Main Report of the National Review of Primary Care Out of Hours Services

Annex F: Commissioned Research

Commissioned Research Evidence

To underpin the work of the Review, a rapid systematic literature review and qualitative study was commissioned via the Scottish School of Primary Care and undertaken by Professor Catherine O'Donnell and colleagues, General Practice & Primary Care, Institute of Health and Wellbeing, University of Glasgow.

A full report of the research work undertaken is available on the Review website.

This research work aimed to a) identify the key literature on OOH care services, b) focus on the structure, use and evaluation of OOH primary medical care, c) sought to identify gaps in the knowledge base and d) analyse the literature in order to inform the development of future OOH services. The research examined primary clinical care but also key interfaces, including community, social care and A&E services.

The literature review included those countries with health care systems broadly similar to that of Scotland or where there might be new types of service development potentially transferable to Scotland. There has been a number of service models developed in the last 10 to 15 years, operating in OOH periods (for example NHS 24, NHS Direct, walk-in clinics). The scope of the literature review therefore covered:

• UK and appropriate international settings, mainly Europe, Australia, New Zealand and the US.
• Primary medical care (excluding dentistry and social work out-of-hours services).
• Services which impact on primary medical care, including: out-of-hours telephone-based services such as NHS 24, NHS Direct and the NHS 111 service.
• A&E/emergency department initiatives designed to interface with primary care services.
• Community-based or social work services designed to interface with primary care services.

Aims of systematic review of peer-reviewed literature

• To identify the peer-reviewed literature focussed on the structure, use and evaluation of OOH primary care services
• To identify gaps in the knowledge base with respect to OOH services
• To help to define what quality OOH services should look like in the future

In summary, the research work report is presented in five sections:

Section 1: outlines the key definitions used in the research

Section 2: reviews the international literature on OOH primary care

Section 3: summarises the wide set of literature on demand, use and outcomes

Section 4: reviews the published literature in relation to the Review Task Sub-Groups

Section 5: reports on a series of interviews conducted with new and more experienced GPs

Section 6: summarises this evidence and outlines our own recommendations for future research and evaluation in this area.

Overall summary and recommendations

The evidence identified by this rapid systematic review indicates a preponderance of quantitative research. The relative ease of collecting quantitative data on demand, use and outcome, indicates that around one quarter of the 274 papers included in this review dealt with such issues. Indeed, over all the research areas, the use of quantitative data and observational methods such as case/record review, routine data and questionnaires predominated. Despite the importance to policy makers of knowing which models are more effective in terms of meeting patient need, only four randomised controlled trials were identified. There were also very few studies which conducted an economic analysis of the costs associated with OOH care.

Much of the research studies have focused on GP-led models of care, or on nurse-led telephone triage. Other issues, such as the future role of pharmacists in OOH care provision, and links to social care and third sector organisations are conspicuously under-researched.

While there has been some work researching the issues faced by service providers - mainly GPs - in caring for palliative care patients, other patient groups are very much overlooked. There was little or no evidence in relation to meeting the needs of elderly patients, particularly frail elderly, patients with dementia, patients with particular communication needs, such as the deaf community, or patients whose first language is not that of the host country. Such gaps need to be addressed

Key areas identified as being crucial in the development of high quality OOH services

• Good communication and information technology, both across out-of-hours service providers but also across the daytime and OOH interfaces.
• Better understanding of how patients view OOH services and the decisions they make in relation to which service they choose to attend.
• Development and evaluation of new professional roles in OOH care, in particular pharmacy, but also other organisations out with health care
• Better engagement with early career GPs, with trainees and with undergraduate medical students to promote the value and professionalism of providing out-of-hours care.
• Improvement in career development and training for other professional groups.
• Single, centralised systems have to be 'future proofed' to address the contextual realities of different areas, for example patients in remote and rural areas have different needs and capacity to respond compared to those in urban areas. This is also true in relation to socioeconomic deprivation
• Co-location and integration of services will have to be rigorously evaluated, including process evaluations to understand the impact and challenges this brings to different professional groups.

Recommendations for research and evaluation

Future models of care need to be rigorously evaluated using experimental research designs which will allow both clinical and cost effectiveness to be addressed. The methodology used should include cluster randomised controlled trials and alternative study designs, such as stepped-wedge study designs, to best inform the development of OOH delivery programmes. This research should pay particular attention to the requirements of key groups with specific needs, including palliative care, mental health, frail older people and individuals with communication and accessibility issues.

Future evaluation designs should include economic evaluation to assess not only the immediate costs of new models of care, but also the wider impact on other parts of the health and social care system, in relation to health and social care integration imperatives.

A better understanding is required of the decision-making of patients and carers in terms of: what they know and understand of different parts of the OOH system and what makes them choose one service provider over another (for example phoning NHS 24 versus attending A&E services).

Co-location, co-working and integration of services should be underpinned and informed by evaluation, including qualitative process evaluation to understand the challenges and facilitating factors for co-location.