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| Journal of the New Zealand Medical Association,
18-May-2007, Vol 120 No 1254
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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.
Methods
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.
ResultsData 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.
*Logs; †Visits.
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.
DiscussionThe 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: phil.hider@chmeds.ac.nz
References:
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