Quelles solutions pour la garde en médecine générale? - KCE

44
5.4. Analysis
of after-hourrs
organization in five countriees
This part analyyzes
country speecific
situations: the description of each
country and aall
sources of information
from national websittes
and
published papeers
are displayed in
appendix 8.4.
5.4.1. Typess
of reforms of aafter-hours
care in i the 5 countriees
The reform in Denmark, The NNetherlands
and the UK focusedd
on the
creation of largge
scale general ppractitioner
coope eratives. Denmarkk
started
its reform in 19992.
In The Netheerlands
and the UK U the reform toook
place
around 2000.
France implemented
the after-hours
reform betw ween 2003 and 20005.
For
Italy there is noo
formal date of naational
reform ava ailable, as the 20 different
regions have implemented chhanges
in after-hours
care at different
moments in timme.
France and Ittaly
set a focus on o the implementtation
of
primary care ceentres,
serving ass
regional ambula atory contact poinnts.
The
difference betwween
the latter aand
GP cooperat tives in the Nethherlands,
Denmark, the UK is that theese
primary car re centres also employ
specialists, whoo
are independently
working or are e related to a hosppital.
For
this reason a ddifferent
terminoloogy
is chosen (GP P cooperative vs primary
care centre) in tthe
context of thiss
study.
5.4.2. Situattion
before the reeform
of after-ho ours care
In the Netherlaands,
GPs provideed
care in small-c call rotations (gennerally
5
to 10 GPs): theey
provided after-hhours
care for each
other’s patientts
during
evenings, nightts
and weekends.
In the UK, the situation before the
reform was he eterogeneous: some
GPs
provided themsselves
after-hourss
care and others s joined a practicee
rota or
area cooperativve.
In addition somme
GPs were emp ployed by or referrred
their
patients to a coommercial
deputizing
service.
Before the refoorm,
Danish GPss
were responsib ble for their own patients
24/7/365. In ruural
areas, three too
ten doctors co-o operated to providde
after-
hours care in a rota system. In laarge
towns, a loca ally organized rotaa
system
provided after-hhours
care for reggistered
patients of o 20 to 100 GPs. In some
of the largest ttowns
some rota groups contracte ed with a central service
where receptionists
handled thee
patients’ calls, but b in most cases doctors
themselves answered
the phone.
There were emergency conssultation
centres, rarely uused;
90–95% of patients received home visits.
Affter-Hours
Primaary
Care
KCE Reportss
171
In
France, after-hours
care wass
organized by the local physiicians
aassociation
which scheduled on-calll
rounds.
In
Italy, patients ccontacted
their GPP
or consulted a llocal
hospital. In some
rregions
rota systems
were organizeed
by small groupss
of GPs.
55.4.3.
Drivers ffor
system reformm
55.4.3.1.
Main ddrivers
from the practitioners’ peerspective
In
the Netherlandss,
UK and Denmark
the initiative ffor
re-organising after-
hhours
care mainlyy
came from the GGP
profession. Thheir
main drivers were
ddissatisfaction
witth
the organizattion
of rotation groups in after- hours
pprimary
care e.g. high perceived workload, lack oof
separation bettween
wwork
and private life, many non-uurgent
interventioons
during after- hours
pperiods,
a growingg
demand for servvices
by the public,
aggressive behhavior
oof
patients, low ffinancial
remunerration,
lack of peersonnel,
material
and
loogistic
support. Inn
particular in ruraal
areas from UK, GP complained aabout
the
disproportionaately
low remuneraation
in comparisoon
with urban areaas.
In
France, the main
drivers for system
reform were the
elements explained
aabove
but also thhe
workload perceeived
by emergenncy
departments. . This
ooverload
had been
related to a lacck
of access to prrimary
care ambulatory
sservices
as well as to a lack of available hospital
beds for emerggency
aadmissions.
55.4.3.2.
Main ddrivers
from the authorities persspective
DDrivers
for afteer-hours
care rreform
furthermoore
came from the
ggovernments.
Foor
example The Netherlands annd
the UK obseerved
inncreasing
demannds
from the pubblic
for after-hourrs
care, a shortage
of
GGPs,
safety issuess
i.e. inadequate standards of caree
(failure to investtigate,
aact
upon and leaarn
from serious incidents), accesssibility
problemss
and
rrising
costs. The eefficiency
of caree
organization wass
the main driverr
from
the
Danish authorities’
perspective.
In
Italy, no major driver has been identified:
the refoorm
of after-hourss
care
hhad
mainly to do with who is organizing
after-hourss
care rather thann
with
the
way after-hourrs
care is organizeed
and delivered.