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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.
KCE Reports 1771 5.4.4. Financial incentives Data on econommic analysis are ssummarized in the e chapter 6. This ppart only mentions the financial incentives set up to attrac ct health professiionals in the new after-hoours care model. In The Netherlaands and in the UUK GPs are paid per hour on call: there is no financial inccentive to influennce the patient’s choice (GP coooperative versus emergenncy department). In Denmark, GGPs are paid a fee per consulta ation according to a fee schedule. The ffees are graded: doctors are enco ouraged to give teelephone consultations rrather than face-to-face consultat tions or home vvisits. In France and Italy, after-hours caare is paid on a fee f for service baasis, but generally with a fixed remuneratiion. 5.4.5. Charaacteristics of the model most frequently used in the 5 countrries The model of ccooperatives is thhe most common one in The Nethherlands, UK and Denmaark and the GPs wwere the main initia ators. In France and Italy primary caree centres are org ganized and regulated by regional authorities comprising inndependent bodie es of GPs. 5.4.5.1. Faccilities Number of cenntres in the counntry The Netherlannds and the UKK count more than t 130 and 1152 GP cooperatives reespectively. In Deenmark there are e 16 county-baseed after- hours organizattions with five reggional based servi ices. For France aand Italy no data are avaailable. Population covvered by the afteer-hours organization In The Netherlaands 50 to 250 GGPs take care of populations ranging from 100,000 to 5000,000. In Denmaark the population n served by the different cooperatives iss equal to the nuumber of people living in the five regions (ranging fromm 580.515 citizzens to 1,7 million). In Itaaly, the physician/population ratio is oone after-hours care doctor peer 5,000 inhabitants. Theere are no data avvailable for France e and the UK. Affter-Hours Primaary Care LLocation In the Netherlandss, UK, Denmark aand France facilities for after-hourss care aare often situatedd near or withinn a hospital, but there is no forrmally rregulated patient fflow with the hosppital or its emergenncy department. TThe trend in the NNetherlands, Denmmark and the UK is to co-locate thhe GP ccooperative and thhe emergency deepartment (ED), often with one entrance aand desk with a triiage nurse. In Italy after-hourss primary care cenntres work independently from hosppitals. 55.4.5.2. Humaan resources GGeneral practitioners • Proportion of GPs or practices taking part in afteer-hours care In the Netherlands and in the UK respectively 98% % and 90% of thee GPs taake part in after- hours care. In Deenmark GPs havve a legal obligatiion to taake part in afterr-hours care, but in practice this is often delegated to yyounger doctors. In France 78% oof the primary carre practices offer after- hhours arrangemennts. For Italy, theere are no official data available oon the nnumber of physicians taking parrt in after-hours care, neither oon an inndependent basiss nor within a primmary care centre. • Workload of GGPs In the Netherlandss GPs are 4 hours on call per weeek, and GP shifts last 6 too 8 hours. GPss have differentt roles including home visits, ccentre cconsultations, andd telephone triagee consultation (larrger cooperatives have a specific telephone GP who only provides teleephone consultaations, ssupervises the nurrses and authorizee the triage nursee contacts). In Denmark the wworkload varies acccording to GPs and regions: somee GPs aare 8-16 hours onn call per month but other GPs hhave a more impoortant wworkload (up to 488 hours per monthh). In Italy after-hourss doctors’ duty shifts lasts 12 hours. FFor the UK and Frrance there is no oofficial informationn available. 45
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KCE REPORTS 2011 171B QUELLLES SOOL
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Contrôle Direction Contact Comm mi
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COLOPHOON Titre : Auteurs : Experts
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