After Hours Care
Primary Health Care After Hours Position Statement
(Revised December 2007)
As part of the provision of quality primary health care, it is important that
all patients have access to timely, appropriate primary health care. New
Zealand’s geographic population spread and an aging general practitioner
workforce however has meant that access to and delivery of after hours services
in many parts of New Zealand are increasingly facing a range of difficulties.
The fact that in 2004 the Government set up a working party to look at the
provision of after hours primary health care is a recognition of this growing
problem.
After consideration the NZMA has adopted the following stand point about general practice obligations for providing after hours primary health care:
- Medical Practitioners have an ethical and professional obligation to ensure that their patients have continuous access to appropriate care and continuity of care.
- This responsibility is reinforced by Clause 1 of the NZMA's Code of Ethics, and by recommendation 9 of the Code.
- After hours care is to be provided to cover situations of urgent need. It is unreasonable to expect the same level of service to be available after hours as it is during working hours.
- Government agencies, (such as the MoH, ACC and District Health Boards), share the obligation to guarantee access to 24/7 care by ensuring that sufficient resources (including appropriate funding), are provided to allow appropriate patient access to services, including 24 hour, 7 day services. Other organisations, including public hospitals and PHOs/PCOs, have a primary contractual responsibility, (clearly specified in contracts), as well as a moral duty, to ensure appropriate access to care. Doctors have a responsibility to provide reasonable assistance to organisations to which they are contracted, or are employed by.
- The obligation for providing 24/7 after hours care to the community rests with PHOs. Any contractual requirements they may place on general practices to provide after hours care must be both reasonable, and sufficiently flexible as to allow for changing circumstances. Where circumstances change so that it is no longer reasonable for general practitioners to continue to provide 24/7 it is the obligation of the PHO to find an alternative reasonable solution. General Practitioners however should try to accommodate any proposed solutions as is reasonable.
- It is acknowledged that in some areas the numbers of general practitioners are so few that it is unreasonable to expect the general practitioner to participate in a rostered after hours primary health care system. In those situations the general practitioner’s obligation is to inform the PHO of their inability to offer after hours care and to work with the PHO to see that an alternative arrangement can be made that meets this requirement.
- Doctors' responsibilities for arranging, or participating in
arrangements for the provision of 24 hour/7 day care must be assessed in
light of:
-- patient safety;
-- available resources, including funding, support and locums;
-- the doctor's own health and well being and that of his or her family;
-- legal and contractual requirements, including those in respect of safe working conditions and employment arrangements. - Regardless of the above, doctors have a duty to provide care in an emergency. This duty must not be used by government agencies or contracting bodies to require services to be provided in unreasonable circumstances.
- Where an investigation requested by a Doctor is performed by an intermediary diagnostic service out of normal working hours and discloses a serious abnormality which requires urgent treatment before the next normal hours working session then either the requesting Doctor should be available to take clinical responsibility for contacting the patient and arranging appropriate treatment or the requesting Doctor should have delegated this responsibility to an after hours provider to take all reasonable and necessary steps to contact the patient and arrange treatment. It is unsatisfactory for the requesting Doctor to expect or cause the intermediary diagnostic service to take clinical responsibility for the patient in such circumstances.
- All agencies and persons involved in the provision of after hours care
should (subject to the patient’s consent) pass any medical information about
the patient back to the general practice the patient is enrolled with.
- Access to after hours care may take a variety of forms.
- NZMA endorses inventive general practice teamwork that develops new ways for providing after hours care, including the greater role of nurses in supporting the provision of this service.
- In the delivery of after hours care, teamwork is essential. The team may include the resources of hospitals (including provincial/rural hospitals) and can transcend primary and secondary interfaces.
Current Issues
- Although the requirements of after hours care needs to be considered at a local level, the policy framework and standards for the equitable provision of services should be set at a national level.
- NZMA considers that the current capitation formula provided by Government for primary health care does not include funding for 24/7 after hours care.
- In rural areas Prime has the potential to provide a satisfactory basis for response to accidents and some emergencies. However, there are aspects of Prime which are currently unacceptable and which need to be addressed.
- Telephone advice lines such as Healthline or Plunket, function as triage
and advisory services; they are not treatment services. Thus while it may
support the provision of 24 hour/7 medical services it cannot replace it.
- It is likely in the future that technology will play a greater role in the delivery of the provision of primary health after hours care. NZMA endorses moves to do this provided that in doing so the quality of the health care service given is not compromised.