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Criterion 1.1.4 Care outside normal opening hours

Our practice ensures reasonable arrangements for medical care for patients outside our normal opening hours.

Explanation

Sometimes patients of the practice require provision of medical care outside normal opening hours. Practices are required to make and be able to demonstrate reasonable arrangements for access to primary medical care services for their regular patients at these times. Some practices use their own GPs to provide care or use a local cooperative of GPs, a medical deputising service (MDS) or - where a MDS is not available - have an agreement with a local hospital. Some practices use a combination of all these arrangements.

It may be necessary for practices to consider the quality and sustainability of the potential options and to make judgments about which will provide the highest quality of care, while maintaining the safety of patients and GPs. In these circumstances, GPs may want to discuss those trade-offs with peer surveyors.

Regardless of the arrangements used to provide care outside the normal opening hours, there needs to be documentary evidence of the system the practice uses to provide such care. If the practice uses other GPs to provide care (such as a MDS or cooperative), the practice needs to have evidence of how and when it receives information about any care provided to their patients outside normal opening hours, and also how the GPs providing care can contact the practice in an emergency or in the case of exceptional circumstances. Regular patients of the practice who seek care outside the normal opening hours of the practice may be better known to the practice than to the service providing care on behalf of the practice, with the practice being more likely to have accurate information about the patient's current care. It may be of substantial benefit if the doctor providing care is able to contact a GP within the practice for clarification or help regarding background information relating to that patient (especially in an emergency).

The successful follow up of abnormal life threatening results outside the normal opening hours of the general practice relies on general practices having robust and reliable systems for contact. Failures in these processes in pathology follow up have been the subject of criticism, and recommendations for improvement in recent coroner inquests where patients have been harmed through the lack of robust ways to convey urgent information.

General practices need to have after hours arrangements in place to allow abnormal and life threatening results identified by pathologists to be conveyed to a medical practitioner who will ensure that an informed appropriate medical decision is made and acted on promptly.

If the general practice uses another service (ie. a cooperative, MDS, hospital) then the general practice must have a defined, reliable means of access for the deputising practitioner to patient health information and to the practice in exceptional circumstances. This places an obligation on the general practice to establish this means of contact (eg. a contact telephone number for one or more of the practice doctors). It also places an obligation on deputising services to contact the general practice in exceptional circumstances.

General practices need to clarify what is expected of the deputising doctors in cases of urgent and life threatening results being communicated to the deputising doctor in lieu of the GPs in the general practice and vice versa. Ideally this will be outlined in a formal agreement between the general practice and the after hours care provider.

General practice care outside normal opening hours needs to be performed by a recognised GP (either Fellows of the RACGP or vocationally recognised). In some areas it may not be possible to recruit recognised GPs. In such circumstances, doctors who provide general practice care outside normal opening hours, and who are not recognised GPs need to be appropriately trained and qualified to meet the needs of the practice community. Doctors performing general practice care who are not recognised GPs need to have been assessed for entry to general practice and be supervised, mentored and supported in their education to the national standards of the RACGP (as outlined in criterion 3.2.1).

When the practice's GPs themselves cannot safely or reasonably deliver care outside normal opening hours, the practice must be able to clearly document the alternative system of care that is available for their patients at these times. Assessment of this criterion needs to take into account the approach of similar practices in the area. It is necessary that the care be appropriate to the needs of the patient; that it be timely and reliable; and that what is claimed to be available is actually provided. What is 'safe and reasonable' has not been defined here as it is a decision that each practice needs to make in their local context (eg. with regard to location, patient population). What is safe and reasonable needs to be considered by the practice in light of what their peers (or practices in the same area) would agree was safe and reasonable.

Arrangements for medical care outside normal opening hours need to be communicated clearly to patients of the practice.

It is the obligation of general practices which have arrangements with after hours care services to describe their preferred arrangements for the management of patients who live beyond the boundaries of the after hours service(s) to that service(s).

At the time of writing (June 2005) there are no arrangements for the accreditation of cooperatives or other types of 'after hours care' services with the exception of MDS. The RACGP expects that all such 'after hours' facilities and services will be aiming to meet the relevant criteria in these RACGP Standards.

The environment of general practice is dynamic and GPs are referred to the RACGP 'Primary medical care outside normal general practice opening hours' position statement (available at the RACGP website www.racgp.org.au).

The Australian Competition and Consumer Commission (ACCC) has developed an information kit for the medical profession, available at www.accc.gov.au/content/index.phtml/itemId/532394. This may be of assistance to GPs who want to ensure that their arrangements comply with the Trade Practices Act (ie. are not anti-competitive as defined within the Trade Practices Act).

Indicators

1. There is evidence of one (or a combination) of the following for our patients:

1. our practice's GP(s) provide(s) their own care for patients outside normal opening hours of the practice either individually or through a roster, or
2. formal arrangements for cooperative care outside the normal opening hours of our practice exist through a cooperative of one or more local practices, or
3. formal arrangements exist with an accredited medical deputising service, or
4. formal arrangements exist with an appropriately accredited local hospital or an after hours facility, in the circumstances where we do not use an accredited medical deputising service or cooperative.

Where a practice is providing care as indicated by A ii, A iii, or A iv, then the documentation of the arrangement must include:

• reference to the timely reporting of the care provided back to the patient's nominated practice, and
• a defined means of access for the deputising practitioner to patient health information and to our practice GP(s) in exceptional circumstances, and
• assessment by our practice that the care outside normal opening hours will be provided by appropriately qualified health professionals (document review).

2. Patient health records contain reports or notes of consultations occurring outside normal opening hours by or on behalf of our practice (health records review)
3. A message on our practice's telephone answering machine, call diversion system or paging system, and a sign visible from outside our practice, provide information to patients on how to obtain care outside our practice's normal opening hours (direct observation)
4. Our practice has a written policy for the provision of medical care outside its normal opening hours (document review)
5. Our practice has used patient feedback to establish whether patients of our practice are aware of our arrangements for medical care outside our practice's normal opening hours (patient feedback).
6. Our service can demonstrate that:

• timely reporting of the care is provided back to the patient’s nominated general practice/GP
• there is a defined means of access for the deputising practitioner(s) to patient health information and to the practice(s) whose patients are seen, in exceptional circumstances, including the contact details of the general practices and their normal opening hours
• the care is provided by appropriately qualified health professionals (document review).

Publication Date: 27 July 2007
Authorised By: Standards