The population demographic projections ensure that health issues of older people will be a focus for research, health service planning, and provision for at least the rest of this century. Longevity has increased by 10 years over the last half century in New Zealand and it is projected to increase by another 5–6 years by 2050.1

In 2002, 39% of the Vote Health budget of New Zealand was spent on 12% of the population—those over age 65 years.2 By 2021, 18% of the population will be 65 years and over and (considering current per capita expenditure) 50% of the health budget will be needed for them alone.2

As the absolute number of those in the oldest age groups will increase by up to 600% over the next half century,1 it is easy see why there are increasing calls for primary, secondary, and tertiary preventive measures with potential to prolong healthy life expectancy and reduce health expenditure.

As absolute numbers of older people increase, it will be particularly important to have a comprehensive strategy in place to meet the growing needs of the older population. After hours care is part of that need. Consultations with older people make up 23% of all GP consultations, more than expected for 12% of the population.3 Emergency referrals from GPs also occur at up to three times the rate compared with referrals for those aged 15–54 years,3 and illness events are not tied to convenient times of the day.

The article by Eastwood and Dowell,4 in this issue of the Journal, shows that...‘the young-old are particularly under-represented in after hours (primary health care) attendances’...as measured by examination of the two largest after hours practices in the Hutt Valley.

This finding is against the tide of evidence suggesting that consultation rates should be higher in this age group. It did not seem that the young-old prefer the emergency department, rather suggesting that they just don’t go to the after hours providers available in the Hutt Valley region.

Do older people under-recognise important symptoms that prompt their younger counterparts to seek care after hours, or do they find it difficult to get there? As Eastwood and Dowell acknowledge, it is likely that the discrepancy is not wholly explained by purely medical modelling and that societal problems such as inadequacy of public/private transport and fear of venturing out at night are also implicated. Further qualitative work is suggested to illuminate the reasons for this.

The addition to the analysis of two large practices in the Hutt Valley that were not able to be included in the study would have been interesting. After hours in those practices was provided by the practice GPs themselves, thus potentially allowing an important comparison between two of the ways after hours care is delivered. The Eastwood study was also not longitudinal and there was no examination of outcomes of care (and thus causality cannot be implied).

Simultaneous presentations to the emergency department after hours for older people were recorded as resulting in greater admission rate (not surprising in itself) but also as having greater severity (assessed by triage codes) than those for younger people.

Well documented age-related physiological differences in the appreciation of symptoms such as bronchoconstriction and thirst (dehydration) can surely explain only a minority of the difference observed by Eastwood and Dowell. Thus, potential for more accessible after hours primary care visits to mediate these admissions seems possible.

Since 1988/89, ambulatory sensitive hospitalisations (those that would reasonably be expected to be reduced by appropriate primary care) have increased at a higher rate than unavoidable hospitalisations for those aged 65–74 (4.8% average annual increase compared with 2.8% for unavoidable admissions).5

Is there capacity to make after hours care more accessible and acceptable for older people? Gone are the days when a phone call after hours about a health issue was answered by a known voice. Equally remote is the possibility of actually being seen by someone at night who knows you well.

Today’s graduates hesitate to commit themselves to a professional lifetime of full time work in one community.6 Consequently, this increasingly threatens longitudinal continuity and the provision of after hours care to enrolled populations.7

The difficulties with negotiating adequate and appropriate after hours care are well documented.8 Primary care has evolved from high levels of round-the-clock continuity between individual providers and their patients to more moderate levels of continuity with groups of providers, with after hours cover provided by a completely different organisation. Although Eastwood and Dowell did not attempt to consider outcomes, perhaps one consequence of this change is that older people avoid consulting after hours—to the detriment of their health.

New Zealand’s Health of Older People Strategy calls for a continuum of care that is responsive to older people’s diverse and changing needs and that optimises their health and wellbeing.9 Coupled with the Primary Health Care Strategy,10 which aims to provide integrated and accessible services in the community, implementation has the potential to ensure accessible, acceptable after hours care for older people.

Would the simple provision of dedicated transport to and from after hours surgeries help, and if so, would such a service be cost-effective? And are schemes like the alternative provider medical services currently (and controversially) under trial in the United Kingdom needed,11 or can the current system rise to the challenge of providing continuous, comprehensive accessible care for older people?

These questions are important and need to be answered.

Author information: Ngaire Kerse, General Practitioner & Associate Professor, Department of General Practice and Primary Health Care; Martin J Connolly, Freemasons’ Professor of Geriatric Medicine, Department of Medicine;
University of Auckland, Auckland

Correspondence: Ngaire Kerse, Department of General Practice and Primary Health Care, University of Auckland, Private Bag 92019, Auckland. Fax: (09) 373 7006; email: n.kerse@auckland.ac.nz