Why patients attend after-hours medical services: a cross-sectional survey of patients across the Australian Capital Territory

Keywords: after-hours care, emergency department, general practice, health-seeking behaviour, health services research, health systems, primary care, survey.

After-hours medical care in Australia includes emergency departments (ED) and community-based services such as general practice (GP). However, concerns have been raised about patients presenting ‘inappropriately’ to EDs, with around one-third of after-hours ED presentations labelled as ‘potentially avoidable’ (Jackson 2014; Australian Institute of Health and Welfare 2020). A popular idea from international literature, echoed by national government and local media, is for potentially avoidable ED presentations to be managed by community-based medical services, such as general practice (Australian Institute of Health and Welfare 2020; Health Policy Analysis 2020; Hong et al. 2020; Roy 2021). However, not all potentially avoidable ED presentations are appropriate to be managed by community-based services, particularly in the after-hours periods (Cheek et al. 2016; Duwalage et al. 2021).

In urban and metropolitan Australia, community-based medical services are available and well utilised, servicing specific medical issues (Britt et al. 2016; Turner et al. 2017; Barnes et al. 2022). Common after-hours community-based medical service presentations include a mixture of urgent as well as non-urgent infections, injuries and ongoing care conditions (e.g. depression) (Baker et al. 2020; Barnes et al. 2022). In contrast, commonly reported potentially avoidable ED presentations include abdominal pain, chest pain, and viral infections (Cheek et al. 2016; Australian Institute of Health and Welfare 2020). From presentation data alone, it appears after-hours services are being used mostly appropriately (Barnes et al. 2022). However, presentation data are reported from practitioner perspectives after assessment of a patient, and after the patient has chosen to present to a specific service (Turner et al. 2017; Baker et al. 2020; Barnes et al. 2022). To better understand health service use, patient health-seeking behaviours must also be considered (Cheek et al. 2016; Barnes et al. 2022).

Patient reasons for seeking after-hours medical care have been explored in limited contexts. Common reasons for after-hours ED presentations in Australia, and similar international health systems, include patient-perceived need for care and high patient-perceived urgency (Masso et al. 2007; Coster et al. 2017; Toloo et al. 2020), convenience of collocated services (e.g. radiology), and no out-of-pocket cost (Masso et al. 2007; Cheek et al. 2016; Coster et al. 2017; MacKichan et al. 2017). Common reasons for attending after-hours community-based services also include perceived need and urgency (Keizer et al. 2015; Payne et al. 2017). Current literature on patient reasons for after-hours medical service access only refers to single health services such as EDs or medical deputising services (MDS); and not to other available community-based services such as extended hours GPs or nurse-led clinics that commonly report non-urgent presentations (Barnes et al. 2022). As such, it is unclear why patients choose a specific service within a whole health system.

This paper explores patient-reported reasons for presenting after hours, and reasons for selecting specific services within a health system. Findings may inform after-hours health system and service planning, and support public health messaging that encourages access to appropriate levels of care.

A cross-sectional survey of after-hours medical services was undertaken from 6 pm 27 May to 8 am 3 June 2019. This paper focusses on patient responses. Clinician perspectives have been reported elsewhere (Barnes et al. 2022).

The overall study method, including recruitment of services, has been previously described (Barnes et al. 2022). Briefly, potential study sites included any medical service in the Australian Capital Territory (ACT), Australia, open after 6 pm Thursday or Friday for at least 2 h, and anytime over the weekend. Potential sites included 50 general practices (56% of GPs in the ACT) with a range of billing practices, three MDS locations staffed by GPs generally incurring a co-payment with appointments offered after phone triage; three nurse-led walk-in-clinics (WICs) offering services free at point-of-care; and two public EDs with services free at point-of-care. Potential patient participants included any person presenting to a study site during the snapshot period, without obvious barriers to consent. Potential patient participants to the EDs were identified by triage nurses so as to only include triage codes 4 and 5.

Patients completed a paper-based questionnaire in the waiting room prior to being seen (see Supplementary material). The questionnaire was developed by the research team, informed by literature review and stakeholder consultation. The questionnaire included six sections: demographics and characteristics, usual healthcare providers, reasons for access of current service, previous use of other health services, descriptors of current issue, and prior use of services during the study period. To reduce participant burden, all responses were categorical. This paper focusses on multiple response questions: ‘why did you choose to attend after hours?’ and ‘why did you select this specific service?’.

Face and content validity were provided through piloting with patients, providers, and patient advocacy groups. The paper questionnaire was available only in English and took approximately 12 min to complete.

All paper questionnaires were entered into a purpose-developed database and exported into SPSS v26 for cleaning and analysis (IBM Corp.).

Date and time of presentation were computed based on opening hours of the site and data collection shifts. Categories were created for day of completion, with Saturday split into Saturday morning (8 am−12 noon) and Saturday afternoon (Medicare Benefits Scheme 2021). A variable was created to compare Saturday morning and all other after-hours periods. Age was collapsed into age groups for easier comparison across sites and to the ACT general population. Open-text entries for ‘other’ options were collated to report common entries.

All data are presented using simple descriptive statistics (frequencies, percentages, and medians where applicable). Analyses are presented overall and by site type (GP, WIC, MDS, and ED). Stratified Pearson Chi-squares were used to explore differences within sites for Saturday morning and other after-hours time periods. Patient age and sex were compared to ACT population descriptors for generalisability using Chi-squared Goodness-of-fit (Australian Bureau of Statistics 2019). Significance was set at P < 0.05.

This study was conducted in accordance with the Declaration of Helsinki, and approved by the ACT Health Human Research Ethics Committee (2018/ETH00618) and Calvary Public Hospital Human Research Ethics Committee (CPHB HREC 10-2019).

Of 3371 patients, 1992 completed a survey (response rate: 59.1%). GP patients returned the greatest number of surveys, though provided the lowest response rate. Table 1 outlines the response rate overall and by service.

Table 1.  Participant response rate by site (n = 1992).

Table 2 displays availability of sites and participation. EDs were open continuously. The MDS were open 6 pm−10 pm weekdays, 10 am−10 pm weekends, and were on-call between 10 pm and 8 am. WICs reported daily opening hours of 7:30 am through 10 pm. GPs were variable in opening hours, with no site open before 8 am, and all sites closed by 10 pm.

Table 2.  Site availability and patient presentations by date and time.

Most participants presented for care on Saturday (n = 1021, 51.2%), when the greatest number of sites were available. GPs saw a greater proportion of patients on Saturday morning compared to WICs, MDS and EDs (31.1% vs 8.8%, 10.9% and 15.9%, respectively). WICs and MDS saw a greater proportion of patients on Sunday, compared to GPs and EDs (45.4% and 40.9% vs 32.2% and 34.2%, respectively).

Participants predominantly were female (n = 1107, 56%), had private health cover (n = 919, 46%), and were presenting with a ‘new problem’ (n = 987, 50%), except for patients attending GP services who most often reported non-urgent issues (n = 547, 47.6%). Most participants were uncertain on the urgency of their issue (n = 732, 36.7%). Table 3 outlines participant characteristics as a whole and by service (GP, WIC, MDS, or ED).

Table 3.  Patient participant demographic and characteristic profile (n = 1992).

Compared to the ACT general population, this sample has a slight overrepresentation of females (55% vs 50%, χ² = 9.59, P < 0.001) and underrepresentation of the 60- to 69-year age group (5.5% vs 8.8%, χ² = 9.59, P < 0.001) (Australian Bureau of Statistics 2019).

Patient reasons for seeking after-hours medical care are outlined in Table 4 from most to least common reported responses. No significant differences were noted when comparing Saturday morning versus any other after-hours time within each service type (P > 0.05).

Table 4.  Patient-reported reasons for choosing to attend out-of-hours, from most common to least common selected answers (n = 1992).

The most commonly reported reasons for seeking after-hours care in WICs, MDS and EDs were ‘the problem occurred outside of usual hours’ (n = 764, 38.2%), followed by ‘I was too concerned or sick to wait until usual hours’ (n = 635; 31.9%), indicating perceived need for immediate care. Few people were unaware that their visit was after hours (n = 103, 5.2%).

The most common reason for seeking after-hours GP care was ‘I could not afford to take time off work/life to be seen in usual hours’ (n = 435; 37.9%). The problem occurring after hours and being concerned were common reported reasons for accessing after-hours GP care (n = 275, 23.9% each). Personal factors such as ‘this is when I could get here’ were also common (n = 270, 23.5%). Other reasons reported for seeking GP care were related to personal preference (e.g. preferred time (e.g. before work) (n = 59, 5.1%)), and availability (e.g. soonest available appointment (n = 21, 19%)). Patient-reported reasons for choosing a specific service during the study period are outlined in Table 5, ordered by the most to the least common reported responses. No significant differences were noted when comparing Saturday morning with after-hours times within each service type.

Table 5.  Patient-reported reasons for choosing the specific service they attended during the snapshot period, from most commonly reported reason to least (n = 1992).

The most common overall reasons for choosing a specific service was, ‘This is my regular GP’ (n = 669; 33.6%) and ‘The services here are free or I am bulk billed’ (n = 631; 31.7%). Almost half of participants who chose a non-GP after-hours service (n = 843; 42.3%) reported that ‘My regular GP service is not open now’ (n = 395; 46.8%).

The most common reason for choosing a GP service was ‘This is my regular GP’ (n = 645; 56.1%) followed by ‘I could make an appointment’ (n = 494; 43%). One-third of participants chose a GP because ‘Services here are free or I am bulk billed’ (n = 418; 36.4%). Another third reported they ‘like the quality of care’ (n = 363, 31.6%). ‘Other’ reasons included: convenience (n = 40) and inability to get an appointment with their usual GP (n = 11).

The most common reported reason for choosing a WIC service was ‘I could drop in and I know I will be seen, even if I have to wait’ (n = 213; 67.2%), followed by ‘Services here are free or I am bulk billed’ (n = 159; 50.2%). One-third of patients chose the WIC because ‘It is quicker to be seen here than elsewhere’ (n = 113, 35.6%). ‘Other’ reasons included: an alternative to ED (n = 6) and having a minor issue (n = 6).

The most common reported reason for choosing an MDS was ‘my regular GP service is not open now’ (n = 141; 73.1%), followed by ‘I could make an appointment’ (n = 106; 54.9%). One-third of patients reported choosing an MDS because ‘It is quicker to be seen here than elsewhere’ (n = 57, 39.5%). Despite two of three MDS being co-located at public hospitals with access to X-ray and pathology, few patients recognised that an MDS ‘has the facilities that I need (e.g. pathology or X-ray)’ (n = 13, 6.7%). ‘Other’ reasons included: needing after-hours GP care (n = 12; 35.2%) and inability to get in anywhere else (n = 8, 34.7%).

Most common reported reason for choosing an ED service was ‘This service has the facilities I need (e.g. pathology or X-ray)’ (n = 132; 39.6%). One-third of ED patients chose the ED because ‘My regular GP is not open now’ (n = 102, 30.6%). One-quarter of ED patients chose the ED because they did not think that anywhere else could help them (n = 94, 28.2%), or on the advice of another health professional (n = 95; 28.5%). Only 14% (n = 47) of participants selected ‘services here are free or I am bulk billed’ as a reason for choosing to attend the ED. ‘Other’ reasons included: a want for urgent care (n = 13; 30.2%), and being brought in by ambulance (n = 11, 25.6%).

This paper explored patient reasons for accessing after-hours medical services to better understand health-seeking behaviours and service use. Most patients accessed after-hours services because their issue occurred outside of hours, or they were too concerned to wait. Patients selected services based on both perceived need and personal preferences.

Most patients chose to present to GP services out-of-hours, which is not surprising given that GP had the greatest number of sites available during the study period. Although the contribution of after-hours GP in the ACT has previously been reported from the perspective of clinicians (Barnes et al. 2022), these results from the patient perspective highlight two new findings. First, of patients attending a non-GP after-hours medical service, half reported accessing the service because their usual GP was not available. Although the overall study results show a proportional shift towards presenting to GP sites on a Saturday morning and toward non-GP sites at other times, there was no change in types of presentations treated by the different sites at different times (Barnes et al. 2022). As such, these new results from a patient perspective show that availability of after-hours GP services influenced where people presented, but not why patients were presenting after hours. Clearly, patients are selecting services to meet their needs after hours, and prefer to attend their GP if available.

Patient-reported reasons for accessing extended hours GP were more diverse and lifestyle driven than other after-hours medical services. Although many patients attending after-hours GP had perceived need for GP care, most patients were attending after hours to fit health care around their existing work/life demands (e.g. caring duties, or work). Further, most patients were presenting with long-term issues, and lower urgency or preventive health issues. Combined, these results indicate that patients want access to routine medical care with their usual GP at times that best fit around other established priorities and commitments. However, Australian Government definition for after-hours general practice is for urgent issues that cannot wait for treatment in usual hours, and not as a replacement for usual primary care (Australian Government Department of Health 2021). These data from the patient perspective further support an apparent contradiction between intended and actual use of after-hours GP care, and that GP may have limited capacity to absorb additional ‘preventable ED presentations’ after hours (Barnes et al. 2022).

Patient reasons for attending WICs, MDS and EDs aligned mostly with each services’ advertised purpose. Patients reported attending WICs for quick care with no out-of-pocket cost, for patient-perceived non-urgent, new and short-term issues, aligning with previous findings of patient presentations of wound care (Barnes et al. 2022). Patients sought care from MDS for perceived urgent GP care when their usual GP was unavailable, aligning with previous findings of patient presentations of infections (Barnes et al. 2022). Patients sought care from EDs for perceived urgent issues that may require extra facilities not available in the community-based after-hours services (e.g. X-ray and pathology). Although the presentations to WICs and MDS appear to be ‘preventable ED presentations’, it is unclear if patients would present to EDs if the WICs and MDS services were not available. Still, it appears that most participants were selecting non-GP after-hours health services mostly appropriate for their needs.

This study has limitations that may impact interpretation. The ACT health workforce is unique in that there are fewer GPs per 100 000 population than other Australian states and territories, there are low rates of bulk billing GPs (Australian Institute of Health and Welfare 2018; Steering Committee for the Review of Government Service Provision 2021), and there are nurse-led WICs that may not exist in other states and territories. As such, generalisability to other areas of Australia may be low. Still, these results provide an insight into whole-of-system use of after-hours medical services, and may provide comparison data for other health systems. These data were collected prior to the coronavirus disease 2019 (COVID-19) pandemic. Changes to the health system (e.g. telehealth and introduction of GP respiratory clinics), and in public understanding and trust of health services may have new influences on patient choice. Clearly, these data have value for health system and service planning in the after-hours periods; though the study should be replicated to best understand local contexts and changes over time. Overall, patients present to after-hours medical services for both perceived need and convenience.

Most patients appear to be self-selecting after-hours services appropriately aligned with advertised services; however, patients in the ACT are currently using extended hours GP services for mostly ‘usual primary care’ issues, instead of the intended ‘urgent GP care’ issues. Findings from this study can help inform public health messaging and service delivery options.

Supplementary material is available online.

The data that support this study cannot be publicly shared due to ethical or privacy reasons. De-identified data may be shared upon reasonable request to the corresponding author and approval from the original institutional ethics committee.

The authors declare no conflicts of interest.

This study was funded by ACT Health as part of regular health service evaluation and planning. ACT Health also fund salaries for KB, DC and KD. The funder had no input into the study design, data collection, analysis, or interpretation.