After-hours coverage

Abstract

OBJECTIVE

To determine the prevalence and content of existing or developing policies and guidelines of medical associations and colleges regarding after-hours care by family physicians and general practitioners, especially legal requirements.

DESIGN

Telephone survey in fall 2002, updated in fall 2004.

SETTING

Canada.

PARTICIPANTS

All national and provincial medical associations, Colleges of Family Physicians, Colleges of Physicians and Surgeons, local government offices for the north, and the Canadian Medical Protective Association (CMPA).

MAIN OUTCOME MEASURE

Response to the question: “Does your agency have a policy in place regarding after-hours health care coverage by FPs/GPs, or are there active discussions regarding such a policy?”

RESULTS

The College of Physicians and Surgeons of British Columbia was the first to institute a policy, in 1995, requiring physicians to make “specific arrangements” for after-hours care of their patients. The College of Physicians and Surgeons of Alberta adopted a similar policy in 1996 along with a guideline to aid implementation. In 2002, the College of Physicians and Surgeons of Nova Scotia approved a guideline on the Availability of Physicians After Hours. The Saskatchewan Medical Association and the College of Physicians and Surgeons of Saskatchewan formulated a joint policy on medical practice coverage that was released in 2003. Many agencies actively discussed the topic. Provincial and national Colleges of Family Physicians did not have any policies in place. The CMPA does not generate guidelines but released in an information letter in May 2000 a section entitled “Reducing your risk when you’re not available.”

CONCLUSION

There is increasing interest Canada-wide in setting policy for after-hours care. While provincial Colleges of Physicians and Surgeons have traditionally led the way, a trend toward more collaboration between associations was identified. The effect of policy implementation on physicians’ coverage of patients is unclear.

EDITOR’S KEY POINTS.

• This survey describes official policies or guidelines for after-hours care provided by family physicians and general practitioners reported by the Canadian Medical Association (CMA), its provincial associations, branches of the College of Family Physicians of Canada, provincial Colleges of Physicians and Surgeons, and the Canadian Medical Protective Association (CMPA).

• Only the Colleges of Physicians and Surgeons of British Columbia, Alberta, and Saskatchewan have policies. Nova Scotia has a guideline; the Newfoundland Medical Board has a guideline pending.

• The CMPA recommends explaining practice arrangements for after-hours coverage to patients. The CMA addresses workload and lifestyle when it recommends 1 in 5 days or weekends on call.

• Despite the few policies currently available, there appears to be a growing interest in this area as part of primary care reform. Collaboration between medical organizations is also increasing. Expect more policies in the near future.

POINTS DE REPÈRE DU RÉDACTEUR.

• Cette article décrit les politiques et directives relatives aux soins fournis après les heures normales par les médecins de famille et les omnipraticiens, telles que rapportées aux enquêteurs par l’Association Médicale Canadienne (AMC), ses associations provinciales, les branches du Collège des Médecins de Famille du Canada, les Collèges des Médecins et Chirurgiens provinciaux et l’Association Canadienne de Protection Médicale (ACPM).

• Les Collèges des Médecins et Chirurgiens de Colombie-Britannique, d’Alberta et de Saskatchewan sont les seuls a posséder de telles politiques. La Nouvelle-Écosse a une directive et le Bureau médical de Terre-Neuve en a une en instance.

• L’ACPM conseille d’expliquer les mesures adoptées pour la couverture des soins après les heures de fermeture. L’AMC recommande des gardes un jour ou une fin de semaine sur cinq, ce qui risque d’affecter la charge de travail et le mode de vie des médecins.

• En dépit du peu de politiques actuellement disponibles, on semble s’intéresser de plus en plus à cette question qui s’inscrit dans une réforme éventuelle des soins primaires. Il y a aussi de plus en plus de collaboration entre les organismes médicaux. D’autres politiques devraient voir le jour prochainement.

Interest and concern regarding provision of after-hours care by family physicians and general practitioners in Canada have grown recently as ministries of health at both provincial and federal levels examine how primary health care is delivered. This attention is manifest in proposals for primary care reform that require 24-hour, 7-day-a-week coverage of patients. In addition, creation and funding of Telehealth services by several provinces demonstrate governments’ willingness to support extended hours of health coverage.

Primary care practitioners have traditionally included some arrangement for care of their patients outside usual office hours. This concept is implicit in the four principles of family medicine promoted by the College of Family Physicians of Canada (CFPC). These principles include statements that the family physician “provides continuing care” and “organizes the practice to ensure that patients’ health is maintained whether or not they are visiting the office.”¹ This study was conducted to determine the current regulatory environment in Canada regarding after-hours care.

Medical associations in several other countries have set standards for after-hours care. In Australia, The Royal Australian College of General Practitioners requires general practices “to ensure reasonable arrangements for 24-hour medical care for practice patients.”² The New Zealand Medical Association expects general practice physicians to assist the public health office in providing access to primary care outside weekday business hours.³

The British Medical Association has required physicians who are off duty to ensure that “suitable arrangements are made for patients’ medical care.”⁴ The 2004 contract between general practitioners and the British government, negotiated by the British Medical Association, however, now allows physicians to opt out of after-hours care.⁵

A literature review looking at after-hours care revealed few Canadian studies. Patel et al⁶ compared after-hours care of children by family physicians and by pediatricians in four Canadian cities in 1994. Their findings suggest considerable regional variation in after-hours availability. While there is little Canadian information on after-hours care, there is more on on-call duty. The CFPC’s 2001 National Family Physician Workforce Survey elicited responses from 14 319 family physicians and general practitioners from across Canada. Preliminary findings from the self-reported survey⁷ suggest on-call duties also vary greatly by region (Figure 1).

Figure 1.

Percentage of family physicians who provide on-call service, by province or territory

In the National Family Physician Workforce Survey, on-call duty is defined as “time outside of regularly scheduled clinical activity during which you are available to patients.”⁸ “After-hours care” and “on-call duty” can differ in the Canadian medical environment. After-hours care in the context of family practice is defined as providing care to all practice patients outside normal office hours. While after-hours care is often provided using an on-call system, being on call can also refer to coverage of only certain patients, such as hospital inpatients, obstetric cases, and patients in long-term care. On-call duty could also be viewed as being required to be available to provide care, from the perspective of physicians, whereas after-hours care is the ability to access care outside usual office hours, from the point of view of patients.

To understand regional differences in after-hours care properly, we must first determine whether requirements for such care differ throughout Canada. We conducted a national survey of medical associations known to set policies, write guidelines, or give guidance in the area of policy development, in order to identify the current legal obligations of Canadian family physicians and general practitioners to provide after-hours care. We also contacted the Canadian Medical Protective Association (CMPA), which does not set policy, but provides legal advice.

METHOD

The original survey was conducted from October to December 2002; it was updated from July to September 2004. The Canadian Medical Association (CMA), the CFPC, the CMPA, the provincial chapters of the CMA and the CFPC, every provincial College of Physicians and Surgeons, and local government offices in the territories were contacted by telephone by a single research assistant using each organization’s main telephone number. The interviewer asked to speak to the appropriate member of the organization who could answer the question, “Does your agency have a policy in place regarding after-hours health care coverage by family physicians or general practitioners, or are there active discussions regarding such a policy?” The suitable director; registrar; communications, information, or public affairs officer; administrator; or administrative assistant, once identified, was asked the question, and responses were noted. A follow-up e-mail message was sent to the interviewee to confirm the content of the telephone conversation. Organizations that had policies, guidelines, or draft documents were asked to send copies.

RESULTS

Responses to the telephone survey are shown in Table 1. Overall, 36 of 38 agencies provided interviews, representing a response rate of 95%. We were unable to contact the Northwest Territories Medical Association or the Yukon Medical Association after numerous attempts. No organization asked for a further definition of after-hours care. Three relevant policies (one policy was from two organizations) were reported to be in place. One guideline was released on December 13, 2002, which offered “suggestions” for after-hours care. One agency was in the process of releasing its statement on after-hours care and is listed as “pending.” Several medical associations noted that they were in active discussions about after-hours care.

Table 1.

Policies or guidelines for after-hours care by family physicians and general practitioners

*No—policy relates to on-call duty.

†Pending—draft paper at approval stage.

Canadian Medical Protective Association

While the CMPA does not generate clinical guidelines, its advice influences policy development and vice versa. In the May 2000 Information Letter, the CMPA addressed the issue of after-hours care in a section entitled “Reducing your risk when you’re not available.” The advice in this publication is oriented to communities where physician resources are scarce. It recommends explaining “to your patients, in advance, the parameters of your practice, including the availability of off-hours coverage, and from whom a patient should seek help in your absence.”⁹

Canadian Medical Association and branches

The CMA cited their Charter for Physicians¹⁰ and two policy papers (Physician Compensation Update 2001¹¹ and Rural and Remote Practice Issues¹²) as their policy documents regarding after-hours care. These policy papers address the issue from a quality-of-life perspective, discussing the need for a reasonable workload for physicians. The Charter recommends limiting call to 1 night in 5, or weekends. Neither document specifically mentions after-hours care.

The Saskatchewan Medical Association had collaborated with the College of Physicians and Surgeons of Saskatchewan to formulate a joint statement, “Medical Practice Coverage” (Table 2¹³). The policy and companion paper were adopted in March 2003. It states that physicians “have an obligation to arrange for 24-hour coverage of patients currently under their care.” The Fédération des médecins omnipracticiens du Québec was addressing this area by negotiating financial incentives for care outside office hours. The Newfoundland and Labrador Medical Association stated that they were discussing the topic of after-hours care, and its financial aspect would be part of the association’s arbitration discussions with government. The Alberta Medical Association considered after-hours coverage to be addressed by the Primary Care Initiative to which it had agreed, and the Medical Society of Nova Scotia had negotiated on-call funding in hospitals.

Table 2.

Policy for medical practice coverage of the College of Physicians and Surgeons of Saskatchewan and the Saskatchewan Medical Association

Data from the College of Physicians and Surgeons of Saskatchewan.¹³

College of Family Physicians of Canada and provincial Chapters

As noted above, the four principles of the CFPC allude to “continuing care,” but neither the CFPC nor any of its provincial Chapters had a specific policy or guideline for after-hours care. The CFPC discusses family practice networks in its position paper, Primary Care and Family Medicine in Canada: A Prescription for Renewal.¹⁴ These networks are described as providing coverage of patients 24 hours a day, 7 days a week. Several provincial Chapters of the College also indicated that they were working on a family practice network model. The Nova Scotia College of Family Physicians stated that they had been actively involved with the College of Physicians and Surgeons of Nova Scotia in guideline development.

Colleges of Physicians and Surgeons

Of the 10 provincial Colleges of Physicians and Surgeons, four had developed guidelines or requirements relating to after-hours care. The Colleges of Physicians and Surgeons of British Columbia¹⁵ and Alberta¹⁶ have clear policies regarding after-hours care, while the Nova Scotia College has developed a guideline.¹⁷ The Saskatchewan College had released their policy statement together with the Saskatchewan Medical Association as stated above. The Newfoundland Medical Board had developed a guideline, but it was not ready for general release.

In June 1995, the College of Physicians and Surgeons of British Columbia was the first medical body to institute a policy statement¹⁵ requiring physicians to make specific arrangements for after-hours care of their patients (Table 3). In November 1996, the College of Physicians and Surgeons of Alberta adopted a similar policy¹⁶ (Table 4), along with a guideline to aid physicians with implementation.

Table 3.

Statement on practice coverage from the 1995 College of Physicians and Surgeons of British Columbia Policy Manual

Data from the College of Physicians and Surgeons of British Columbia.¹⁵

Table 4.

College of Physicians and Surgeons of Alberta’s policy for after-hours availability of physicians

Data from the College of Physicians and Surgeons of Alberta.¹⁶

The College of Physicians and Surgeons of Nova Scotia approved Guidelines on the availability of physicians after hours¹⁷ in 2002 for care “outside of normal working hours, when the severity and acuity of a patient’s medical condition warrants” it. The guideline offers several suggestions for providing urgent care to patients without compromising patient safety or physician health.

Northern Canada

It was difficult to locate local medical organizations for the Yukon, Northwest, and Nunavut Territories. In the North, the regional government office (which is responsible for licensing physicians) was contacted. No policies or guidelines were reported for the North.

DISCUSSION

Requirements for after-hours coverage by physicians vary by province, ranging from specific policy papers to no recommendations at all. The study by Patel et al⁶ was conducted in provinces where no policies existed, and yet it found that many physicians (range 28% to 87%) were providing after-hours care. The limited data quantifying provision of after-hours care by primary care practitioners throughout Canada make it difficult to determine the relationship between policy statements and practice coverage.

While the most notable finding from our survey was the lack of policies or guidelines from most organizations contacted, many agencies demonstrated definite interest in exploring the issue. After the first policy papers were released in British Columbia and Alberta, 6 years went by with no new developments in the area. Now the topic is actively being discussed in many organizations, and new policies and guidelines are being devised and released. In contrast, the United Kingdom (which has a long history of providing after-hours care) no longer considers provision of this service the responsibility of individual physicians.

The provincial Colleges of Physicians and Surgeons have historically released policies and guidelines regarding after-hours care. In our discussions a movement toward collaboration between associations has emerged. Several provincial Chapters of the CFPC and provincial medical associations have been assisting their respective Colleges with policy development. This trend could facilitate acceptance of guidelines.

This survey was intended as a rapid assessment of current policies and guidelines for provision of after-hours care by family doctors in Canada. In the interest of obtaining useful data quickly, we chose to contact organizations by telephone, asking for the call to be directed to the person best qualified to provide an accurate response to our question. While this could have introduced an element of sampling bias, in our judgment it was a better tactic for obtaining timely data on accessible policies than a standardized written letter. It is possible that lesser known policies and guidelines were missed, as the accuracy of the data depended upon the knowledge of respondents.

CONCLUSION

While only a few medical agencies have policies or guidelines on after-hours care, our survey notes two important trends in Canada. The first is a considerable increase in interest in the topic Canada-wide, and the second is more collaboration among medical bodies with respect to policy development. As governments, society, and the medical profession continue to explore the issue of primary care reform, more and more medical associations are moving toward making specific recommendations for after-hours care.

Biography

Dr Bordman is Professional Development Director and Dr Wheler is Undergraduate Family Medicine Program Director at the Scarborough Hospital in Ontario. Dr Bordman is an Assistant Professor, Dr Wheler is a Lecturer, and Dr White is an Associate Professor in the Department of Family and Community Medicine at the University of Toronto in Ontario. Dr Drummond is an Associate Professor in the Departments of Family Medicine and Community Health Sciences at the University of Calgary in Alberta. Dr White is Chief of Family and Community Medicine at the North York General Hospital in Ontario. Mr Crighton is a Research Associate in the Primary Care Research Unit of the Department of Family and Community Medicine at Sunnybrook and Women’s College Health Sciences Centre in Toronto.