The findings of this phase of the project provided more detailed information about some of the main areas of concern regarding the provision of after hours palliative care that were identified in phase 1 of the project . In particular these data present the views of two different groups of health professionals, GPs and palliative care nurses, regarding how after hours care of palliative patients in the community might be improved.
The demographic details of the participants provided some points of interest. Almost all (GPs 89% and nurses 98%) who participated in the study had more than 11 years experience and in both cases the majority of those who responded had more than 20 years experience. If this is representative of the general GP and PC nurse work force, this has important implications for future palliative care services in the community as many of these people are approaching retirement age. In the case of GPs this is consistent with other findings , which identified that in a sample of GPs working in the southern and north western regions of Sydney, those not involved in providing PC were likely to be younger and have less GP experience than those who did provide this care. In our study the percentage of GPs who had undertaken postgraduate palliative care training (14%) was higher than that identified in the above Sydney study (9.1%) . It should be noted that our finding of 69% of nurses having undertaken palliative care training is not representative of the general nursing population, as participants were all drawn from a PC nurses special interest group.
While many (more than 60%) of the participants were associated with practices or organisations which provided after hours PC services there was a notable lack of knowledge about service provision. For example, 47% of GPs were unaware that EPC Medicare items could be used for care planning for people receiving PC, both in the development of advance care plans and for team meetings with multidisciplinary PC teams, even though this information is provided on relevant Division of General Practice websites. It was also found that 49% of GPs did not know if after hours triaged telephone services were available in their area. One explanation for this may be that the majority of the participating GPs did not personally provide after hours services but relied on locum services, a notion supported by the data presented above in relation to the use of locum services. Clearly the availability of locum services is one of the inequitable situations in the provision of health care (and no doubt after hours palliative care) between urban and rural/remote areas. Phase 1 of this study also indicated that some of the problems experienced with after hours locum services included costs, lack of PC training among locum doctors, lack of knowledge of specific patient needs and very long delays in getting service . Limited literature is available regarding provision of after hours PC services by locum GPs in Australia and so this offers opportunity for further investigation.
It was also observed that GPs (77%) considered that current after hours services were either very satisfactory or satisfactory (combined result) compared to only 67% of nurses who participated. Given that nurses participating in this study were recruited from a PC nurses' special interest group, this difference may be a reflection of greater nurse involvement in the provision of after hours PC services.
Factors which may impact of after hours PC services
Both nurses and GPs were asked to indicate their agreement or otherwise with a number of statements about factors which may impact on after hours service provision. For six of the nine factors listed there was no significant difference in the views of GPs and nurses. The factor on which there was closest agreement and which also had the lowest mean score across the two groups (i.e closest to 'strongly agree') was 'poor communication between GPs and nurses will impact on after hours PC service provision'. Another factor on which there was close agreement was 'patients being unwilling to call after hours services when they were available'. These factors have also been identified in earlier studies [20–24].
The three factors on which there was a significant difference of view between the two groups were: nurses feeling unsafe at night, limited access to after hours emergency medication, and limited availability of GPs after hours. In each case the nurses indicated that these issues were more likely to impact on after hours services than did the GPs. There are two likely factors which may have contributed to the difference of views in relation to nurse safety. Nurses are more likely to be focused on that than other work force sectors. Also in this study, as already indicated very few of the GPs personally attended to after hours calls these being addressed by locum services. It is very likely that among the participants of this study nurses were much more likely to be making after hours calls than the GPs. Limited access to emergency medication after hours has also been reported as problematic . There is potential for further investigation of this issue. Are factors such as poor communication, incomplete planning and lack of access to GPs and pharmacies after hours contributing to this problem? As already indicated the use of locum services in the provision of after hours PC, including the issue of cost to patients, needs further investigation. Greater access to GPs after hours was also cited as important by patients in a UK study .
Strategies which may improve after hours PC service provision
A high percentage of both nurses and GPs agreed or strongly agreed that standardised written or individual patient protocols would improve after hours services. It needs to be acknowledged that these are only helpful in relation to after hours care if after hours on call staff, including locums, have access to them.
Of the thirteen suggested strategies for improving after hours PC services there was no significant difference in the views of nurses and GPs in relation to nine of these. Again in each case the nurses agreed more strongly that these strategies would improve after hours services. One of these strategies involved a formal protocol between PC services and aboriginal Australians. Some of the participants (more GPs than nurses) in this study indicated that lack of experience with aboriginal clients prevented them from forming an opinion on this matter.
One important area of significant difference between the two groups was the usefulness of multidisciplinary team meetings, which include the GP, in improving after hours PC services. Possibly GP concerns about the time involved in such meetings and that 49% were unaware that they can use EPC Medicare items to fund this activity, may in part explain this difference. One study has reported that GPs expressed concern about the degree to which they should refer to specialist teams . It is not known if this was a contributing factor to GPs lesser enthusiasm for multidisciplinary team meetings in our study.
Another area of significant difference of view between the two groups related to having more PC trained nurses staffing after hours telephone services. It has been reported  that referral and the type of follow-up of triaged after hours calls was related to nurse training and confidence in palliative care. This would support the very strongly held view of nurses that after hours service provision would be improved by increasing the number of PC trained nurses available to these after hours call services.
Support both for carers, either the provision of such opportunities as support groups or respite care provided by PC trained respite carers, or for professionals in the form of great opportunities for debriefing, were other strategies considered. Nurses were significantly more likely to consider that PC trained respite carers would improve after hours service. They were also more likely to consider that service provision would be improved by greater support for staff. This difference may have occurred because participating nurses, who were all members of a PC nurses' special interest group, were much more likely than GPs to be working on a daily basis with people receiving PC and their carers.
The other contentious issue related to changing legislation to allow nurse evaluation of death. Of the thirteen strategies considered this one resulted in the greatest variation in mean scores between the two groups. It is noteworthy that the Victorian Department of Human Services (DHS) has recently (July 2009) issued a Guidance Note  relating to the verification of death. This note reinforces that Division 1 and 3 Registered Nurses (as defined by the Health Professionals Registration Act 2005) and Paramedics (as certified by Ambulance Victoria) in an employment context, can verify death, allowing the removal of a body from the site of death. Only registered medical practitioners may certify death by completing the required form.
While all of the issues raised by the participants in this second phase of the project were considered important, it was not possible within the scope of the project to address them all in the final phase, which focused on the production and evaluation of educational tools. For example, some issues such as the shortage of PC trained staff and respite carers cannot be addressed by a project of this nature. However, four main areas, which were considered most feasible in the context of the project, were selected for action. These were: perceived reluctance of patients and carers to utilise available after hours services; poor utilization by GPs of Enhanced Primary Care Medicare Items for palliative care planning and team communication; the importance of advance care planning in relation to appropriate after hours care and communication within multidisciplinary teams which include the GP. A brochure directed to patients and their carers and a DVD, with website version, for health professionals, were produced promoting these main areas. The web address is: http://www.med.monash.edu.au/ahpc.