To our knowledge, this study is the first to report the results of the implementation of a new GPC in a open access health care system. Caseload of the GP were doubled while there was no significant decrease of patient turnover at the ED. We also describe changes in patient contacts; consultations, home visits and ICPC2 codes for RFE and diagnosis.
We simultaneously collected data at GP services in other regions, where no GPC was established. Although not completely matched and lacking data of ED in the other regions, this methodology is probably the most feasible design to study changes in caseload when establishing a GPC. In the original study design we considered a time series study over 3 years time. However, due to changing software program at one of the hospitals, we were not able to collect comparable data during the third year. Therefore this design was not feasible.
In Belgium, all patients have free access and free choice during out-of-hours between the GP on call as well as to the ED of a hospital. GPs do not have a gatekeepers' role and entrance to health care is possible without referral by a physician or prior telephone contact. The possibility of a telephone consult or treatment by a practice nurse, as it is known in the Netherlands for instance, does not exist. In most regions, there are no defined regional catchment areas. Patients can easily seek help in a neighbouring village or city.
We chose Turnhout region as our study domain. This city has a well-defined catchment area, meaning that GPs as well as both hospitals cover the same region with negligible overlap with neighbouring regions. This enabled us to obtain a valid view on caseload at the GP and the ED. We included other regions in the neighbourhood of the cities of Ghent and Antwerp to have some account for changes like seasonal influences on epidemic changes or changes in patients' awareness of the use of out-of-hours services. Unfortunately including a control region for the ED was not feasible, because regions with tight boundaries are scarce. Secondly, there were (at the time of our study) no uniform information technology systems at the EDs in hospitals in Belgium. Similar to former research, we observed an increase of patient contacts at the GPC over a one year period [12, 18, 20, 21]. However, in contrast with the studies performed in the Netherlands and the UK, we did not observe a significant decrease in patient numbers at the ED. This may be explained by the free access in the health care system in Belgium. The GPC was implemented without any changes or restrictions in accessibility to the ED. Moreover, the use of a service may be driven by the availability of this service, which is called the, push-strategy' [22–24]. Although in our study, the number of patients seeking help at the ED after referral by a physician increased, the number of self-referrals stayed the same. This suggests that patients who want to seek help at the ED without a referral, do not change their behaviour because of the presence of a GPC. On the other hand, there was a significant decrease in the number of patients who came to the ED by ambulance, which (in this country) can be called without any referral by a doctor. (table 1) Possibly, the presence of a GPC could lead to more efficient use of ambulances by creating an accessible and recognisable alternative when people are anxious or worried.
Currently there is a trend in this country, decreasing the share of home visits also during normal working hours [21, 25]. In this study, this effect also occurs during out-of-hours and seems to be accelerated after implementation of a GPC. The decrease of home-visits was observed for all age categories, except for the very elderly. Home visits are necessary for this age group because of diminished mobility and are also the strength of general practice care . The amount of home visits to the very elderly does not change significantly after establishing a GPC. This might indicate that equity for the elderly is also accomplished at the GPC.
There is a significant decrease at the ED covering RFE on circulatory (K) and psychological (P) problems. On the other hand digestive (D) and psychological (P) diagnosis decreased at the GPC. We have no explanation for this. We also observed a significant decrease in 'trauma' cases at the ED, whereas the contacts with wound- or trauma related diagnoses ('L' and, 'S' diagnoses) slightly increased at the GPC. We might hypothesise that the presence of the GPC lowers the threshold to seek medical advice from a GP, also for minor trauma. One of the aims of the GPC is dealing with minor trauma and wound-care by being well-equipped. Accessibility has improved due to the fixed, central and recognisable location of the GPC in the city. The results seem to affirm that patients tend to recognise the role of the GP in these types of medical problems.
In this study we found a large amount of technical examinations at the ED. We could expect lower costs when more trauma cases could be dealt with at the GPC. Future research is needed to study the difference in costs due to a possible difference in assessment of the same medical problem at the GPC and the ED. Also outcome data in terms of health benefit should be investigated between services.
More is needed to realize effective shifts of patients from the ED to the primary care setting during out-of-hours services. A more explicit image of primary health care is needed, as stated in the latest WHO report . Thanks to our former research in which we studied patients' preferences, we can confirm this need also in Belgium. In this specific health care system, centrally delivered information to patients about the tasks and skills of GPs, is necessary. A first-time contact of high-quality influences patient attitudes positively. From former research we know that people prefer a doctor who informs them about the illness and the treatment in a clear way. If this condition is met, patients tend to return to the service they are familiar with . In the same subject we look out for the results of another study we performed in Belgium, using discrete choice analysis. This methodology is adopted from management studies and was already used in medical research by several authors [29, 30].
The GPC is not available during weekdays. Therefore changing behaviour in patients might be more difficult. In future research, a comparison in patient choice during weekdays or weekends can clarify whether establishing a GPC during weekdays is a useful option. It certainly would clarify the role and organisation of out- of- hours healthcare for the users.