primary care. http://www.health.gov.au/internet/main/publishing.nsf/Content/primary-ahphc

[4] BEACH (2015), General practice activity in Australia 2014-2015, University of Sydney, GP Series No 38. https://ses.library.usyd.edu.au/bitstream/2123/13765/4/9781743324530_ONLINE.pdf

[5] BEACH (2015), A Decade of Australian General practice activity 2005-06 to 2014-15, University of Sydney GP Series No 39.

[6] Ibid

[7] Ibid


Published: 11 Nov 2011