CAIRN-INT.INFO : International Edition

■ Introduction

1Regulating the demand for out-of-hours (OOH) services is, in most European countries, the subject of some consideration and even sizeable reforms, to address new developments in medical practice and to reduce inefficiencies in the current delivery of OOH services.

2On the one hand, the increasing number of women among doctors and its impact in terms of working hours, the lack of appeal of remote areas lacking facilities and professional opportunities for spouses, and the desire for some freedom of choice with regard to the constraints of on-call status are issues that challenge the traditional form of OOH services delivery. Yet OOH service accounts for a substantial part of a doctor’s activities and is one of the stumbling blocks in negotiations inasmuch as its operation is largely governed by regulatory methods and medical density. On the other hand, the demand for OOH services is on the increase, mainly because of demographic and cultural, but also epidemiological, factors. This trend reinforces the role of OOH primary care as the entry point into the health system in all countries.

3More specifically, the notion of OOH services refers to the organisation set up by public authorities (and possibly health professionals) in order to offer structured, appropriate, coordinated facilities in response to patients’ demand for services at times when medical practices and primary care centres are closed. This extended provision of medical services must be effective throughout the whole territory, although organisational arrangements may depend on the geographic and demographic characteristics of the region and its medical and ancillary staff density. It may be freely determined by the profession itself or imposed by the regulator. [1] Quite frequently, the organisation of OOH services is co-managed at local level together with the medical profession and involves a large number of care providers: health care professionals, primary care centres, hospital A&E (accident and emergency) departments, OOH medical aid services, etc.

4The efficiency of OOH services can be assessed in two respects: the ability to respond as quickly as possible with quality care to the patient’s demand; and the ability to produce the services expected while minimising production costs, whether these result directly from the way the system operates (compensatory payments to doctors, referral to or misuse of secondary care and congestion of A&E departments, etc.) or indirectly because of a lack of continuity in providing health care or passing on the patient’s records. Equal treatment requires that access to OOH services be guaranteed, irrespective of the geographic area, to all users. [2]

5Last but not least, the issues involved in the delivery of OOH services go beyond objectives of efficiency and geographical equity in terms of access to health care, inasmuch as it is also a potential means of combating social health disparities (Couffinhal et al. 2005).
In European countries, the way OOH services are organised is closely linked to the institutional architecture of the health system. Methods for regulating demand for OOH care are accordingly quite specific, even though they are organised around common principles and objectives. The purpose of this contribution is to enquire into the possible convergence of alternative models of demand regulation in some of the countries surveyed: Germany, Spain, France, Italy, the United Kingdom and Sweden (see Table 2). The first part of the article outlines the traditional patterns of demand regulation for OOH services in these countries and their possible limitations. The second part is devoted to new forms of OOH service organisation and the possible emergence of a common model largely supported by new information and communication technologies and the ability of health systems to devise new professional roles, empower the demand for care and subject its operation to regular economic assessment. [3]

Box 1: this study was carried out in collaboration with:

Ariadna Garcia Prado and Eunate Mayor: Public University of Navarra,
David Heaney: University of Aberdeen, Scotland Björn Lindgren: University of Lund, Sweden Sophia Schlette: Bertelsmann Foundation, Germany
Paolo Tesdeschi and Davide Galli: Bocconi University, Milan, Italy

■ The traditional regulation of OOH services

6The regulation of demand for OOH services represents an important aspect of recent reforms designed to improve the working of health care systems in Europe. Solving the equation between efficient delivery of OOH services and recent trends in medical density may be particularly difficult in countries characterised by geographic disparities in the distribution of doctors: not only do they need to be encouraged to set up practice in areas where there is a shortfall (or to stay there) but also to establish appropriate on-call arrangements. Current forms of organisation are closely tied to a society’s perception of the doctor’s role, be it via medical studies (how and when the labour market is entered), practice set-up conditions (restricted or not), or the relationship between primary and secondary care (in particular the presence of a “gatekeeper” figure).

Box 2: Methodology

The selection of countries was driven both by the variety of their organisation, combining to varying degrees social insurance and a national health scheme, but also by the level of advancement in the reform of primary and OOH services.
This comparison is based on an original method inasmuch as, apart from the conventional collection of institutional data, a large part of the qualitative data was obtained from semi-directive interviews with around a dozen stakeholders (health professionals, payers, users, and so on) in each country, highlighting the relationship between hospital and GP care, GPs’ behaviour and perceptions regarding OOH services, and the obstacles to its development, incentives (or legal requirement) to operate them and schemes set up specifically for OOH services provision.
This international comparison gave rise to a report for the French ministry of health (Ulmann, Hartmann, Rochaix et al. 2005), the main findings of which are presented here.

7Accordingly, two types of regulation coexist: one the one hand, upstream regulation aimed at motivating providers to set up practice in under-serviced areas, which only applies for countries with an unequal distribution
of doctors; [4] on the other, traditional methods used in organising OOH services delivery: making it an obligation, offering an incentive for its supply or delegating its operation to another party.

The traditional patterns of OOH service delivery

Co-management of OOH services between care providers and social insurance based on duties and on-call rotas, in Germany, Spain and France

8In Germany, Spain and France, OOH service provision is a matter for regional authorities comprising independent bodies of general practitioners established on a regional or sometimes local level, as specified in the national regulations. The areas and rotas are determined by the professional doctors’ bodies, which are required to ensure permanent access to primary care during and out of normal practice hours. As a result, all GPs working under the social insurance system in Germany (locally the regional medical association, Kassenärztliche Vereinigung, KV), or any doctor working under the basic public service contract in Spain, are required to take part in OOH services. In France this commitment has been made voluntary since 2005, with the Conseil Départemental de l’Ordre des Médecins (CDOM) organising the rotas. However, the regional préfet may occasionally require doctors to make up for shortfalls in the rota system.

9In Spain, OOH service provision is handled by organisations specific to each autonomous region with its own legislation drawn up under the law on cohesion and quality of the national health service, with the participation of health professionals. Every region must be subdivided into health areas (200,000 to 250,000 inhabitants), then into basic health zones of 5,000 to 25,000 inhabitants, which must contain a primary care centre that can be reached in theory within 30 minutes. As a result, there is some variability between the regions as regards the organisation of OOH services provision in coordination with the hospital A&E departments, and considerable variability in the level of payment per hour of rota duty (when this is not included in the work contract, which is a special case), since some forms of remuneration are based on a duty time slot while others are determined on an hourly rate. A doctor working in the public service is usually committed to working 50 duty hours per month, including 12 during weekends. Services accessible out of normal hours in primary care are family medicine, paediatrics, gynaecology and psychiatry, together with nursing services. Out-of-hours duty is an obligation for primary care doctors but may be optional in certain cases. All public service doctors (i.e. almost all doctors) must in principle be on call 50 hours per month including 12 during weekends.
The German and French models are somewhat similar. In France, the oncall periods are relatively shorter than in Germany because of the longer regular working week (self-employed doctors being free to fix the opening times of their practices, however), while these services may be provided indiscriminately by general practitioners or specialists and are generally subject to flat-rate remuneration. There is no single system of OOH services, with ad hoc regional variations taking account of local needs and geographical factors. As far as Germany is concerned, policy guidelines are laid down by each state and the organisation is as it was before reunification. [5] Several models can be identified, some of which are in some cases superimposed:


  • the conventional on-call system: a duty system, compulsory in Germany and voluntary in France, the rotas being determined by a zoning system concerning all primary care doctors;
  • the French “on-call medical centres” or the German “in-town system”: services are provided in certain walk-in centres in town by self-employed doctors working their obligatory on-call hours, or by hospital doctors on a flat rate, or by doctors employed exclusively at these centres;
  • hospital A&E departments (with direct access).
Compensation for OOH duty takes various forms in Germany under the systems adopted by the Länder, and a complex form in France associating hourly rates for the regulating doctors with higher fees for care provided and a time-slot-based on-call care payment formula. Whatever the prevailing model for OOH care, the usual procedure is the availability of a call service 24/7 and the provision of services ranging from telephone advice to surgery consultation or house calls, or referrals to pre-hospital A&E. Because of the fragmented nature of such an organisation, the OOH service delivery system is inefficient despite the relatively high density of doctors by European standards and quite short hospital access distances. Difficulties are also encountered by GPs in rural areas since the on-call system represents a heavy workload for them. Moreover, a system of this kind generates extra costs (see below).
In the major cities of these three countries, doctors work voluntarily on the duty rotas – sometimes exclusively so – and constitute separate structures to which part of the OOH service is subcontracted. These structures may be private (in Germany, SOS Médecins in France) or public (Spain).

Regional public management of OOH services in Sweden and the regional model of primary care OOH units

11In Sweden, OOH services come under the exclusive responsibility of the county councils. The representatives of the professions (such as the Swedish Medical Association) have no involvement in managing the provision of OOH care. The procedures are laid down independently by each county council as regards handling patients’ calls and the use of new technologies. The organisation of OOH services is, however, driven by professional rules governing doctors’ activities, which officially represent 40 hours per week. Any activity after 5 p.m. on weekdays is considered as overtime and remunerated according to an hourly rate, but it should be noted that duty hours at the primary care centres are strictly limited. Moreover house calls are rare. The population must usually wait until the primary care centre opens, go to an hospital A&E department or to a doctor in the private sector (against payment of a fee). All doctors employed by the public sector in primary care (as well as specialists) are required to take part in providing OOH services (for doctors in the private sector, who are a minority, it depends on the contract with the county council). For some years now, a health care network has made for better coordination, particularly by setting up a system of priorities in care provision: primary care centres, primary care OOH centres (generally manned by general practitioners working one or two rotas per month), hospital A&E departments (for specialist care). Each OOH primary care centre usually serves 10 to 15 primary care centres. The number of visits represented around 8% of total primary care visits in 2004. This number has decreased over the last few years in all counties in Sweden, probably as a result of the establishment of health information call centres. [6]

Delegation of OOH services and pattern of delegated medical care in Italy

12In Italy, the local health authority must ensure OOH GP care and the availability of medicines and necessary equipment. It also provides doctors’ surgeries, health supplies and service vehicles. The organisation of OOH care in each region is laid down by laws and agreements in which professional representatives have an active role to play: services and rotas, standards regarding the workforce and deputising rules. During regular hours, care is provided by GPs; there is a handover to OOH service doctors (medici di continuità assistenziale) for nights, weekends and public holidays, a fulltime OOH service 24/24 (via 118), an ambulance service and the hospital A&E services. If they wish, general practitioners can also become involved in OOH services: they then have two different contracts (including one for a 24-hour minimum week). The OOH service doctor is generally paid in the form of an hourly flat rate under a regional scheme: the mean annual gross income is around 30,000 to 50,000 euros, a relatively low level compared with general practitioners. Unlike emergency physicians, OOH doctors in Italy do not enjoy a high social image and the posts are subject to heavy turnover. OOH doctors have no specific training but hold a general practitioner (even specialist) diploma, and perform these duties for five to eight years before setting up practice. If they receive a call while on duty rota, they follow specific protocols; if they visit a patient (or vice versa) they give him or her a form that has to be passed on to the family doctor. Their prescriptions are valid for a short period and require confirmation from the family doctor. When a call comes in, they decide whether to send the patient to the primary care point, make a house call or provide telephone advice. Each OOH care point has its own specific telephone number; there is no single call centre covering the doctors’ surgeries in the district or run by the local health authority, as in OOH care systems with a call centre (118).

Table 1

Overview of the way OOH services operate

Table 1
Contractual Organisation Level at which OOH services is regulated Funding of OOH services Operating rules France Legal framework: the public health code applied nationwide. Usual duration: from 8 p.m. to 8 a.m. for nights from Monday to Friday and from 10 p.m. to 8 a.m. on the following working day on weekends or public holidays. The Département, via a departmental board of the medical council, broken down into sectors. Hourly payment for regulating self-employed doctors – payment of time on call for OOH doctors (per duty session) specific additions per procedure. Telephone service, house calls or visits to surgery. Access regulated, co-payment possible. Germany Legal framework: the social code as adapted by the Länder, particularly by the regional associations of KV doctors. Usual duration: 12 hours on Mondays, Tuesdays and Thursdays; 18 hours on Wednesdays, Fridays and the eve of a holiday; 24 hours on Saturdays, Sundays and public holidays. The Länderausschuss, the regional committee fixing the rota schedules for each district. Considerable variations inter– and intra-Länder (off-budget and on-budget flat rates, fixed or salaried, subcontracting). Considerable variation in OOH care schemes between Länder. Coexistence of several more or less coercive systems covering OOH care. Free access, co-payment possible. Italy Legal framework: the DPR national agreement, multi-level agreements between public services (regions and ELS) and professional associations and medical trades unions. Adaptation at local level. Usual duration: from 8 p.m. to 8 a.m. for nights from Monday to Friday and from 8 p.m. to 8 a.m. on the following working day on weekends or public holidays. The district, which employs OOH care doctors. Remuneration specifically designed for OOH care doctors. Direct or telephone according to protocol. Continuity with the GP (ad hoc intervention). Open and free access to one of the medical help centres. Spain Legal framework: law on national health service cohesion and quality adapted by the autonomous regions. Usual duration: regular service from 8 a.m. to 3 p. m; from 3 p.m. to 8 p.m. on call; from 8 p.m. OOH or hospital service. The autonomous region, broken down into basic zones (in line with well-defined zoning criteria). Hourly wage for OOH doctors (in the work contract specifying 50 hours per month on duty, or by duty session or hourly rate) and for OOH nurses (telephone consultations). Considerable variation in OOH schemes between autonomous regions. Free access; co-payment considered. Sweden Legal framework: the Swedish Health Act. Adaptation to local level. No active role for Swedish Medical Association. Usual duration: after 5 p.m. every weekday; 24 hours Saturdays, Sundays and public holidays. The county board, in charge of workforce planning. National agreement: a basic OOH service is included in the working schedule (but can be made up by working extra regular hours: one hour OOH for two hours regular). Local agreement: Hourly rate for overtime done by GPs. OOH care limited to primary care centres. Telephone consultations. Access regulated, co-payment possible. United Kingdom Legal framework: the General Medical Service contract, adapted at regional level. Usual duration: after 6.30 p.m. every weekday, Saturdays, Sundays and public holidays. The health authorities, responsible for ensuring OOH care provision. GPs free to join an OOH care scheme. Hourly rate. Mainly telephone consultation services. Continuity of care with information passed to patient’s GP. Access regulated and free.

Overview of the way OOH services operate

Regional public management and the pattern of service delegation in the UK

13Since the beginning of 2005, [7] the health authorities have exercised responsibility for the design, recruitment and operation of OOH services for which the framework is laid down by the recent General Medical Services (GMS) contract. This contract gives GPs the opportunity for the first time of contracting out their responsibility for OOH service delivery for patients on their list. In areas where doctors choose this option, the regional health authorities purchase the services of doctors employed seasonally or on a short/medium term basis to cover OOH care for a given budget, but they are also looking into the ways in which the provision of care might develop in the longer term. As a result, rather than being requested to provide a service, GPs are given an incentive to remain in the OOH service scheme as contractors to the health authority. While in England some GPs do choose this option, in Scotland, almost all GPs – except for those in the most remote areas – have contracted out. The GP OOH service associations are disappearing and the health authorities are developing alternative models. The schemes in Scotland currently offer GPs between 72 and 115 euros per hour to take on locum (replacement) duties [8] and it is still too early to determine the incentive power of this level of remuneration. It should be noted that GPs enjoy fairly high levels of remuneration for OOH services in urban areas: between €74 and €118 per hour. Full-time OOH service GPs, usually working within a co-operative, are paid between €118,000 and €147,000, as against €100,000 on average for the other GPs). These methods are perceived as a “delegation of services” and have so far operated in urban areas in the United Kingdom.
While these various traditional forms of organisation have succeeded in providing OOH services until now, it seems that this is no longer the case, as in France. Furthermore, they are not always felt to be satisfactory by users and may generate substantial extra costs.

The limitations of the traditional models

An unconvincing use of physician density regulation

14The way OOH services work should not be appraised independently of the physical location of doctors. Various facilities relating to physical regulation are brought into play in this respect, either to induce doctors to move into remote areas (and take the pressure off the doctors already there) or to get them to participate in the OOH service schemes (usually with substantial allowances). Even so, such means of regulating physician density to achieve a better geographical distribution of doctors and promote a fairer distribution of OOH services duties among care providers, at least in the short term, has had remarkably little effect in Germany, France and the UK. The effectiveness of financial and non-financial incentives designed to attract GPs into areas of shortage is quite limited, particularly in those countries where doctors’ income levels are relatively high. The trade-offs operated by doctors between the quality of life available in a major urban centre and any advantages in cash or in kind weigh clearly in favour of the former. Despite the advantages sometimes granted to doctors in rural areas, they tend to ignore them or accept relocation only on a short-term basis.

15While these results should not stop us from pursuing the objective of greater geographical equality in terms of care provision, they do call for an urgent rethink about other ways of organising OOH services, unless doctors are simply to go where they are told.

Substitutability of medical services in question

16The skills of OOH service providers do not always seem tailored to improving the quality of care and the effectiveness of the schemes: this conclusion is reached when observing rota patterns in Germany and France where GPs and specialists may stand in for one another; it is also to be found in the Italian situation where OOH care doctors may be faced with their first professional experience in the practice of general medicine. In all three countries, where the possible mismatched skills of doctors, who might be highly specialised or insufficiently experienced on leaving training, can lead to misadjustments in terms of treatments on offer and excessive hospital referrals.

17More generally, all the countries in the survey are faced either with a shortage of staff or problems related to the level of skills (all too often those on call are young locums), so the facilities are not up to providing proper OOH services. In some countries, doctors specialising in OOH services have been given a fully recognised status, as in Italy, or have become de facto a means of absorbing doctors who have not passed the public examination requirements to enter a post at a public service hospital or care centre, as in Spain. These professionals are consequently not highly regarded: they are often young, of low quality, with little personal commitment and a high turnover. They all call, however, for greater recognition of this activity through appropriate training, coordination with other sectors and upgraded status and remuneration.

Misuse of the OOH service system

18Insufficient patient information on access rules to OOH services may lead to misuse or even overuse, if it is a way of getting round the disadvantages of regular access to care (avoiding queuing, for instance), a behaviour most likely if such care is free of charge or without extra cost (as in Spain and Italy).

19Experience elsewhere amply demonstrates the role that patient information can play in the use of health care and in successfully ensuring coordination between medical practices and hospitals. However, patients’ understanding of OOH service systems varies substantially. The systematic use of hospital A&E departments seems less acute in the United Kingdom and Sweden where the populations are a little better informed and overall made more aware of their responsibilities.

A two-tier OOH care system

20Subcontracting OOH services out – when private in nature and carried out with profit-making bodies – can be considered as a source of discrimination between patients, particularly if the patient’s contribution is rather high (as in Germany and France), and sometimes a source of extra costs (house calls) for the payers. In Sweden, such a system was abandoned despite its popularity because of what was seen as unnecessary house calls by private GPs (within a basically public system).

Ineffective fragmentation of care

21The main criticism levelled at current OOH care organisations in all countries is the lack of coordination between outpatient and inpatient care, which ideally should operate as a single system. The absence of centralisation of calls and of coordination between the various OOH care providers leads to considerable fragmentation of care and to unnecessary service provision. Most of the time, the doctor in charge of OOH services does not know what the outcome is for a patient he has treated; the family doctor does not always

22know that his patient has seen the OOH service provider. The absence of coordination is basically due to a failure to share information.
Furthermore, in Germany and France, the hiatus between the selfemployed practices and the hospital sector does nothing to facilitate the coordination, nonetheless essential, between outpatient and inpatient care. In France, the separation between the two sectors still implicitly relies on the assumption that these services are substitutable, unlike the UK and Sweden, where they are perceived as complements. There again, any convergence (in particular by harmonising payment schemes, but not solely) would go a long way towards producing a more global and more integrated approach to OOH service delivery.

A potential loss of cost control

23In those countries where an attempt has been made to make OOH services attractive to health professionals (Germany, France), there is an observable increase in costs related to the cumulative impact of various financial incentives. Beyond the complexity of these measures, OOH services turn out to be expensive, especially between midnight and 8 a.m., which poses the question of their appropriateness, since a hospital treatment paid for on a charge-per-service basis could prove much less expensive for the payer.

24New forms of OOH care organisation are taking over from the traditional models, to a greater or lesser degree of success depending on the country but with several common features. The development of OOH services is being supported, among other measures, by a standardisation of legal frameworks, platforms and the e-health card project in Europe.

■ Moving on to new ways of organising OOH services

25In the light of European experience, a common model of OOH service delivery seems to be emerging as a good compromise between the constraints upon doctors and the effectiveness sought in the system of primary care provision. This model involves the operation of a single call centre based on a full-time centralisation and triage system for out-of-hours calls.

Integrated management of OOH services and the single call centre model

26The establishment of a single call centre covering pre-determined areas is an initiative that is tending to spread in Europe. For it to operate smoothly, it seems that four main conditions have to be met: implementing tools that will enable information on the clinical records of a patient’s case-history to be shared, and thus ensure continuity of care; activity sharing for patient triage purposes; increasing patients’ awareness of their responsibilities with regard to OOH services through information dissemination; regular assessment of OOH services.

Information sharing and continuity of care

27The operation of an integrated model of OOH care presupposes the successful coordination of hospital care and doctor’s surgery care, and in particular management of relations between primary care centres (or doctors’ group practices), OOH primary care centres (or help centres), call centres and hospital A&E departments. Continuity of care is generally encouraged through consultation of a single GP, but, at the same time, out-of-hours service cannot guarantee that this relationship will be maintained. That said, all countries agree on the need to share patient information within integrated teams to improve continuity of care. Some of them, as a result, have devised individual and/or collective incentives to promote the creation of various forms of partnership, whether mono- or multidisciplinary – particularly doctor’s surgery networks where patients’ case-history information is shared – capable of providing a structural response to OOH care and better coordination between primary and secondary care (with a view to help relieve congestion in hospital A&E departments).

28In some national health systems, the GP may benefit from feedback in the event of his or her patient consulting out-of-hours. In the United Kingdom, for example, the patient’s GP generally gets a fax next morning to the effect that his or her patient has received a house call, attended a centre or been admitted to hospital. He or she is also notified when the patient is discharged from hospital. This coordination is possible thanks to complete patient data that is stored and centralised, so that the doctor can find out what has happened to the patient and the authorities are informed about earlier patient contact with the health system (and the reasons, where appropriate). There is accordingly a move in the direction of making electronic records available for the benefit of all the services involved in the provision of care. In Italy, in order to improve coordination between care provision systems operating independently, the e-health card project is currently on trial. This project aims at supporting forms of partnership between GPs and OOH care doctors, ensuring that the latter are linked to the specific population looked after by the same doctors in a primary care unit.

29In Spain, some primary care centres are interconnected with hospitals and use telemedicine in the management of chronic diseases. One obstacle to more widespread use of new technologies is the reliability of the data transmitted and the medico-legal cover for remote delivery of care.
In Germany, pilot experiments are being run on new methods of care provision, largely with funding from the public authorities, to overcome the considerable split between outpatient and inpatient care. The e-health card is planned for 2006 with sharing of patients’ records and with the objective of attaining the European health insurance card objective by 2010. The use of intranet platforms (d2d type, doctor to doctor) is dependent on widespread availability of broadband access in rural and remote areas. For France, the “personal medical dossier” (DMP), defined by the August 2004 Law and initially planned to come into effect as of 2007, should eventually see the light of day some time in the next decade, considering the delays in development, the scale of the task and the limited facilities made available.

Cooperation among health professionals and activity sharing

30One alternative to the search for medical staff is to substitute the latter with ancillary services, for pre-diagnosis or routine technical procedures (such as taking blood pressure), or for limited prescriptions (such as renewing prescriptions for chronic diseases). Where this type of delegation of activities is concerned, things seem to be moving ahead in the United Kingdom and Sweden, in both call centres with triage and in care centres. This alternative remains undeveloped or inexistent elsewhere (including France). From another point of view, it is interesting to see the breaking down of barriers between social and health activities in certain regions of Spain and Sweden, where social workers practise in primary care centres alongside teams of doctors and nurses (often specialised in paediatrics, radiology, gynaecology, dentistry, physiotherapy, etc.).

31Patient triage, in countries where the “gatekeeper” model prevails, can be delegated to specialist nurses: by filtering demand, they operate as the “gatekeeper’s gatekeeper”. When this role is allotted to a non-medical health professional, it raises the question of activity sharing, in other words the delegation of tasks and competence. This matter is generally viewed as a long-term trend due to differences in relative wage rates and changes in care technology. According to some experts, this system presents no real problem since these specialist “gatekeeping” nurses are salaried workers, thus eliminating any notion of competition between them vis-à-vis patients. However, it also requires proper training for staff taking the telephone calls if the triage is to be effective (which means not transferring too many calls to the doctors). For professionals standing in for doctors, a development of competence based on specific training is necessary. Activity sharing is accordingly quite formal in the United Kingdom and Sweden with the establishment of triage systems and more informal in Spanish primary care teams (primarily encouraged by group objective incentives). In Sweden, patient triage is generally handled by the county board’s health information centre that can be reached at all times by telephone, putting the patient in contact with nurses specially trained for the purpose. The latter can give advice, make appointments with a primary care doctor during surgery hours and judge whether OOH care is necessary. Nurse triage is considered satisfactory for dealing with minor health problems or handling routine check-ups, because of the high degree of specialisation of staff in certain chronic pathologies (diabetes, asthma, hypertension).

32In the United Kingdom, the nursing advisors, who have at least five years experience, talk to the callers, make a clinical assessment of the symptoms and advise on what action to take, also orienting them to the most appropriate care segment. Clinical assessment over the phone requires a highly specialised level of competence and the nurses are given intensive training for the purpose. The tasks delegated are mainly carried out between medical and non-medical staff, following the American model of the development of the practitioner’s role. In OOH services, doctors are replaced to the greatest extent possible by nurses and paramedics. In former years, calls were handled by doctors, while this is now the exception. At present, telephone operators take down the patients’ details while nurses handle triage and consultation by telephone. The NHS 24 call centre is also set to provide further teaching, training and development for staff, which is crucial to the provision of a quality service nationwide. All the front-line staff undergo a complete training programme designed to guide them through the organisation and equip them with the skills they require to do their job. [9]
It should be noted however that this delegation of tasks is not on the agenda in the other countries. In Italy, it is the OOH care doctors who provide patient guidance, and in Germany and France this role is fulfilled by the emergency doctors or the doctors on call (not necessarily specialists).

Patient information and responsibility

33The improvement of information provided to patients through the implementation of information campaigns naturally appears to encourage patients to use the system more appropriately. On the whole, the population, apart from regular users, is not always familiar with the way OOH services operate. In Spain, several national and regional campaigns have been launched to promote proper use of OOH services according to particular health problems. In Sweden, the approach has been the widespread distribution of a local directory, brochures, information booklets and access to internet services.

34Despite the information made available to patients, the many changes under way in most countries regarding OOH services leave them confused: as a result, non-regular users do not know what procedure to follow when a problem arises. Furthermore, the information campaigns are not always properly coordinated. In the United Kingdom, for instance, while the Department of Health sometimes designs general information campaigns, local authorities or the services themselves will focus on a specific problem (for example, “Make sure you have sufficient prescriptions to cover the festive season”). Hesitations on whether to introduce a more active communication policy are sometimes the reflection of ambiguity as regards the desirability of patient information: some feel that this policy may actually stimulate demand and encourage the use of the services. Consequently the message delivered to the public sometimes appears unclear. [10]

35In a health care system where the first access point is free, there is little to sanction inappropriate use. The population will be treated in any event and the only sanction is an implicit rebuke by health professionals. In the event of daytime attendance, patients may be referred back to their surgery. The services may take measures to deal with patients who are aggressive and violent, although in some cases the staff (driver, receptionist, doctor or nurse) may be in a vulnerable situation. Attempts are made to limit direct attendance (still frequent) at A&E departments by introducing a patient’s contribution, waiting lists for non-urgent cases (self-selection according to severity) and by re-direction towards primary care. It is found that patient re-direction has increased with the use of DRG (diagnosis-related group) type payment schemes, which reduce the incentive to admit patients.
With the increase in use of OOH services (hospital A&E departments in particular), there are disincentives against systematic use: a patient’s contribution is charged in some regions in Italy and Sweden if the patient has not been referred by another professional and if the case proves not to be urgent; patients may be redirected to a care centre in the UK, Sweden and Spain. Whatever the case may be, it seems that there is a general demand for better and simpler information, with a single call number. Moreover, the common call centre should ideally have all the basic personal data available so as to avoid wasting time entering non-medical details, which requires better coordination between the services and sufficient staff and computerised resources to set up and manage the register.

Regular assessment of OOH health services

36Improvement of primary care provision requires public authorities to set up means of assessing the quality of care, the reactivity and safety of the service, the accessibility of the services overall (as judged by the patients, among others), the efficiency of the services and possibly the impact of the OOH services on other services. Furthermore, it is important to identify the barriers to or factors explaining the success of integrated models. In Scotland, the health authorities evaluate OOH services in terms of a series of quality standards. The assessments take into account a large number of quantitative dimensions but also include qualitative surveys carried out among doctors and local health committees in rural areas to devise relevant strategies for further development. In Sweden, a number of consumer satisfaction surveys are carried out among patients and call centres. In France, reports from the national regulatory body for social services (the IGAS, Inspection Générale des Affaires Sociales) regularly takes stock of how OOH services are operating nationwide.

Towards a European model of the single call centre?

37OOH numbers are available to the public everywhere, but what the call centres actually do and, above all, the resources allocated to them vary considerably. In France, Germany, Spain and Italy they simply provide guidance, while in Sweden and the United Kingdom they screen incoming calls on the basis of a preliminary diagnosis, a form of “double gatekeeping” with specially trained front-line nurses to provide effective triage.

38The experience of the various countries clearly shows how essential it is, in cases where an emergency call number and a number for an OOH service coexist, that these services be backed up by a patient information campaign. In countries where there are several numbers, problems of user confusion crop up, as is the case in the United Kingdom and in Spain. This is an indication of the advantages to be expected but also the difficulties resulting from setting up a single Europe-wide health number, an issue currently under discussion.

39In the areas of the United Kingdom where OOH services are integrated (NHS 24 in Scotland, NHS Direct in England in the integrated sites), there is a specific number to contact but often patients call their family doctor and the calls are either automatically transferred or handled by voicemail. In urban areas, GP co-operatives have been operational since the mid-1990s, so patients in these areas are used to a less personalised service.

40In rural areas until very recently, patients contacted their own doctor outof-hours and have accordingly been faced with considerable changes lately in the way their service is provided. GPs working in OOH services can

41screen incoming calls (except for the integrated areas where this service is handled by NHS 24/NHS Direct nurses), carry out telephone consultations, make calls in situ or house calls. They may carry out more than one task when on call on the phone. The primary OOH centres are usually placed in the most convenient location for patients to attend: generally the centre covers an area in which there are a number of surgeries. GPs carry out multiple activities more frequently in rural areas inasmuch as they are more involved in front-line OOH services and mental health problems.

42In Sweden, the widespread establishment of health information centres based on call screening is considered a priority by the county boards: experiments with this scheme have cut back attendance by about 16%, particularly at hospitals. Assessments show a substantial decrease in attendance at primary care centres or hospital A&E departments during regular hours or out-of-hours (patients being free to attend an OOH care centre even if they have been discouraged from doing so by the call centre and without prior consultation, which accounts for only 3% of patients). Consequently, Sweden is planning to have county boards set up a single health information centre shortly to be interconnected with the various care providers and with one identical number everywhere (that can be reached electronically) as the first patient contact point for any request for OOH care.

43In Germany, urgent medical services are integrated with other types of OOH services: there are 360 control and coordination centres with a single telephone number and patient orientation criteria. No complete integration of the chain of OOH services has yet taken place.

44In France and Spain, a single number designed to coordinate emergencies has been set up, where a telephone operator (generally a doctor) determines the type of care needed and transfers the call to the appropriate centre for treatment. These call centres have been created to ensure that primary care and hospital services operate as one. In Spain, the 112 call centres have been developed in each region to ensure coordination between health and non-health services (police, fire brigade). There may still be a different regional single number. In France, since 2003, the principle of prior screening of requests for non-elective care has been adopted, implying in principle a protocol classifying calls according to three criteria of severity (urgent medical assistance, medical consultation within the half-day, counselling). Care out-of-hours and urgent medical assistance may be managed separately but the two management centres are interconnected.
In Italy, there are experiments in certain areas with the setting up of a single call centre for all OOH care doctors, aiming at screening incoming calls and directing the caller, as appropriate, to the nearest OOH care doctor. Little by little, the OOH care doctors are becoming the link between primary care and primary OOH care, particularly since the adoption of quality standards and a physician/population ratio of one OOH care doctor per 5,000 inhabitants.

Table 2

New developments in OOH services

Table 2
Increasing patient responsibility NTIC (new technologies of information and communication) Activity sharing Subcontraction of OOH care Coordination of in/outpatient care France Occasional communication campaigns. Misuse of OOH care system. Generalised emergency aid services (SAMU), single call centres. Triage by doctors (regulation by SAMU may be handled by call centre of an OOH care partnership if linked to SAMU). Occasional (as part of the urban model of OOH care). Congestion in regulating calls and insufficient coordination between doctor’s surgery and hospital. Trial phase. Germany Divide between former East Germany and West Germany regarding demand for care (attendance at hospital A&Es more frequent in the new Länder). Misuse of the OOH care system. No single model in terms of telephone access to OOH care. Development of an intranet platform for care providers. E-health card introduced in 2006. Triage performed by doctors. Occasional (as part of the urban model of OOH care). Fragmentation of in- and outpatient care. Trials under way. Italy No communication campaigns. Misuse of OOH care system. Single primary OOH number and multiple numbers for OOH care practices. Triage by doctor (OOH doctor according to guidelines). No. Various trials with centralised calls systems. Spain Regular communication campaigns driven by the autonomous regions (posters) Redirection of patients attending hospital unnecessarily without calling up beforehand. Single call centres in each autonomous region organise coordination of health and non-health services (fire brigade, police). Results communicated between care providers via Internet. Triage performed by doctors or nurses. In some autonomous regions, subcontracting of OOH services to the private sector. Trials with systems of interconnection between primary care doctors and specialists. Sweden Communication campaigns: “blue pages”, Internet pages, information leaflets on contacting the OOH number. Patient contribution higher in event of direct access to hospital departments and discouragement via waiting lists. Redirection to primary care if hospital care unnecessary. Generalisation of health information call centres, open full-time (centralised in half of the counties – planned in the others); E-mail facilities for making appointments and renewing prescriptions; Goal: national interconnection. Triage by nurses: pre-diagnosis, routine check-ups, advice on minor health matters, direction towards OOH doctor or service. Nurses specialised in chronic diseases. No. But some experience with an “SOS médecins” service recently abolished. Integration of care: primary OOH care units accessible at GPs’ surgeries and hospital A&E departments (GPs and specialists). United Kingdom Occasional communication campaigns (posters, radio announcements). Automatic transfer of calls to centralised number. Redirection of patients attending hospital unnecessarily without calling up beforehand. Emergency call centres: NHS Direct in England, NHS 24 in Scotland. A&E tele-consulations. Triage by nurses: pre-diagnosis, routine check-ups, advice on minor health matters, direction towards an OOH doctor or service. Nurses specialised in chronic diseases. Yes. Essentially to GP cooperatives (delegation of services), particularly before the new GMS contract Centralisation of data on patient case-history: “traceability”.

New developments in OOH services

Box 3: The single call centre in the United Kingdom: towards new models

Each health authority is at an early stage in the establishment of new models, their main features being:


  • consultation by a front-line nurse, who takes down patients’ details (in some cases referring to a single patient number, which reduces the amount of information to be collected); when the nurse is in direct contact with the patient or in consultation, he or she uses a special computer program as a decision-taking aid. The options that the nurse may suggest are: self-care recommendations, with advice to call back if the situation persists or worsens; checking with a pharmacist; seeing a doctor on a routine or OOH basis; checking with social or non-medical services (a rare case);
  • services provided by a multidisciplinary team, involving few doctors (working more intensively) but more nurses, paramedics, pharmacists and other health professionals;
  • services integrated with secondary care services;
  • the development of Primary care emergency centres (PCECs), located in general hospitals, community hospitals or health centres depending on the local and geographical situation;
  • the establishment of Minor Injuries Units;
  • increased incorporation of services such as mental health, children’s health, social care, dental health, etc.;
  • planning ambulance services to develop the role of paramedics in OOH services;
  • house calls always available but reduced to cases where there is clinical need and sometimes carried out by health professionals other than doctors making use of PCEC transport facilities;
  • services provided in accordance with a set of quality standards.
These are the key features of current health authority activities aimed at developing OOH services not as an ancillary service but built into a global approach towards non-appointment services available 24/7. This type of approach is one that pre-supposes the standardisation of “GMS OOH services”.

46This overview of the developments in each country suggests that the Europeans are opting for the same basic pattern of OOH services. It is nonetheless too soon to arrive at any definite conclusion. Such assessments as have been made on the most advanced forms in Sweden and the United Kingdom do not, at this stage, allow any final conclusions to be drawn concerning improvements in the service rendered to the users and even less any comparisons to be made, considering the very different points of departure. More time and more thorough assessments will be necessary to determine the real effectiveness of these new tools and facilities.

■ Conclusion

47OOH service forms part of a model largely subscribed to in European countries, i.e. a local OOH care organisation within a legal framework determined at national level, and international comparisons show that responsibility for OOH care and its organisation is usually attributed to local authorities. Even though doctors originally handled OOH care, they have been gradually relieved of this task as reforms have progressed (sometimes with relief on their part, as is notably evident in the United Kingdom). There are, however, notable disparities in the involvement of doctors between decentralised countries such as Italy and a country such as Germany, where the involvement of doctors and their associations remains significant, particularly where the design of schemes is concerned.

48While the underlying principles adopted in the reforms of several European countries fall within a model which is common to the six countries, it is clear nonetheless that major differences subsist. All the countries on the panel are regionalised or decentralised to various degrees, so that they face both the advantages and the disadvantages of these forms of organisation in running the system:

  • • Advantages: greater flexibility, innovative capability, better knowledge of local realities and accordingly greater ease in implementing facilities matched to local needs;
  • • Disadvantages: the very marked disparities between the most regionalised countries (Spain, Italy and Sweden) may mean some inequity, in terms of access to treatment and innovation as well as financially.
The current reforms sanction the role of OOH service associations, not only as a link with private medical surgeries or primary care centres but also as a third structure existing at the same level as the other health care players. The move towards concentrating doctors in primary care or especially created OOH care units is a trend broadly shared by the countries in the survey. It is found that:
  • countries where primary care centres were practically non-existent are today adopting them to a significant degree, including Germany (despite the fact that they are still negatively associated with the former East German polyclinic model) and France (despite the traditional lack of enthusiasm for group medical practice, which seems to be becoming more attractive, however);
  • OOH primary care centres are also developing in most of the countries surveyed, often close to hospitals (Spain, Sweden, UK, Italy, etc.) so as to decongest A&E departments. It is interesting to note that in Sweden, the use of these structures has diminished with the establishment of the regional OOH telephone service.
Foreign experience has clearly shown that OOH care is easier to provide when doctors’ associations and those of health professionals in general are involved. [11]

49Furthermore, as regards coordination between hospitals and care centres (or GPs), fast-developing modern communication facilities (e-health card and intranet with patient records, for example) are viewed in the countries surveyed as a real resource for developing communication between care providers. Improved communication between providers is less strongly asserted in the UK and Sweden because cooperation between doctors’ surgeries and hospitals seems to be better here than elsewhere. Paradoxically, it is interesting to notice that, unlike France, the views and demands expressed by the population and health professionals in Spain and Sweden are more pronounced in the towns than in the country. In some countries, coordination between hospitals and care centres or between regions or even countries is developing already, as in Spain or Sweden, thanks to tele-medicine, with tele-transmission being used in radiology, dermatology and cardiology. Overall, the value of NTIC (new technologies of information and communication) is mainly perceived via intranet systems or e-healthcards pertaining to patients health records or shared software for orientation in the system. This doctor’s surgery – hospital coordination strengthens the case for sharing a clinical database of patient records and consequently generalised use of NTIC facilities; yet, in this respect there is a considerable gap in the use of tele-medicine between countries (and even regions) at a time when projects are taking on a European dimension.

50The diversification of the ways in which OOH services are organised in each country (owing to decentralisation) results in major difficulties in assessing the schemes, for which there is generally only a partial picture. This difficulty in evaluating the effectiveness of the systems according to a standard specification is often due to a lack of qualitative and quantitative information because of the varying degree of fragmentation of OOH care organisation. Once resources are used to fund the constitution of integrated teams to provide more effective OOH care, the question of the reallocation of resources between hospital and outpatient services also arises, so it seems essential to appraise the effectiveness of OOH systems in terms of a reference model (equity of access, resourcefulness of the schemes, quality of the care provided). The definition of good-practice specifications in terms of regulation and operation, together with monitoring schemes, may certainly help to get round the obstacles to making standard, periodical assessments of the performance of local and regional OOH care.
In the case of France, one of the first bricks of the new system of OOH services was laid by the decree dated 7 April 2005. This reform came about following several reports either directly addressing the issue of OOH care (Brunhes et al. 2001; Descours 2003) or indirectly via an investigation into geographical aspects (Polton 2000; CREDES-MSA-URCAM 2002), future developments (Commissariat Général du Plan 2005) and the operation of the health system during the heatwave of 2003 (IGAS 2003). However, the appraisal appearing in the recent report by IGAS (2006) shows that considerable consolidation of the existing system must be undertaken with dispatch, in order to eliminate major malfunctions that call into question its reliability and efficiency. IGAS recommends, inter alia, that “in the interest of the quality of regulation and clarity of information for users, the solution of a single call number is to be borne in mind”.


  • [*]
    Laurence Hartmann: Lecturer at the University of Lille II, Regional Epidemiology Service (Faculty of Medicine), and Institute of Public Economics (IDEP) (France).
    Philippe Ulmann: Lecturer at the Conservatoire National des Arts et Métiers – chair of Economics and Management of Health Services – (France).
    Lise Rochaix: Professor at the University of Aix-Marseille II, member of the Executive Board of the High Health Authority (Haute Autorité de Santé), Chair of the Health Strategy Evaluation Committee (CE2S) (France).
  • [1]
    OOH service is not to be confused with the notion of continuity of care, which generally constitutes an obligation under the medical code of ethics.
  • [2]
    Efficiency refers here to both allocative efficiency (i.e. the ability to meet users’ preferences) and productive efficiency (producing a certain target at minimum cost). Equity is defined here as horizontal equity (the equal treatment of equals).
  • [3]
    The references in the report by Ulmann et al. (2005) are not reproduced here owing to lack of space.
  • [4]
    This aspect is not addressed in this article.
  • [5]
    Confusion is compounded further by the different names given to OOH service systems.
  • [6]
    The four main tasks of an OOH primary care centre are handling the visits to the unit (with children representing a large proportion compared with visits to primary care centres during regular hours), house calls for the elderly, health information (if there is no health information centre or if it is closed), and drawing up death certificates and other urgent documents.
  • [7]
    In former years, GPs were responsible for OOH care, which they were able to delegate to others and which they attempted to organise collectively in order to fill in for one another. It was possible to contract out one’s OOH care duty, depending on the type organisation that the GP could join. For example, a GP belonging to a large urban co-operative could give the revenue from night house calls to the co-operative or pay a subscription to the co-operative (a non-profit-making body managed by local GPs). The subscription could then be re-distributed to the doctors taking the rota duty. Thus it was possible to pay to avoid working outof-hours. It was also possible to take more on-call sessions to increase one’s income. The co-operative could change the subscription rates and the price of rota duty (raising fees in the case of unattractive rotas) in order to balance supply and demand, and most practices sought to recover their contributions. Evaluations made in Scotland show that the operating cost of medical co-operatives is about double that of rotas and delegated services, just as costs go up when the size of the population covered by the service increases.
  • [8]
    The current marked distinction between daytime working and OOH care ensures more ready compliance with the directives on working hours (involving time off on the day following a doctor’s night duty). However, GPs working in remote areas are always on call at weekends.
  • [9]
    The nurses receive seven weeks’ training at evening classes. The training covers criticalmindedness, life skills, clinical guidance, accountancy and law, performance management, telephone counselling, decision-aid software, flow diagrams, communication during consultation, handling calls on children, child protection, mental health, pharmaceuticals, menopause, diabetes.
  • [10]
    During the assessment of the NHS 24 service after nine months’ operation, patients having used the service received a questionnaire. Out of the 356 patients who replied, 64% knew of the existence of NHS 24. Among the 266 persons (75%) in the survey who had had to use the OOH care service: 18% called the NHS 24 number, 70% called their own GP OOH number and were transferred and 13% called the old co-operative number and were transferred. Nonetheless, 87% stated that access to the NHS 24 services was easy.
  • [11]
    Although this dimension falls outside the scope of this survey, it might at least be conjectured that any case made for promoting group practice in France will have beneficial effects on the effective management of OOH health care.


Regulating the demand for out-of-hours (OOH) services is, in most European countries, the subject of some consideration and even sizeable reforms, aiming to address new developments in medical practice and reduce inefficiencies in the current delivery of OOH services. The purpose of this contribution is to enquire into the possible convergence of alternative models of demand regulation in some of the countries listed: Germany, Spain, France, Italy, the United Kingdom and Sweden. The article outlines, on the one hand, the characteristics and limitations of the traditional models of organising OOH services delivery and, on the other, the new forms of demand regulation for OOH services. A common model seems to be emerging in the form of a single call centre; the emergence of this model is supported not only by new information and communication technologies but also by the ability of health systems to define new professional roles, empower health care demand and subject its operation to regular economic assessment.


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Laurence Hartmann
Philippe Ulmann
Lise Rochaix [*]
  • [*]
    Laurence Hartmann: Lecturer at the University of Lille II, Regional Epidemiology Service (Faculty of Medicine), and Institute of Public Economics (IDEP) (France).
    Philippe Ulmann: Lecturer at the Conservatoire National des Arts et Métiers – chair of Economics and Management of Health Services – (France).
    Lise Rochaix: Professor at the University of Aix-Marseille II, member of the Executive Board of the High Health Authority (Haute Autorité de Santé), Chair of the Health Strategy Evaluation Committee (CE2S) (France).
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