Journal of the New Zealand Medical Association, 18-May-2007, Vol 120 No 1254
Practitioners, patients, and their visits: a description of accident and medical (A&M) clinics in New Zealand, 2001/2
Phil Hider, Roy Lay-Yee, Peter Davis
In the late 1980s, New Zealand primary care witnessed the development of a unique form of general practice—the accident and medical (A&M) clinic. These commercial clinics were usually located in central urban areas and offered extended opening hours, consultations without an appointment, and limited links to traditional general practice.1 The clinics likely arose from international trends that included rising patient demands for out-of-office hour care2 and an increasing willingness by the medical profession to find new collective solutions to providing after-hours medical care.1
Since the 1980s, many Western countries have witnessed the rise of cooperative after-hours centres3 where general practitioners have joined together to provide their after-hours care from one centre thereby reducing their isolation while on-call and rationalising their workload.4 In addition, deputising services have also flourished especially in the United Kingdom.5
Unlike co-operatives, these services function as commercial organisations that effectively provide locum services to GPs out-of-hours thereby relieving them of this task. Medical A&M clinics are, however, unique to New Zealand with their closest parallel being provided by walk-in clinics in Canada.
In common with New Zealand clinics, the Canadian version operates out of convenient, central city locations and provides extended hours with no-appointment schedules.6 These clinics have developed in parallel with general practitioners and do not attempt to minimise their overlap with family practices or routinely organise follow-up with the established primary care-giver.7 Surveys have suggested that these clinics are primarily attended by younger people with predominantly minor infections and injuries.8, 9
Only one study has previously attempted to describe the characteristics of patients, practitioners, and practice features associated with medical A&M centres in New Zealand.1 That study was conducted in the Waikato region between 1991–2 and included three clinics and 70 “orthodox” general practitioners. Patients at the clinics were more likely to be younger, employed, and new to the practice. Patients usually visited with single, new, acute, and relatively minor problems such as injuries and respiratory infections. Although important, that research was limited by the small and regional nature of the sample.
The National Primary Medical Care survey (NatMedCa) was undertaken to describe primary health care in New Zealand. Study methods and an overview of results, particularly those related to traditional general practice, have been described.10 This study followed the methods employed by the previous Waikato-based research1 and describes the characteristics of practitioners, patients, and patient visits.
A&M clinics were defined by the following criteria:
A list of 52 A&M clinics was compiled from White Pages telephone book listings and supplemented by data from the Accident & Medical Practitioners’ Association (AMPA), which provided a supporting letter, and other sources.
A&M practitioners are typically salaried and are not listed in the White Pages. Clinics were distributed throughout the country, with particular concentration in cities. A 50% random sample of all A&M clinics (n=26 clinics) were invited to participate. Data collection was spread over a year and around the geographical areas. Data were collected in relation to two time periods: either between usual hours (Monday–Friday, 8am–6pm) or at other times.
Practitioners from each clinic were asked to provide data on themselves and their practice; they were also asked to report on their patients over a week-long period. The log questionnaire, completed for all patients seen during the data collection period, recorded demographic data. The visit questionnaire recorded data about the patient’s problem(s) and management. The practitioner questionnaire obtained data on practitioner background and activities.
Reason-for-visit and diagnosis were coded using READ version 2 software, while drugs were classified using the anatomically based Pharmacodes/ATC system.
Approval was obtained from ethics committees in all areas represented in the survey. The study received advice from an advisory and monitoring committee that included representation from consumers and relevant professional groups.
Data were obtained from 12 clinics (response rate=55%), predominantly based in Auckland (8/12) with the remainder equally shared between the rest of the North and the South Islands. Compared with data describing the national distribution of A&M clinics in New Zealand at the time of the survey, Auckland and the South Island were slightly over-represented among participating clinics—at the expense of the rest of the North Island (Table 1).
Table 1. Distribution of all available accident and medical (A&M) clinics in 2001/2, sample, and location of clinics participating in NatMedCa survey
6205 visits were logged, and detailed data were obtained from 1,430 attendance—590 (41%) of which occurred during usual working hours (Monday–Friday, 8am–6pm).
A&M practices were staffed by a mean number of 2.7 FTE A&M practitioners, assisted by an additional 0.8 FTE general practitioner—but no community worker participation (Table 2). Slightly more than half of the doctors provided maternity care, but health promotion was less common. Only 25% of practices utilised computerised patient records. Most practices were governed by a separate management structure and were operated as a limited liability company. No practice needs assessment was undertaken, but a written policy on complaints was a uniform feature of all practices.
The characteristics of 67 participating doctors are described in Table 3. A quarter were female, with a mean age overall of 40 (over half the practitioners being in the 35–44 age group).
On average, doctors had been in practice for just over 10 years, and had been in the sampled practice only 2.9 years. Over a third of doctors had not trained in New Zealand, with the majority—a quarter of the total—from a country other than the United Kingdom or Australia.
On average, doctors saw nearly 90 daytime patients a week, and to do so worked 6.3 half days with an average of 13.7 patients per half day.
† Community Services Card (CSC) or a High User’s Health Card (HUHC)—card holders receive subsidised healthcare due to their lower incomes or frequent use, respectively.
Table 4 presents the age- and gender-specific log and visit information as a ratio to the corresponding national population data. Overall, there were more than three times as many patients under the age of 5 years visiting the sampled A&M clinics than national figures would indicate, a slight elevation in the 15–24 years age group, and an under-representation of between a third to three-quarters in the groups aged 35 years and over.
This age-related pattern was most marked for “out of hours” visits, with the under 5s more than four times the national indication, and those over 45 generally a half or less than expected. Visits in the 8am–6pm period were in an intermediate position. A slight difference in gender distributions was also evident, with males disproportionate in the youngest age group, and females over the age of 15 “out of hours” over-represented.
Data on the ethnicity and card status of A&M clinic patients are presented in Table 5. For about 60% of visits, the recorded ethnic group was New Zealand European. The next largest single group was Māori (9.0%), followed by Samoan (6.1%). Taken together, Chinese and Indian accounted for just under 10% of all patient visits, second only to New Zealand European. This, overall ethnic distribution was relatively stable between normal and “out of hour” periods.
Nearly three-quarters of all patients did not have a benefit card of any kind—i.e. either a Community Services Card (CSC) or a High User’s Health Card (HUHC). Little over a fifth had a CSC. This pattern was not so marked for visits in normal hours, where a quarter of patients had a CSC. There was no information on card status for nearly 5% of patients visiting out of normal hours.
Table 5. Patient characteristics: percentage distribution of A&M patients, by ethnicity, card status, and NZDep2001 decile (log and visit)
Note: missing data have been excluded; *Logs; date and time were not collected; †Visits; ‡Ethnicity was self-reported, with multiple categories allowed. One ethnic category was assigned per patient according to prioritisation of Māori and Pacific people; § NZ Deprivation decile is a measure of deprivation based on the area of residence.
Aspects of the visit characteristics are described in Table 6. For most patients, the clinic was not their usual source of care especially among those patients who presented after-hours. For about two-thirds of patients outside of normal hours, the current visit was the first visit to the clinic over the preceding 12 months.
Although the majority of patients presented with an urgent condition, relatively few were judged by the practitioners to be severe. Self-limiting conditions were more common after-hours. For at least a third of visits, the practitioners did not identify any disability (the proportion was higher for visits out-of-hours). On average, visits lasted slightly more than a quarter of an hour regardless of when they occurred. Patients identified just over one reason per visit at any time during the week.
Note: missing data have been excluded; *Patient-reported; includes the current visit; †Up to 4 reasons could be recorded per visit; ‡Significant difference between normal and out-of-hours visits.
Injury or poisoning was the most common problem identified by practitioners during usual working hours, whilst respiratory illnesses predominated after-hours (Table 7). Nervous system sense organs and infectious conditions were also relatively common after hours. Most problems encountered at the clinics were new or related to short-term follow-up. Visits for preventive care were rare.
Table 7. Frequency of problems (per 100 visits) and percentage of problem status
Note: missing data have been excluded; *Up to 4 problems could be recorded per visit; classified according to READ2 chapters; †Status categories are not mutually exclusive; a visit was assigned to a category if any one of its related problems fell into that category; ‡Significant difference between Normal and Out-of-hours visits.
Laboratory and radiology tests were ordered more frequently during normal working hours (Table 8). Visits after-hours were more likely to be provided with a prescription but not other types of treatment (such as health advice, dressings). The most frequent types of medications provided at the clinics were antibiotics and analgesics.
Follow-up or referrals were less frequently arranged for patients who presented after-hours. Referrals were made for about 15% of visits at any time. However, whilst emergency referrals and referrals to medical/surgical specialties were more likely during usual working hours, referrals to non-medical health workers (such as counsellors, physiotherapists, dentists) were more common after-hours.
Table 8. Tests and investigations ordered, treatments and medications provided, follow-up and referral
Note: missing data have been excluded; *Any number of prescription or other treatments could be recorded; †Up to 4 problems could be recorded per visit; ‡Most frequently prescribed; classified according to Pharmacodes/ATC level 2. ║Follow-up and referral are not mutually exclusive; one referral is counted per visit; referral types are mutually exclusive; and Emergency referrals are given precedence; ¶Significant difference between Normal and Out-of-hours visits; NSAIDs=Non-steroidal anti-inflammatory drugs.
The NatMedCa survey, conducted in 2001/2, provides a rare description of a novel branch of primary care, the A&M clinic, which has arisen in New Zealand over the last 20 years. The clinics are defined by their extended hours, their community location, and the provision of X-ray facilities.
The clinics attract a young, ethnically-diverse clientele but relatively few people who hold CSCs or HUHCs. Most patients do not have an ongoing relationship with the clinic and attend for an urgent but often relatively minor, self-limiting problem. Many attendances relate to new injuries or respiratory problems and antibiotics and analgesics are the most frequently prescribed items regardless of the time of the day.
Follow-up is arranged for between one third to one-half of visits. Referrals are infrequent (about 15% of visits) and relatively stable throughout the week.
The characteristics of patients and visits during usual hours are generally similar regardless of whether they were made during usual hours or at other times. Some differences are evident in the types of problems that people presented with out of hours and either investigations or follow-up were less frequently arranged outside normal hours whereas pharmacological treatment was more frequently provided.
The overall impression is that the medical A&M clinics provide episodic treatment for relatively young patients—mainly related to a new, short-term problem, particularly an injury or a respiratory illness. This picture is fully consistent with the previously published regional description of clinic activities in 1998. It is also compatible with reports from walk-in clinics in Canada that have also documented the preponderance of younger patients, with visits related to infectious illnesses or injuries.7,8,11
However, in contrast to these overseas surveys, the users of New Zealand clinics were not more likely to be female or unemployed.8, 12 Instead, visits by patients possessing CSCs appear to be less frequent in New Zealand. In addition, attendance rates appear to be fairly constant across all levels of deprivation.
Relatively high local charges for visits at the clinics, regardless of the time of day, are likely to be a significant factor in attracting more affluent clients while subsidised visits for injury-related problems may ensure that significant numbers of lower socioeconomic groups can still attend.
Patients who attend A&M clinics have a wide ethnic diversity. In particular, a high proportion of Māori and Pacific Island people attend the clinics. The presence of a higher proportion of practitioners from a range of ethnic groups underlines some ability of the clinics to provide culturally acceptable health care to a wider ethnic range of patients.
Canadian research based in similar walk-in clinics indicates that the extended hours, central city locations, and the availability of X-ray facilities on-site are widely appreciated by younger patients who disproportionately reside in central city areas, participate in contact sports and work in physically demanding jobs.13
Indeed, for over 20 years in Canada, commercial walk-in clinics have sought to occupy a niche between emergency departments and after-hours GP services.6 Since they first appeared in Western Canada during the early 1980s, walk-in clinics have now become well established in British Columbia, Alberta, Saskatchewan, and Manitoba.14 Most clinics now offer a range of medical and allied health services including physiotherapy, massage therapy, and chiropractic treatment under one roof.6, 14 In Canada, many patients attend walk-in clinics in preference to visiting their own GPs, often attracted by the availability of many services under one roof.9,12
Some data exist in New Zealand to describe the extent of the expansion in the number of A&M clinics and practitioners. The New Zealand Medical Register indicates that since it was first made a vocational branch of medical practice in 2001, the number of doctors registered as accident and medical practitioners has grown by over 25% per annum to include some 103 doctors by 2004.15 By 2000 it has been estimated that some 2 million consultations (about 9% of consultations in primary care) were provided by A&M doctors.15
The arrival of the clinics has not always been welcomed by other primary care practitioners, and claims and counter claims have bounced to and fro about protective practices and unfair competition.16,17 Empirical evidence about why patients choose to attend the clinics and what they want from primary care providers are uncommon in New Zealand. One rare example documents the preferences of 355 North Shore residents and underlines the importance of continuity of care to many patients.18
Among respondents with regular GP contact, some 80% indicated they would attend an A&M clinic after hours—although only 25% suggested they were more convenient and 89% considered that GPs were better value for money. Meanwhile, 78% of patients who had no regular GP welcomed the extended hours and appointment-free schedules at the clinics. 18
Although the data used in the study was collected in 2001/2, and precedes the Primary Health Care Strategy, it still provides a unique and important snapshot of an area of primary care that has received relatively little research attention.
In Canada, concerns by general practitioners19 that walk-in clinics may fragment care, increase costs, and compromise the quality of care have not been demonstrated by the limited research that has been conducted.11,20
Further work is urgently needed in New Zealand to reliably compare the characteristics of different practice types along with their practitioners, patients, and visits. Additional research should also closely examine the reasons that patients choose different providers and undertake assessments of the relative quality of care that is provided.
Competing interests: None.
Author information: Phil Hider, Senior Lecturer, Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch; Roy Lay-Yee, Research Fellow, Department of Sociology, University of Auckland, Auckland; Peter Davis, Professor, Department of Sociology, University of Auckland, Auckland
Acknowledgements: This study would not have been possible without the generous assistance of all its participants—general practitioners, nurses, A&M practitioners, practice support staff, and their patients.
The NatMedCa study was funded by the Health Research Council of New Zealand.
We also thank the academic Departments of General Practice, the Royal New Zealand College of General Practitioners, Accident & Medical Practitioners’ Association, and coinvestigators Gregor Coster, Marjan Kljakovic, Murray Tilyard, and Les Toop for their support as well as Alastair Scott, Antony Raymont, Peter Crampton, Sue Crengle, Daniel Patrick, and Janet Pearson for their assistance.
Additional assistance was provided by the Advisory and Monitoring Committee chaired by John Richards—other members are Jonathan Fox, David Gollogly, Ron Janes, Vera Keefe-Ormsby, Rose Lightfoot, Arapera Ngaha, Bhavani Pedinti, Henri van Roon, and Matt Wildbore.
Ashwin Patel developed key coding instruments and assisted with the coding of clinical information. Marijke Oed provided secretarial assistance, Andrew Sporle gave advice on Māori health issues, and Barry Gribben provided consultancy services. Sandra Johnson, Wendy Bingley and Lisa Fellowes all contributed substantially at earlier stages of the project.
Correspondence: Dr Phil Hider, Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, University of Otago, P O Box 4345, Christchurch. Fax: (03) 364 3697; email: firstname.lastname@example.org
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