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Tier 3 - Health system performance

3.16 Access to after-hours primary health care

Key facts

Why is it important?

‘After-hours’ health care refers to services provided on Sundays, before 8 am and/or after 12 pm on a Saturday, or at any time other than 8 am to 6 pm on weekdays. An important component of comprehensive primary health care services is the capacity for patients to access services after hours. At the same time, many factors contribute to uptake of after-hours care, including perceptions of health care effectiveness, severity of illness, family requirements, convenience, location and the availability of in care services. The absence of after-hours primary health care may result in delays by patients to seek care and the importance of after-hours care for ongoing treatment should be recognised. After-hours care is also a practical strategy for improving continuity and coordination of care, often through flexible service delivery relative to patient needs. Technology plays a role in improving the operation of after-hours care and streamlining administrative processes, with strategies such as sharing of electronic patient records across settings in real time, use of telehealth and embedded use of case conferences between services.

It is often preferable for after-hours primary care to be provided by a patient’s usual general practitioner (GP), because the GP is more likely to know the patient’s condition and history and be able to provide an informed judgement about the treatment required. Many patients are provided with after-hours primary care services by their regular GP or at their usual health service through extended hours clinics, on-call arrangements, the provision of home visits, and cooperative arrangements that involve GPs from several practices participating in a shared roster system.

As this is not always possible, several of other after-hours primary care arrangements exist. These include medical deputising services (where GPs contract another service to provide after-hours services on their behalf), dedicated after-hours services (GP and/or nurse-led clinics that only open during the after-hours period) and telephone triage and advice services (which involve telephone-based nurses and/or GPs providing advice and directing people to the most appropriate point of care). Many patients also attend emergency departments during the after-hours period.

The Medicare Benefits Schedule (MBS) includes after-hours items that provide increased benefit rates to medical practitioners. Rates are highest for urgent after-hours consultations where practitioners are required to provide a home visit or return to the clinic specifically for that consultation.

Findings

What does the data tell us?

Self-reported data from the 2018–19 National Aboriginal and Torres Strait Islander Health Survey indicate an estimated 8% of Aboriginal and Torres Strait Islander people living in Non-remote areas reported seeing a doctor outside normal business hours in the previous 12 months (Table D3.16.1).

According to 2017–18 Medicare data on MBS services claimed for after-hours care items, there were 312,886 after-hours services provided to Indigenous Australians, representing 2.5% of all after-hours MBS services provided. Note that these data may double-count after-hours care provided in selected emergency departments. After adjusting for differences in the age structure between the two populations, the rate of after-hours MBS services claimed for Indigenous Australians was 0.8 times that for non-Indigenous Australians (397 per 1,000 compared with 492 per 1,000) (Table D3.16.1).

For Indigenous Australians, MBS claims for after-hours services ranged from 147 per 1,000 population in Remote areas to 652 per 1,000 in Major cities (Figure 3.16.1). By jurisdiction, rates varied from 165 per 1,000 in the Northern Territory to 661per 1,000 in South Australia (Figure 3.16.2). Rates for after-hours MBS services claimed for Indigenous Australians were 1.7 times the rate for non-Indigenous Australians in Very remote areas. In the Northern Territory, the rate for Indigenous was only 34% as high for non-Indigenous (Table D3.16.3, Figure 3.16.1, Figure 3.16.2).

Figure 3.16.1: Age-standardised rate of MBS services claimed for after-hours care, by Indigenous status and remoteness, 2017–18

This bar chart shows that the rate of claims was higher for Indigenous Australians than non-Indigenous Australians in all areas of remoteness. The highest rate of claims, by far, for both populations occurred in Major cities, at 652 and 582 per 1,000, respectively. The rate of claims in Inner and Outer regional areas were similar for Indigenous and non-Indigenous Australians, ranging from 265 to 305 per 1,000 across both populations in these areas. In Very remote areas the Indigenous rate was substantially larger than the non-Indigenous rate; 201 compared with 121 per 1,000.

Source: Table D3.16.3. AIHW analysis of Medicare data.

Figure 3.16.2: Age-standardised rate of MBS services claimed for after-hours care, by Indigenous status and jurisdiction, 2017–18

This bar chart shows that the rate of claims was higher for Indigenous Australians than non-Indigenous Australians in South Australia, 661 per 1,000 compared 515 per 1,000. For all other jurisdictions the rate was either similar to (Qld, WA, Tas, ACT) or lower (NSW, Vic, NT) than the non-Indigenous rate. For all of Australia, the rate was lower for Indigenous Australians, 397 per 1,000 compared with 492 per 1,000 for non-Indigenous Australians.

 Source: Table D3.16.3. AIHW analysis of Medicare data.

The Bettering the Evaluation and Care of Health (2010–15) survey data estimated that 84% of general practitioner encounters for Indigenous patients were with practices that had after-hours care arrangements in place, compared with 96% for Other Australians (Table D3.16.4, Figure 3.16.3).

Figure 3.16.3: Rate of GP encounters, by whether the GP has after-hours arrangements in place, by Indigenous status of the patient, April 2010–March 2015

This bar chart shows that Indigenous Australians were more likely to have GP encounters at practices with no after-hours arrangements than non-Indigenous Australians, 163 per 1,000 encounters compared with 35 per 1,000 encounters. The rate of encounters was similar across the two populations for practices with their own after-hours arrangements (around 300 per 1,000 encounters) and that co-operated with other practices (around 130 per 1,000 encounters). Indigenous Australians were half as likely as non-Indigenous Australians to have encounters with practices that had implemented deputising services, 286 compared with 548 per 1,000.

Source: Table D3.16.4. AIHW and Family Medicine Research Centre, University of Sydney analysis of BEACH data.

Data from the 2017–18 Online Services Report showed that 47% of Commonwealth-funded Indigenous primary health-care organisations provided after-hours services. The main types of services provided after hours were transport (72% of organisations that provided some type of after-hours service), followed by treatment of injury (69%), diagnosis and treatment of infectious illness/diseases (61%), and social and emotional wellbeing/mental health/counselling services (57%). Other after-hours services provided included: antenatal care (39%), care in police station/lock-up (37%), maternal and childcare (31%), diagnosis and treatment of chronic illness/disease (29%), substance use/drug and alcohol programs (24%), hospital inpatient/outpatient care (15%) and tobacco programs (8%) (Table D3.16.5).

Hospitalisation

Data on services provided by emergency departments are limited to large public hospitals, mainly located in major cities. In these hospitals, in the period July 2015 to June 2017, there were 959,967 emergency department presentations by Indigenous Australians (6.4% of all emergency department presentations) (Table D3.16.6).

Around 56% (533,134) of these episodes were classified as semi-urgent or non-urgent and 58% (560,655) occurred after hours (Table D3.16.7, Table D3.16.8, Figure 3.16.4, Table 3.16-1). For semi‑urgent or non-urgent presentations, 57% occurred after hours (Table D3.16.9). Presentations for Indigenous Australians accounted for 7% of the total after-hours presentations to emergency departments (Table D3.16.12).

Of after-hours presentations to emergency departments for Indigenous Australians, 54% were semi-urgent or non-urgent, for non-Indigenous Australians this was 49% (Table 3.16.12).

Figure 3.16.4: Non-admitted patient emergency care episodes for triage categories 4 (semi-urgent) and 5 (non-urgent) by time of day and Indigenous status, July 2015–June 2017

This line chart shows that, by the proportion of care episodes occurring in a particular hour over all care episodes in a day, admission for Indigenous and non-Indigenous Australians followed a similar pattern. Around 6% to 7% of episodes occurred each hour from 9 am to 9 pm; just over 70% of episodes for both populations occurred in this 12 hour period. The Indigenous time of episode trend tended to lag behind the non-Indigenous trend by around one hour, for example the proportion for non-Indigenous episodes at 7 am is similar to the proportion for Indigenous episodes at 8 am.

Source: Table D3.16.7. AIHW analysis of National Non-admitted Patient Emergency Department Care Database.

Table 3.16-1: Emergency department presentations after-hours, by Indigenous status, July 2015 to June 2017

All emergency department presentations

Indigenous Number

Non-Indigenous Number

Indigenous %

Non-Indigenous %

On Sunday

141,275

2,107,341

14.7

15.1

Before 8am or after 12pm on Saturday

111,702

1,561,155

11.6

11.2

After-hours weekday

307,678

4,130,629

32.1

29.6

Total after-hours

560,655

7,799,125

58.4

55.8

Between 8am and 12pm on Saturday

24,887

429,711

2.6

3.1

Between 8am and 6pm weekdays

374,425

5,737,982

39.0

41.1

Not after-hours

399,312

6,167,693

41.6

44.2

Total

959,967

13,966,818

100.0

100.0

Semi-urgent or non-urgent (triage category 4 and 5) emergency department presentations

Indigenous Number

Non-Indigenous

Number

Indigenous %

Non-Indigenous

%

On Sunday

81,101

1,105,696

15.2

15.8

Before 8am or after 12pm on Saturday

60,909

776,451

11.4

11.1

After-hours weekday

159,660

1,918,725

29.9

27.4

Total after-hours

301,670

3,800,872

56.6

54.2

Between 8am and 12pm on Saturday

16,071

249,403

3.0

3.6

Between 8am and 6pm weekdays

215,393

2,961,721

40.4

42.2

Not after-hours

231,464

3,211,124

43.4

45.8

Total

533,134

7,011,996

100.0

100.0

Note: These data are limited to large public hospitals mainly located in major cities.

Source: Tables D3.16.8, D3.16.9. AIHW analysis of National Non-admitted Patient Emergency Department Care Database.

What do research and evaluations tell us?

Canuto and colleagues (2018) identified the perceived motivators, barriers and enablers of the utilisation of primary health care services among Indigenous males, and note the important role of after-hours care for service uptake (Canuto et al. 2018). The study explores patient experiences and suggestions to improve the uptake of services by Indigenous men in South Australia and Far North Queensland. Factors that motivated patients to use primary health care services included: patient judgements about ‘feeling sick’ and the requirement for action; the need for a specific service; personal importance of regular check-ups; and family encouragement. Barriers to the use of health care included long waiting times; inconvenient opening hours, lack of health knowledge; and culturally inappropriate staff or services. These factors are, in turn, important to the discovery and discussion of factors that could encourage the use of primary health care. Suggestions made by the study participants to improve service accessibility included: increasing opening hours; better proximity to work and home; and bringing services to patients that work full-time. Convenience was noted as a deciding factor for service uptake, often above perceived quality of service. Participants advocated the provision of after-hours health services.

De Witt and colleagues (2020) examined service improvement for Indigenous cancer patients in Queensland, including the importance of accessible and coordinated after-hours care (de Witt et al. 2020). Interviews were conducted with health professionals at several Aboriginal Community Controlled Health Services and one tertiary hospital. Results were analysed relative to the World Health Organization integrated people-centred health services framework that promotes health systems that are driven by continuity and coordination of care. A key driver of continuity and coordination of care is ‘flexible continuity’ (the ability to adjust care and treatment plans in response to patients changing individual needs across time). Factors that may improve the ‘flexible continuity’ of health systems include: flexible care delivery, such as telehealth; ‘Drop-in’ clinics; extension of primary health care clinic hours; longer patient consultations; consideration of individual patient needs when scheduling appointments; and availability of clinics outside of business hours to access allied health staff.

A review of after-hours primary health care in 2014 found significant variation in the arrangements for after-hours care across Australia, particularly between Remote and Non-remote areas and provided recommendations for future arrangements (Jackson 2014). The review found:

  • unnecessarily complex processes for managing services
  • benefits and drawbacks of competition between services
  • a need for better triaging of care
  • a lack of patient awareness of services available
  • stakeholder concerns over the integration and continuity of care between regular sources of care and after-hours care.

The review found that better use of eHealth solutions would provide patients with tools to self-manage and enhance communication with regular care providers and improve continuity of care. There was strong interest among providers in returning after-hours care arrangements to a Practice Incentive Program payment.

Following this review, changes to arrangements relating to after-hours service provision were implemented on 1 July 2015, coinciding with the advent of Primary Health Networks (PHNs), which included:

  • a PIP After-Hours Incentive payment available to eligible accredited general practices registered for the PIP
  • funding to PHNs to support locally tailored after-hours services
  • the new after-hours GP advice and support line to better support all Australians who do not have access to face-to-face GP services in the after-hours period.

Implications

Nationally, Indigenous Australians have a lower rate of MBS after-hours services claimed than non-Indigenous Australians (rate ratio of 0.8). However, this masks some variation by jurisdictions and remoteness. Rates were particularly low in Remote and Very remote areas for both Indigenous and non-Indigenous Australians and the largest gap was in the Northern Territory (rate ratio of 0.3).

Indigenous Australians accounted for 7% of the total after-hours presentations to emergency departments with over half of these being semi-urgent or non-urgent.

A better understanding is required of the needs of Indigenous Australians for health services after-hours, and the best ways of providing coverage.

The PIP After-Hours Incentive is designed to provide a nationally consistent model for access to after-hours primary health care for the majority of Australia. Recognising that the PIP after-hours incentive is not a one-size-fits-all solution, PHNs are being funded to address gaps in after-hours service provision, including where there is an unmet need. PHNs will focus on access to care for ‘at-risk’ or vulnerable populations (such as Indigenous Australians) and improving service integration, particularly where gaps exist due to a lack of access to general practices registered for the PIP After-Hours Incentive.

Evaluation of these changes to after-hours service provision is needed to assess the effectiveness of meeting the needs of vulnerable populations such as Indigenous Australians. Existing barriers to accessing primary health care will be factors in accessing after-hours care. The cultural competency of service providers, particularly if these are not the usual care givers, will be an important factor in ensuring appropriate care.

The policy context is at Policies and strategies.

References

  • Canuto K, Wittert G, Harfield S & Brown A 2018. “I feel more comfortable speaking to a male”: Aboriginal and Torres Strait Islander men’s discourse on utilizing primary health care services. International Journal for Equity in Health 17:185.
  • de Witt A, Matthews V, Bailie R, Garvey G, Valery PC, Adams J et al. 2020. Communication, Collaboration and Care Coordination: The Three-Point Guide to Cancer Care Provision for Aboriginal and Torres Strait Islander Australians. International Journal of Integrated Care (IJIC) 20:1-16.
  • Jackson C 2014. Review of after hours primary health care. (ed., Health AGDo). Australian Government Department of Health.

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