Out-of-hours co-operatives: General practitioner satisfaction with governance and working arrangements

Abstract

Objective. General practice co-operatives have led to significant improvements in quality of life for general practitioners. Little is known about general practitioners’ own experiences with the working arrangements and governance of co-operatives. This study investigates GP satisfaction, the working environment, governance and future developments in co-operatives. Methods. A questionnaire was sent to GPs in two co-operatives in the Republic of Ireland, covering mixed urban and rural areas. Results. Of 221 GPs in the co-operatives, 82% responded and confirmed the co-operatives’ positive effects on their lives. However, 57% still received requests for out-of-hours care while off duty, most commonly from patients who preferred to see their own doctor. Half felt overburdened by out-of-hours work, especially those over 40 y of age. Twenty-five per cent were dissatisfied with the GP complaints mechanism. The majority (63%) would prefer a GP/health board partnership for the organization of out of hours, while 23% wanted sole responsibility. GPs indicated a strong need for better ancillary services such as nursing, mental health, dentistry, pharmacy and social work. Access to records is an important issue in terminal care and mental illness. Conclusion. While GP co-operatives are a success story for general practice, they will work better for general practitioners and their patients if nursing, mental health, dentistry, pharmacy and social services are improved. Support and training is needed in mental health, palliative and emergency care to increase competence and reduce stress. GPs are willing to work with health authorities in further co-operative development. More attention needs to be paid to the complaints and suggestions of GPs in the running and governance of their co-operatives.

• Co-operatives
• governance
• out of hours
• GP views

Introduction

The co-operative movement has deep roots in rural Ireland with the Co-operative Workers’ Society and Sir Horace Plunkett establishing creameries in rural County Limerick in 1889 and in 1891. Rural general practice has been an important driver in GP co-operatives, which have arisen out of the need to make increasing out-of-hours demands manageable for general practitioners (GPs) [1].

General practice out-of-hours co-operatives have developed rapidly in Ireland since 1998 when the first was set up in St James's Hospital in Dublin [2]. Since that time, 11 different co-operatives have been set up, providing service to 40% of the Irish population [3]. Most co-operatives are sited outside Dublin and cover 70% of this population, while many areas of Dublin are still reliant on the commercial deputizing services for out-of-hours support. The co-operatives vary in terms of triage mechanisms, treatment centre and domiciliary visits; however, they have high satisfaction ratings within the populations they serve [2], [3].

Before the first co-operatives were established in Ireland, general practitioners worked an average of 46 h per week on call [4]. GPs in many rural and mixed rural/urban areas worked longer hours than urban counterparts because locum and deputizing services were more difficult to obtain, and because of the relative absence of alternative sources of healthcare [5]. Doctors in such situations report substantial adverse effects on the quality of their family and social life as a direct result of their on-call commitments [5–7].

A number of recent studies agree on the benefits that out-of-hours co-operatives bring to quality of life for participating GPs [1], [8–11], and to the considerable decrease in out-of-hours workload [10]. Studies to date asking GPs about the running of co-operatives have largely addressed the service provided to patients [1], [13]. This study views co-operatives from the GP perspective, investigating the working environment and governance together with future developments.

Methods

The setting was two out-of-hours co-operatives in Ireland (Caredoc and North-East Doc) whose 221 GPs serve rural and mixed urban/rural areas with a population of approximately 360 000 patients. Both co-operatives used a call centre to triage patients over the phone. Patients most commonly received advice over the phone or had arrangements made to see a doctor at a treatment centre if necessary. The major difference in the service model was that initial calls to Caredoc were triaged by nurses, whereas all calls to North-East Doc were given straight to general practitioners. Both models offered only general practice services, and required the participation of member GPs for their provision. Contractual arrangements differed substantially for the two organizations. Whereas North-East Doc, run in conjunction with the local health authority, paid an hourly rate to their GPs, Caredoc GPs were paid on a consultation basis with no provisions made to reimburse phone consultations, general medical services consultations or down-time where the GP has no patients waiting to be seen.

Themes were identified from previous research [14], and also included issues raised in discussion with GPs, patients and co-operative management. A literature review also identified a number of topics, of relevance to co-operatives and out-of-hours care, more generally [1], [14–20]. Amendments were made to the questionnaire following a pilot study of GPs from a third co-operative not involved in the study.

The confidential questionnaire was sent to all general practitioners who were members of either co-operative, and was followed by a written reminder 3 week later. A second reminder was issued by telephone 4 wk later to those who had yet to respond. Up to three phone call attempts were made over a 2-day period in order to contact the remaining subjects.

Results

The final response rate was 82% (182/221) overall, although not all respondents answered all questions.

Ninety-seven per cent (175/181) reported improvement in their own quality of life as a result of joining the co-operative. Large proportions reported improvements in their quality of family/social life (91%, 165/182), their ability to cope with the demands of work (75%, 135/180) and their levels of stress generally (77%, 139/180).

Interestingly, 57% (104/182) of respondents still received personal requests for out-of-hours consultations when not on call. Twenty-two per cent (22/102) of these said that these typically occurred on a weekly basis or more often. The most commonly agreed reasons for patients not contacting the co-operative concerned the patient's preference for their own doctor who was familiar with their problem.

Despite the evident lifestyle benefits, half the respondents (88/178) still felt overburdened by taking on co-operative responsibilities. A greater proportion of those aged 40 y or more reported being overburdened (52%, 71/137) when compared to those aged less than 40 y (41%, 17/41). There was a degree of dissatisfaction with the number of shifts after midnight (20%, 32/161), the advance notice given of shifts (16%, 28/176) and the frequency of shifts worked (12%, 21/175). There was no difference in response seen between the two co-operatives.

There was strong satisfaction, however, with medical and support staff (94%, 162/173), the method by which shifts are allocated (92%, 151/164), and their own skill level for out-of-hours work (95%, 168/177). However, doctors over 55 years of age were less confident with their own skills for out-of-hours work (83% (25/30) vs 97% (143/147), p<0.01).

Ninety per cent of respondents were satisfied that their co-operative had adequate provision of both medicines and medical equipment, while 96% were satisfied with the independence they had in deciding how best to treat a patient.

Almost a quarter (40/173) of GPs were not satisfied that there was an adequate procedure to deal with their own complaints in their co-operative. They felt that suggestions or complaints were often not acted upon and that the process for making a complaint was unclear.

Respondents felt that their personal involvement as local doctors providing care was more important before midnight than after midnight. A large majority (71%, 126/178) indicated that their own regular involvement was required before midnight. Conversely and surprisingly, a majority (58%, 103/179) considered there to be no need for their personal involvement in the “red-eye” shift (midnight to 8.00 AM).

The area where considerable differences were evident between the co-operatives in terms of satisfaction regarded the pay and hours required to work. Satisfaction with the frequency with which locums were used after midnight was 83% (80/96) in North-East Doc compared to just 58% (45/78) in Caredoc (p<0.01), where there were more stringent requirements for the members to undertake their own shifts. This is also reflected in a decreased level of satisfaction with the proportion of red-eye shifts being allocated among Caredoc GPs. While satisfaction with the overall amount paid was roughly equal at 46% (36/79) in Caredoc and 41% (39/96) in North-East Doc, satisfaction with the method of payment did vary significantly between co-operatives: 84% (82/98) in North-East Doc were satisfied with their hourly rate payment method, compared with just 58% in Caredoc (46/79, p<0.01).

The majority (63%, 113/180) of respondents would prefer a health board/general practitioner partnership approach to the organization of out-of-hours primary care in the future, while just 23% (41) wanted this responsibility to lie solely with general practitioners.

Sixty-eight per cent (124/182) of respondents agreed that there are patient groups who pose particular difficulties out of hours. Twenty-three per cent of all respondents (42/182) specified those with mental illnesses, 30% (55/182) those requiring palliative care, and 28% (51/182) mentioned various other patient groups. Poor knowledge of the patient and lack of access to the patient's record were widely cited as obstacles to the satisfactory treatment of such patients.

GPs revealed general dissatisfaction with the current provision of ancillary out-of-hours services (Table I). There was strong agreement that the provision of mental health, dental and social services was inadequate out of hours, with community pharmacy provision scoring best at 42% (74/176).

Table I.  General practitioners’ attitudes about the provision of out-of-hours services from ancillary health-related services.

	% of doctors choosing each category
	Adequate	Inadequate	Not required	Total number responding
Public health nurses	20	72	8	175
Dentists	3	95	2	178
Pharmacists	42	50	8	176
Social workers	4	88	8	170
Mental health workers	16	81	4	171
Counselors	4	66	30	169

Overall, 24% (44/182) of all respondents attributed difficulty in caring for certain patient groups to continuity of care issues. More specifically, they cited insufficient knowledge of the patient or claimed that the service they provided could be improved by a database of information about specific patients, especially those with a mental illness or those in palliative or terminal care. A number of doctors indicated that they still personally managed the out-of-hours needs of their palliative care patients for this reason.

Over 70% (130/182) of GPs offered suggestions for improvements in their co-operative:

• A reduction in numbers of shifts after midnight (19%, 36/182)

• Improved, purpose-built premises with better facilities for sleeping, eating, etc. (16%, 30/182)

• An increased role for nurses (13%, 24/182); (these comments were largely from North-East Doc GPs, where nurse triage was not employed)

• A greater say for members in the running and decision-making processes of the organization (12%, 22/182)

• A preference for a flat rate of pay (10%, 8/83, of those receiving a fee per consultation)

• The need for public awareness that the co-operative is an emergency service, not an out-of-hours clinic (7%, 12/182)

• Continuing education courses in relevant areas (5%, 9/182)

• Equitable allocation of shifts (5%, 10/182)

• Stricter vetting of locums (2%, 3/182)

Discussion

Strengths of the study

There was a good response rate to the survey, with GPs generating many ideas for the betterment of their co-operatives. Good-quality information was provided on the concerns co-operative members have about the running and governance of their co-operatives.

Limitations of the study

While the provision of out-of-hours care is similar internationally, the more detailed service concerns of GPs are less generalizable as they are context specific. Moreover, this survey only examined attitudes and preferences after the implementation of the co-operative structure had taken place. An understanding and measurement of the baseline attitudes and working conditions prior to implementation of the co-operative structures would have allowed a more objective measure of the impact of this change rather than this subjective assessment of these organizations.

As general practitioners treasure their independent contractor status, it was surprising to note that the majority were willing to share the responsibility for out-of-hours care with their health board, and less than a quarter wanted sole GP control over the co-operative regardless of current arrangements. It does seem inconsistent that they only want personal involvement in service provision before midnight but not afterwards, perhaps being willing to cede control in favour of uninterrupted sleep.

Over half the GPs in this study of co-operatives still received approaches from patients for out-of-hours consultations when they were off duty, and doctors seem to find it difficult to turn them away. GPs frequently stated the need for better communication with the public, and respecting time off duty is an important message. It is notable that some general practitioners give their telephone numbers to the terminally ill despite the availability of the co-operative. While this commitment to patients is admirable, two of the reasons behind this are probably difficulties in accessing other doctors’ records and lack of support services.

Both GPs and their patients in large urban areas have long been used to deputizing services. However, for doctors in small towns and rural areas, handing over out-of-hours care completely to the co-operative seems not to have happened. This may be because rural GPs build a satisfying relationship with their patients that is based on continuity of care but at personal and family cost [5]. Doctors over 40 are particularly stressed by co-operative responsibilities, which are compounded by lack of knowledge of the patient and, often, absence of medical records. While equipment and drugs were readily available, general practitioners have training needs in dealing with concentrated amounts of emergency medicine. Attention to such training needs and the availability of other health professionals may reduce the stress associated with being on-call. Similarly, support is needed in dealing with both mental health and palliative care out of hours.

It is surprising that co-operatives did not have adequate procedures to deal with GPs’ own complaints and suggestions, and the governance of co-operatives will need to allow members to have a greater say in the decision-making process within their organization.

We wish to acknowledge the co-operation of the management and general practitioners in both Caredoc and North-East Doc, and the unrestricted funding of the study by the Department of Health and Children. We also acknowledge the general practitioners in Dubdoc who helped us with the pilot study.