After-hours patient care needs rethinking
You’re getting home after a long day at work and the cough that has been bugging you just doesn’t seem to be letting up, your muscles ache, you’ve got chills and a slight wheeze. What do you do?
Do you head to the local emergency department? A walk-in clinic? Or does your family doctor have an after-hours service?
As a family doctor, I’d like to think you’d call your doctor’s office or go to their after-hours clinic. But chances are, you head to the emergency department.
Canadians use the emergency department far more than people in other high-income countries. In the last two years, 40 per cent of Canadians were seen in the emergency department compared to 24 per cent in the U.K., 20 per cent in the Netherlands and just 11 per cent in Germany.
Canadian governments have wondered whether one way of curbing emergency department use is to improve access to family doctors after-hours.
About 15 years ago, Ontario introduced new practice models that paid physicians differently and encouraged them to work in groups and take responsibility for a roster of patients. Physicians in these new practice models were also required to provide a certain number of evening or weekend clinics. The hope was to divert some emergency department visits to family practices.
Unfortunately, it didn’t quite work as planned.
Our recent study found that emergency department use did not decrease for patients who joined the new practice models. Between 2003 and 2014, there was actually an increase in the rate of emergency department visits in Ontario, particularly during the day. At the same time, the overall rate of visits to family doctors went down but family doctors seemed to be providing more after-hours care.
Why didn’t asking family doctors to provide after-hours care reduce emergency department visits? It may be that an increase in family doctor availability after-hours was offset by a decrease in availability during the day. Providing more services may also just increase people’s demand for services. Or maybe you do see your family doctor and they are worried about pneumonia so they send you to the emergency department because that’s the only way they can get an X-ray after-hours.
Just asking family practices to provide more care on the evenings and weekends is likely not enough. Family practices need to have the right resources to provide care after-hours, including access to labs and X-rays and, ideally, access to shared electronic patient records.
We also need to improve timely access to primary care during the day. In a recent international survey, 25 per cent said they went to the emergency department because their family doctor wasn’t available.
More after-hours care may not necessarily reduce emergency department visits, but it’s still an important service for patients.
We need to better understand patient values and rethink how we have designed our system for those with an acute health complaint in the evenings or on weekends. Let’s learn from other countries and evaluate related reforms here in Canada.
Tara Kiran is a family physician at the St. Michael’s Hospital Academic Family Health Team, adjunct scientist at ICES, and the Fidani Chair in Innovation and Improvement at the University of Toronto. She is a contributor with EvidenceNetwork.ca based at the University of Winnipeg.