After-hours telephone service at medical centre explained
Thanks to Anne Gentleman for her letter (GBW 11/8)expressing her concerns about the after-hours telephone service Golden Bay Medical Centre is trialing. I am sorry she had such a bad experience. I would like to point out that Anne raised these issues with me personally, and I asked her to put her concerns in writing so we can use them when we review the service; we would welcome anyone else’s constructive feedback.
I am also sorry that we had not put a notice in The GB Weekly alerting people to and explaining the reasons for this trial, but perhaps people will be more interested now it is a problem!
The HML telephone triage service provides a first point of contact for patients to call out of hours. If they only need advice, experienced nurses will give this over the phone. If they need to be seen, the nurse will contact the appropriate service. This system has been used around New Zealand, including every other practice in Nelson/Tasman, for several years. We initially decided not to use it, for a variety of reasons, including:
We felt our doctors were better placed to give telephone advice, as we usually know something of the medical history of patients phoning – this is a pretty unique situation and service.
As Anne comments – by and large, Golden Bay people do not call the doctor through the night without very good cause.
In urban centres and even Motueka now, the triage service can direct patients to services other than the GP if more appropriate, eg ED, ambulance paramedics. In Golden Bay, it’s just the GP, albeit supported by hospital nurses, ambulance crew and mental health workers. So we did not feel the service would reduce our workload, as it does for urban GPs.
The onerous part of after-hours work is being called out, not giving advice on the phone, and we did not see that the service would reduce this.
We changed this attitude for several reasons:
Feedback from practices around New Zealand that this service was very safe and effective.
The direct experience of one of the GPs of working with this system had been positive.
It is part of our development of the capacity of the GBCH nurses to assess and treat minor conditions out of hours without involving the doctor.
Several nights with frequent telephone calls – I had a Saturday night when I was called five times between midnight and 7am, when I finally had to go to see someone. I then had to work all day Sunday, and be on call again on Sunday night.
Safety – I am not sure that having to wake a tired doctor from sleep to get health advice at night is safe for either patient or doctor. Having a trained nurse, who is awake and awaiting calls, as first contact seems better and safer to me.
There is also a wider context to this. New Zealand is now well into a health workforce crisis. We have a growing epidemic of age-related conditions, in addition to lifestyle diseases such as Type 2 diabetes, which will see demand on health services double in the next decade. The number of health professionals will not keep pace with this increase. It has been projected that to keep healthcare at the level it is now, in 20 years every fifth adult would need to be a health care professional. This has relevance to Golden Bay in several ways:
People will not always be able to see a doctor, far less the one of their choice. Patients will increasingly be filtered through highly skilled primary care nurses, only seeing a doctor if specific medical knowledge is needed, eg diagnosis of new conditions, new or complex prescriptions. Similarly, nurses will increasingly plan and oversee care, delivered by health care assistants.
Patients will be asked to take more responsibility for their own health care, especially those with ongoing conditions like diabetes, renal failure and chronic airways disease, connecting to medical services via e-mail and the internet.
Currently, we struggle to attract doctors to Golden Bay. The two doctors who joined the surgery recently came here through family links or a desire for a Golden Bay lifestyle, not in answer to our advertising. We have not had a positive response to advertising for doctors here in the past decade. This situation will get worse before, indeed if, it gets better.
One major obstacle to retention and recruitment of doctors is the after hours commitment and work. If we are to attract doctors we must try to improve this. There is a worldwide shortage of doctors – they are spoiled for choice, so we need to give them very good reasons to come here. Someone commented recently in regard to after hours work, “that’s what they sign up for”. Well, they’ve stopped, because they have alternatives. If, as Victoria Davis alleges, the only people to benefit from our integration plans so far are the doctors, then that is actually good for everyone.
It is quite possible that within 10 years there will be no permanent doctors in Golden Bay. I hope this situation can be avoided, but we cannot afford to ignore it, and must develop plans, especially developing extended nursing skills and links with Nelson Hospital and other health facilities outside Golden Bay who could provide medical support and advice.
People in Golden Bay have enjoyed excellent, stable health services for many years. We hope to maintain, even improve, the quality of care, but there will be changes in the way in which it is delivered which we all, patients and healthcare professionals alike, must adapt to.
Struan Clark
