After-hours primary healthcare is defined as ‘accessible and effective care for people whose health condition is urgent and cannot wait for treatment until regular services are next available’.3 The Commonwealth defined after-hours period is between Monday to Friday from 6.00 pm to 8.00 am, Saturdays from midday, all day on Sundays and all day on gazetted public holidays.1
General practice has a long history of working with after-hours service providers. When after-hours service providers are affiliated with an established general practice, the service can maintain continuity of care for a GP’s patient, while significantly reducing the GP’s need to provide after-hours care.
4.1 Education and training
Working to provide after-hours primary care services can present the same challenges and complexities as clinic-based general practice. Doctors working for after-hours services must therefore have an appropriate level of education and clinical competency, as per the Fellowship of the RACGP (FRACGP) or Australian College of Rural and Remote Medicine (FACRRM) qualification.
The quality and safety of patient care is at risk in the absence of appropriately trained and experienced GPs providing primary care services in the after-hours period. Unsuitable workforce arrangements can contribute to further emergency department presentations and/or follow up appointments with a GP.
After-hours services that attract a Medicare Benefit Schedule (MBS) rebate should only be provided by appropriately trained specialists, including:
- specialist general practitioners
- general practice registrars with appropriate supervision
- medical practitioners actively working toward a Fellowship in general practiceb
- medical practitioners with more than ten years’ experience in Australian general practice.
The RACGP considers that the employment or placement of a general practice registrar by or in an after-hours service should be made in accordance with the RACGP Standards for general practice training (2nd edition).
4.2 Continuity of care
GPs provide continuous, coordinated and comprehensive healthcare. GPs know their patients’ medical histories, can undertake preventive care, manage chronic health conditions and coordinate their patients’ multidisciplinary care needs. Primary care provided outside of this model causes fragmentation, which results in wasted health resources, largely through duplication or provision of unnecessary services.
After-hours services should therefore only be used when a patient’s usual GP or general practice is not available for an urgent health concern that cannot wait until regular services are next available.
Formal arrangements between general practices and after-hours services support continuity of care and the timely handover of clinical patient information to the patient’s regular GP. It is preferred that patients access after-hours services that have a formal arrangement with their usual general practice.
The RACGP recommends that all after-hours services work directly with local general practices to develop appropriate continuity arrangements. Best-practice formal agreements between a general practice and an after-hours service should detail the roles and responsibilities of both parties, as per the RACGP guide to establishing an agreement between your general practice and an after-hours service provider.
After-hours services and general practices should discuss and document areas where continuity of patient care can be enhanced. During this process, general practices should consider their obligations according to the RACGP Standards for general practice (5th edition), including ensuring after-hours services can access important information about patients, particularly in an emergency.
After-hours primary healthcare services play a vital role in ensuring that patients can access appropriate healthcare when they need it and can alleviate demand on hospital emergency departments.
The RACGP considers that dedicated after-hours services should only schedule appointments during the after-hours period as defined by the Australian government. Patients should not be able to make appointments with an after-hours service in advance of the after-hours period.
Appropriate triaging of patients is essential to avoid unnecessary use of after-hours services. The RACGP strongly recommends that only suitably qualified staff employed by the after-hours service undertake triage. This includes GPs, nurses or other professionals trained in appropriate protocols.
After-hours services also have a vital role in preventing avoidable emergency department presentations and ensuring continuity of care for people living in Residential Aged Care Facilities. It is therefore vital that these facilities ensure their residents can access either their preferred GP or an after-hours service provider.
It is important all patients can access culturally safe after-hours care. Services may need to consider cultural safety training for staff, with particular focus on service delivery for Aboriginal and Torres Strait Islander peoples, to ensure their services are culturally safe.
The RACGP recognises that after-hours services are not conventional general practices.
To ensure appropriate clinical and administrative governance, the RACGP recommends that these services are accredited against the RACGP’s Standards for after-hours and medical deputising services (5th edition). Accreditation against these standards will also demonstrate a commitment to supporting quality care.
For after-hours services to be accredited under the Approved Medical Deputising Service Program (AMDS), they need to have obtained certification against these standards.
4.5 Advertising and marketing of after-hours services
After-hours services, like all other regulated health services, must adhere to the Medical Board of Australia’s Code of Conduct and the AHPRA Guidelines for advertising regulated health services. The guidelines indicate that under the Health Practitioner Regulation National Law (section 133), ‘a person must not advertise a regulated health service, or a business that provides a regulated health service in a way that directly or indirectly encourages the indiscriminate or unnecessary use of regulated health services’.4
The RACGP supports a ban on after-hours services employing mass media marketing/advertising (via television, radio, billboards and print media) directly to the public, as this marketing encourages the excessive and unnecessary use of after-hours health services.
4.6 Expansion of telehealth
The COVID-19 pandemic has seen the expansion of access to MBS items for telehealth services, available for use during in- and after-hours periods. Telehealth has presented an opportunity for GPs to facilitate patient access, increase flexibility in service delivery and, during the pandemic and other widespread emergencies/disasters, ensure the safety of GPs, practice staff and patients.
However, there has also been a surge in entrepreneurial, profit-driven telehealth models/businesses which offer often cursory medical services, both in-hours and after-hours. These on-demand telehealth services are typically not linked to a regular GP/practice. The delivery of after-hours telehealth services disconnected from a patient’s regular GP or practice is not aligned with best-practice care. The telehealth environment reinforces the need to support continuity of care and ensure an appropriate level of skill and training for the after-hours workforce.
The RACGP supports linking access to MBS rebates for telehealth through the patient’s usual GP. Telehealth should also remain available through the MBS for AMDS providers who have a formal arrangement with the patient’s usual general practice.