Primary care out-of-hours: Lessons from a rapid systematic review of the international literature
Out-of-hours (OOH) primary care continues to evolve and develop. In the UK, there has been a continued focus on quality of care, service re-organisation, skill mix and demand particularly after the GMS contract in 2004. The Scottish Government recently commissioned a national review of out-of-hours care. To inform that work, we conducted a rapid systematic review of the international literature. The aim was to identify and evaluate the literature on OOH care and to identify gaps in our knowledge base.
EBSCOHost; CINAHL; Medline; PsyARTICLES; PsychINFO; SocINDEX; Ovid; and Embase were searched, from 1996 to 2015, using terms related to primary care OOH. Papers with no empirical data; not concerned with primary care OOH; not in English; were excluded. Titles and abstracts were double-screened. Included articles were reviewed, characterized and assessed for methodological quality by two team members. Data were extracted into summary tables and discussed to ensure key messages were identified.
Searches identified 1364 papers for title/abstract screening; 478 full papers were reviewed, with 274 included. Most were from the UK (55%) or Europe (35%). While the definition of what time period constituted OOH care was uncontested, there was no consensus on whether OOH was urgent care only or unscheduled care, regardless of urgency. Most papers (75%) were quantitative in methodology. Over one quarter dealt with demand, use and outcome patterns; approximately 25% focused on users’ views; 20% assessed new models of care, mainly GP-led services and telephone triage services. In relation to professional roles, there was a clear focus on GPs/family physicians. Other groups addressed were telephone triage and nursing staff. The literature on GP needs in relation to training was scant and there was no literature on training and support needs for any other professional group working in OOH primary care. There was also nothing in relation to developing awareness of OOH in undergraduate curricula or of building professionalism and competencies amongst the workforce. There was little work on the interface between in-hours and OOH care or between health and social care and little on IT or data sharing. There were almost no economic evaluations of OOH care models. Few papers examined care for individual patient groups. Of those identified, 30 papers focused cancer/palliative care patients; only 4 focused on mental health/psychiatric patients and 3 on the elderly.
The literature shows that OOH care was developed to respond to acute care needs. This makes the current OOH model less responsive to the needs of an aging, multi-morbid population with complex health and social care needs. The literature, while of good quality, potentially fails to inform policy-makers needs in relation to providing OOH care in the face of rising demand and increasing fiscal pressures.