Primary care outside normal working hours

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

Along with the ongoing reorganization of the acute function of hospitals, the organization of primary services by general practitioners outside normal working hours is reconsidered. The idea is to merge this function into the hospitals' new acute function. A single telephone number applying to the whole country is to give access to a service where health care personnel can refer a patient to a relevant service like acute hospital service, an acute local clinic or home nursing.

Purpose of health policy or idea

The Danish Health Care Service provides acute services when it is needed 24 hours a day. Acute health care outside normal working hours (8 - 16 on week days) has until now been taken care of through an acute service organized and run by general practitioners, and by hospital emergency departments in case of trauma.

As a consequence of the ongoing reorganization of acute hospital services, the acute service by general practitioners has been reconsidered. The acute service has been seen as an integrated part of the primary care provided by general practitiones and is regulated trough negotiated angreements between the Association of General Practitioners and Danish Regions. The service is organized in five regional services, and the service is provided from local premises provided by the local region, often next to a hospital emergency department. Patients are required to call the service when seeking help. (In life-threatening cases citizens call an alarm service which will take patients directly to a hospital, though).

Doctors on duty are general practitioners who provide telephone consultations, consultations in local out-of-hours clinics (often in connection with local hospitals), or home visits when needed. About half of the contacts are terminated by only advicing the patient, including prescriptions or referral to their own doctor the following day. In emergency cases they refer patients directly to a hospital. The service thus functions as a gate-keeper or gate-opener to hospitals. Modern information technology is used to a large extent, including a patient record, contact to hospital or pharmacy, or the relevant local home nursing service. Information concerning the encounters is sent electronically to each patient's own doctor (98% of all citizens have their own familiy doctor). Doctors on duty are paid a fee per consultation according to a fee schedule.  

A report from the National Board of Health (2007) on strengthened acute service concluded that illness and traumas should to the greatest possible extent be treated in general practice, including the service outside normal working hours, and all referrals to hospitals should be made by doctors. Gradually, the pre-hospital service has been strengthened, and in some places a common acute service or emergency department has gradually taken the gate-keeper role. 

A later report from the National Board of Health (2009) concluded that the primary service out-of-hours functions well. Patient satisfaction is high and fullfills its purpose, although improvements can be made, for example concerning the communication between the service and hospitals. Moreover, when run by general practitioners it functions more or less in isolation, and there may be a need to integrate the service better with the broader acute service, including the municipal home nursing service.

If integrated into the hospitals' new acute function, two rather different cultures will meet and need to cooperate. It is concluded that the service should still be anchored in general practice, although the service should in the future be seen as a part of a broader pre-hospital service, and new modes for cooparation between different services may be relevant. The future centralization of acute services in fewer hospitals may create a need for primary services, both in day time and outside normal working hours, to handle more patients with acute conditions ad traumas. This may increase the need for advice from hospital specialists - although this possibility already exists.  

Compared to some neighbouring countries, the Danish service is characterized by a high number of contacts per doctor per hour (> 15 contacts) and relatively low cost per contact. Total costs per person is relatively high, though, due to a high number of contacts per inhabitant (535 per 1000 per year). In contrast, the use of emergency departments is probably relatively low in Denmark (Flarup 2010). The service has in total 19 call centres, 39 permamently opened consultations and 26 ad hoc opened consultations, serving a population of 5,3 mio people. (Sundhedsstyrelsen, 2009)  

The Association of General Practitioners wants to keep the acute service within their own responsibility, although in a modernized form. The arguments are that the service has been effective and relatively inexpensive, and general practitioners are trained in all kinds of service from giving advice to triage of patients. Moreover, they oppose having nurses in "frontline" responding top acute calls from patients (Pedersen et al., 2009; Larsen 2010). The regions want a one-string system with one central call center for all acute service. The arguments are that the present system is expensive, and two entrance doors to the service (through general practitioners or directly to a hospital) is confusing for the patients. Danish Regions plan to have general practitioners working in the new acute hospital service as hired staff and under the hospital management structure (Larsen 2010).      

Main points

Main objectives

The main objective is to strengthen acute pre-hospital services, and the primary service outside normal working hours is seen as an integrated part of this service. It is suggested by Danish regions and the NBoH that this service should be integrated into the broader acute service.

Type of incentives

This is a pure organizational change. There is no suggestions as to how the remuneration of general practitioners serving in the broader acute service should be.

Groups affected

General practitioners, doctors working in hospitals' acute function

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

The organizational change may improve the professional quality of the service. Whether accessability of the service changes is still to be seen.

Political and economic background

The integration of primary care outside normal working hours should be seen as a part of the broader initiative to strengthen the acute health service. See report (HMP report 16/2010 - Christensen et al.)

Change based on an overall national health policy statement

"Strengthened acute preparedness" by NBoH, 2007.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

While the National Board of Health was unclear in its recommendations in 2007 and 2009 as to the exact structure of a strengthened acute service, Danish Regions with resposibillity for implementing the service clearly plans to include the out-of-hours service by general practitioners into the hospitals' new acute service (Danish Regions, 2009).

Initiators of idea/main actors

• Government: The change is not seen as a political but rather as a practical issue.

• Providers

Approach of idea

The approach of the idea is described as:
renewed: The suggested organizational change can be seen as an integrated part of a broader reorganization of the acute service.

Stakeholder positions

Representatives from the Association of General Practitioners are strongly against closing the present primary service outside normal working hours, arguing that there is no documentation of either improved quality or savings. They also reject the idea that a nurse should take care of the triage as it is the most difficult job within the service.

Actors and positions

Government
Government	very supportive		strongly opposed
Danish Regions	very supportive		strongly opposed
Providers
Association of GPs	very supportive		strongly opposed

Influences in policy making and legislation

The policy is mainly based on the paper on the Future coherent acute system by Danish Regions (2009).

Actors and influence

Government
Government	very strong		none
Danish Regions	very strong		none
Providers
Association of GPs	very strong		none

Positions and Influences at a glance

Adoption and implementation

The merging of the out-of-hours service with the hospitals' new acute service may be an issue in the coming negotiations between Danish Regions and the Association of General Practitioners on the terms of service.

Monitoring and evaluation

No evaluation is foreseen.

Expected outcome

The stated objective of strengthened service, in partcular through better communication between the service and the hospital, is going to be achieved. It may be a challenge to merge staff members from two different cultures, hired hospital staff and independent general practitioners.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

The cost-effectiveness of the change is still to be seen.

References

Sources of Information

• Danske Regioner  Danish Regions] 2009: Fremtidens sammenhængende akutsystem [Coherett future acute system] www.regioner.dk/Aktuelt/Nyheder/2009/December/~/media/FF4D23083F1B41
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• Sundhedsstyrelsen [National Board of Health] 2007: Styrket Akutberedskab [Strengthened Acute Preparedness] www.sst.dk/publ/Publ2007/PLAN/Akutberedskab/StyrketAkutberedskab.pdf
• Sunhedsstyrelsen [National Board of Health] 2009: Kvaliteten i den danslke lægevagtsordning [The quality of the Danish out-of-hours health service in general practice] www.sst.dk/publ/Publ2009/SUPL/Laegevagt/Laegevagtordn_dk_dec09.pdf
• Larsen, Klaus: Blandet velkomst til regeringens akutudspil [Mixed welcome to the government's acute proposal]. Ugeskrift for Læger [Danish Medical Weekly] 2010; 172(1):8.
• Pedersen, Flemming Steen; Crone, Morten: Regioner vil nedlægge lægevagten [Regions plan to close the out-of-hours service by general practitioners].
• www.berlingske.dk/i-laegens-haender/regioner-vil-nedlaegge-laegevagten
• Flarup, Lone et al. Den danske lægevagt i internationalt perspektiv [The Danish out-of-hours service in international perspective]. Forskningsenheden for Almen Praksis [Research Unit for General Practice], Århus 2010.   www.laeger.dk/portal/page/portal/LAEGERDK/Laegerdk/Om%20L%C3%A6geforeningen/L%C3%A6geforeningen%20mener/Politik/Akutomr%C3%A5det/Den_danske_l%C3%A6gevagt_i_internationalt_perspektiv_marts2010.pdf

Author/s and/or contributors to this survey

Terkel Christiansen

Institute of Public Health - Health Economics, University of Southern Denmark

Suggested citation for this online article

Terkel Christiansen. "Primary care outside normal working hours". Health Policy Monitor, October 2010. Available at http://www.hpm.org/survey/dk/a16/2