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3.16 Access to after-hours primary health care

Why is it important?

'After-hours' services are usually services provided on Sunday, before 8 am and/or after 12 pm on Saturday, or at any time other than 8 am to 6 pm on weekdays. An important component of comprehensive primary care services is the capacity for patients to access services after hours. In the absence of after-hours primary health care, patients with more urgent needs may delay seeking care. Many patients are provided with after-hours primary care services by their regular GP or at their usual health service. Common approaches include extended hours clinics, on-call arrangements, the provision of home visits, and co-operative arrangements that involve GPs from several practices participating in a shared roster system.

It is often preferable for after-hours primary care to be provided by a patient's usual GP, as they are more likely to know about the patient's condition and history, and to be able to make an informed judgment about the treatment required. However, as this is not always possible, a number 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

Self-reported data from the 2012–13 Health Survey indicate 9% of Indigenous Australians reported accessing a doctor outside normal business hours.

According to 2013–14 Medicare data on MBS services claimed for after-hours care items, there were around 228,000 after-hours services provided to Indigenous Australians, representing 2.5% of all services (note these data may double-count after-hours care provided in selected emergency departments). After adjusting for the age differences in the two populations, the Indigenous rate was 318 per 1,000 population compared with 390 per 1,000 population for non-Indigenous Australians.

For Aboriginal and Torres Strait Islander peoples, claims for after-hours services were highest in major cities (533 per 1,000) and lowest in remote areas (119 per 1,000) and highest in SA and lowest in the NT (673 and 84 per 1,000). Indigenous rates were 1.9 times as high as non-Indigenous rates in very remote areas and only 29% as high in the NT.

GP survey data collected from April 2008 to March 2013 indicate 87% of GP encounters among Indigenous Australians were with practices that had after-hours care arrangements in place. This compared with 97% of GP encounters among other Australians.

Online Services Report data for 2012–13 indicate 45% of Australian Government-funded Indigenous primary health care organisations provided care outside of normal operating hours. The most common services provided outside of normal operating hours were transport (provided by 70% of services) followed by treatment of injury (60%), emotional and social wellbeing/mental health services (53%), and diagnosis and treatment of infectious illness/disease (52%). Other services provided include: diagnosis and treatment of chronic illness/disease (50%), antenatal care (42%), care in police station/lock-up/prison (42%), maternal and child care (23%), and hospital admitted patient/outpatient care (15%).

Data on services provided by emergency departments are limited to large public hospitals, mainly located in major cities. In these hospitals, in the period 2011–12 to 2012–13, there were about 696,600 emergency department presentations provided to Aboriginal and Torres Strait Islander patients, representing 5% of all presentations. Around 59% (408,706) of these episodes occurred after hours. This was similar for non-Indigenous patients (56%). For Aboriginal and Torres Strait Islander patients, around 57% (233,870) of emergency department presentations provided after-hours were classified as semi-urgent or non-urgent (triage categories 4 and 5) as were 53% of non-Indigenous after-hours emergency department episodes of care.

Implications

Aboriginal and Torres Strait Islander peoples have a lower rate of MBS after-hours services claimed than non-Indigenous Australians (rate ratio of 0.8). Note: not all care delivered through Indigenous primary health care services can be claimed through Medicare. Rates were particularly low in remote and very remote areas for Indigenous and non-Indigenous Australians and the largest gap was in the NT (rate ratio of 0.3).

While Indigenous Australians make up 3% of the population, they represent 5% of emergency department presentations in hospitals for which data are collected. Over half of these presentations occurred after-hours. A better understanding is required of the needs of Aboriginal and Torres Strait Islander peoples for health services after-hours, and the best ways of providing coverage.

The after-hours GP helpline is an after-hours telephone-based GP medical advice service provided by Healthdirect Australia for people who require medical advice and cannot access their usual health service. The after-hours GP helpline started on 1 July 2011 and enables people who require after-hours medical advice to speak to a GP over the telephone when necessary. As of 30 June 2014 the helpline has taken over 500,000 calls (2.5% of the callers identified as Indigenous).

The Australian Government is conducting a review of current after-hours service arrangements. The After-Hours Review is in response to the recommendations of the Review of Medicare Locals. This review will help inform the Government of the most appropriate and effective delivery mechanisms to support ongoing after-hours service provision nationally. The implementation of new after-hours service arrangements will be in place by 1 July 2015.

Figure 3.16-1 Age-standardised rate of MBS services claimed for after-hours care, by Indigenous status and remoteness, 2013–14
chart showing Age-standardised rate

Figure 3.16-1 shows the age-standardised rate of MBS services claimed (per 1,000 population) for after-hours care by Aboriginal and Torres Strait Islander people and non-Indigenous Australians in 2013-14. Data are presented for: major cities, inner regional, outer regional, remote, very remote and total. Rates for Indigenous Australians were highest in major cities and lowest in remote areas.

Source: Medical Benefits Division, Department of Health

Figure 3.16-2 Age-standardised rate of MBS services claimed for after-hours care, by Indigenous status and state/territory, 2013–14
chart showing Age-standardised rate of MBS services

Figure 3.16-2 shows the age-standardised rate of MBS services claimed (per 1,000 population) for after-hours care by Aboriginal and Torres Strait Islander people and non-Indigenous Australians in 2013-14. Data are presented for each state and territory. Rates for Indigenous Australians were highest in South Australia and lowest in the Northern Territory.

Source: Medical Benefits Division, Department of Health

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 2008–March 2013
chart showing Rate of GP encounters

Figure 3.16-3 shows the rate of GP encounters (number per 100 encounters), by whether the GP has after‑hours arrangements in place, among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians between April 2008–March 2009 and April 2012–March 2013. Data is presented for GPs with their own arrangements, cooperative arrangements, a deputising service, other arrangements, total after-hours arrangements, and no after-hours arrangements. The figure shows that 87% of GP encounters among Indigenous Australians were with practices that had after-hours care arrangements in place compared with 97% of GP encounters among other Australians.

Source: Family Medicine Research Centre, University of Sydney analysis of BEACH data.

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 2011–June 2013
chart showing Non-admitted patient emergency care

Figure 3.16-4 shows the proportion of non-admitted patient emergency care episodes for triage categories 4 (semi‑urgent) and 5 (non-urgent) by time of day among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians in the period July 2008 to June 2010. The figure shows a similar pattern of emergency departement presentations for both Indigenous and non-Indigenous Australians. For Aboriginal and Torres Strait Islander patients, around 57% of emergency department presentations provided after-hours were classified as semi-urgent or non-urgent (triage categories 4 and 5) as were 53% of non-Indigenous after-hours emergency department episodes of care.

Note: These data are limited to public hospitals mainly located in major cities classified as principal referral, specialist women's and children's hospitals or large hospitals.

Source: AIHW analysis of National Non-admitted Patient Emergency Department Care Database

Table 3.16-1 Emergency Department presentations after hours, by Indigenous status, 2011–12 to 2012–13
Time of presentation Number
Indigenous
Number
Non Indigenous
Per cent
Indigenous
Per cent
Non Indigenous
All emergency department presentations
On Sundays 102,270 1,842,576 15 15
Before 8am or after 12pm on Saturday 82,045 1,345,650 12 11
Before 8am or after 6pm on a weekday 224,391 3,530,795 32 29
Total after hours 408,706 6,719,021 59 56
Not after hours 287,881 5,270,375 41 44
Total 696,587 11,989,396 100 100
Semi-urgent or non-urgent (triage category 4 and 5) emergency department presentations
On Sundays 61,939 1,048,984 15 16
Before 8am or after 12pm on Saturday 47,612 727,496 12 11
Before 8am or after 6pm on a weekday 124,319 1,805,777 30 27
Total after hours 233,870 3,582,257 57 54
Not after hours 178,067 2,999,479 43 46
Total 411,937 6,581,736 100 100
Proportion of all after hours presentations 57 53

Note: These data are limited to public hospitals mainly located in major cities classified as principal referral, specialist women's and children's hospitals or large hospitals.

Source: AIHW analysis of National Non-admitted Patient Emergency Department Care Database