The findings of the research revealed that residents from Black and Minority Ethnic ..... Number (,000). Percentage. White: British. 77.9. 96.2. White: Irish. 0.8. 1.0 ...... a telephone appointment with the practice nurse to assess who she needed to see as ...... still worried about her child's high fever after seeing the GP and so ...
Use and experiences of front-line health services amongst Black and Minority Ethnic residents of western Cheshire
Fiona Ward Katie Powell Miranda Thurston Paul Cleary
June 2008
© University of Chester 2008 ISBN 978-1-905929-61-0
Acknowledgements There are a number of people who we would like to thank for their involvement: •
the people who agreed to be interviewed or took part in the focus group;
•
Shantele Janes and Madhu Kukar for facilitating our access to members of the Chester and Halton Racial Equality Council Consultation Panel;
•
Elizabeth Bott at the Chester Asian Council for her advice and help with recruitment;
•
Kapo Ho for her interpreting services and help with recruitment; and
•
Wayne Ashbrook at Western Cheshire Primary Care Trust and Darren Mooney at the University of Chester for the provision of background information.
i
Contents Acknowledgements
i
Contents
ii
Tables
vi
Summary
vii
Chapter 1
Introduction
1
1.1
Background and rationale
1
1.2
Local primary care services
1
1.3
Aim and objectives
2
1.4
Structure of the report
2
Chapter 2
Health experiences amongst the Black and Minority Ethnic population of the UK
3
2.1
Introduction
3
2.2
Defining Black and Minority Ethnic groups
3
2.3
The national policy context
4
2.4
Health inequalities amongst Black and Minority Ethnic groups
5
2.5
Use of health services by Black and Minority Ethnic groups
5
2.6
Explaining ethnic health differences
6
2.6.1
Socio-economic factors
6
2.6.2
Cultural differences
7
2.6.3
Discrimination
8
2.6.4
Access to information
8
2.6.5
Language barriers
9
2.6.6
Satisfaction with services
9
2.7 2.7.1 2.8
The local Black and Minority Ethnic population Use of services at a local level
10 14
Conclusion
14
Methodology
15
3.1
Introduction
15
3.2
Sampling strategy
15
3.3
The recruitment process
16
3.4
Methods of data collection
18
3.5
Analysis
19
Chapter 3
ii
3.6
Conclusion
19
Profile of the sample
20
4.1
Introduction
20
4.2
A profile of participants
20
4.3
Area of residence
21
4.4
Language
22
4.5
Caring responsibilities
23
4.6
Self-rated health status
24
4.7
Conclusion
25
Findings relating to primary care services
26
5.1
Introduction
26
5.2
Use of GP services
26
Chapter 4
Chapter 5
5.2.1
Making the decision to use the service
27
5.2.2
The practice as an organisation
30
5.2.2.1
Appointment systems
31
5.2.2.2
Referrals to other services
34
5.2.2.3
Collection of test results
35
5.2.2.4
Local out-of-hours services
36
5.2.3
The quality of interaction with the GP
36
5.2.3.1
Communication
36
5.2.3.2
Rapport with the GP
38
5.2.3.3
Continuity of care
40
5.2.3.4
GP attributes
42
5.2.4
Quality of interaction with the practice nurse
44
5.2.4.1
Communication
44
5.2.4.2
Rapport with the practice nurse
44
5.2.4.3
Continuity of care
46
5.2.5
Quality of interaction with other practice personnel
46
5.3
District nurse
47
5.4
Community therapists
48
5.4.1
Decision to use the service
48
5.4.2
Quality of care
49
5.5
Health visitor
50
5.5.1
The use of the health visiting service
50
5.5.2
Quality of care
50 iii
5.6
Pharmacist service
51
5.6.1
Use of the pharmacist
51
5.6.2
Making the decision to use the service
51
5.6.3
Quality of care
53
5.7
Dental services
54
5.7.1
Quality of care
55
5.7.2
Quality of interaction with the dentist
55
5.8
Optician
57
5.8.1
Decision to use the optician
57
5.8.2
Quality of care
58
5.9
Preventative services
60
5.9.1
Cancer screening
60
5.9.2
Vaccinations
61
5.9.3
General health checks
62
5.10
Conclusion
62
Findings from other front-line services
63
6.1
Introduction
63
6.2
Accident and emergency services
63
6.2.1
Use of accident and emergency
63
6.2.2
Making the decision to use the service
64
6.2.3
Waiting times
65
6.2.4
Quality of care
66
Chapter 6
6.3
NHS Direct
67
6.3.1
Use of NHS Direct
68
6.3.2
Making the decision to use the service
68
6.3.3
Quality of care
69
Antenatal services
71
6.4 6.4.1
Antenatal check-ups and contact with midwives
71
6.4.2
Experience of antenatal classes
72
6.5
Postnatal care
73
6.5.1
Maternity, postnatal care and check-ups
74
6.5.2
Experience of postnatal classes
74
6.6
Hospital services
75
6.7
Conclusion
76
iv
Chapter 7
Discussion
77
7.1
Introduction
77
7.2
The research design
77
7.3
The Black and Minority Ethnic population in western Cheshire
77
7.4
Making choices about services
78
7.5
Experience of organisational processes and systems
80
7.6
Interaction with health practitioners
81
7.7
Key findings
82
7.8
Conclusion
83
References
85
Appendix 1 – Participant Information sheet
90
Appendix 2 – Consent form
93
Appendix 3 – Interview schedule
95
v
Tables Table 2.7.1
Estimated resident population by ethnic group, mid-2004 (Chester)
Table 2.7.2
Estimated resident population by ethnic group, mid-2004 (Ellesmere
11
Port and Neston)
12
Table 4.2.1
Participants by age and sex
20
Table 4.2.2
Participants by ethnic group
21
Table 4.3.1
Length of time in area
21
Table 4.4.1
Participants’ first language
22
Table 4.4.2
Self-rated level of English listening comprehension
23
Table 4.4.3
Self-rated level of spoken English
23
Table 4.6.1
Self-rated health of participants by age
24
Table 4.6.2
Participants with a long-term illness or disability
24
vi
Summary
Introduction Addressing health inequalities between different ethnic groups is a critical part of the overall strategy for reducing health inequalities in the United Kingdom. National research shows that Black and Minority Ethnic groups may experience poorer health and often worse health care compared to the majority White population. These findings, and increased migration to the United Kingdom in recent years, pose new challenges for the National Health Service. To gain a better understanding of the local situation, Western Cheshire Primary Care Trust commissioned this research to study the use and experience of primary care and other front-line services amongst local Black and Minority Ethnic residents to inform the planning and commissioning of local health services.
Study design and methods This small-scale study was designed to explore the use and experiences of front-line health services within the Western Cheshire Primary Care Trust area amongst residents belonging to Black and Minority Ethnic groups. A qualitative approach was adopted for the study as the aim was to explore perceptions and capture experiences. Semi-structured interviews and a focus group were conducted, some with the aid of an interpreter. Data from each interview and the focus group were transcribed verbatim into text. Thematic analysis of the transcripts was conducted using NVivo software.
A total of 36 people took part in the research; 24 participants were female and 12 were male. The sample included participants from a wide age range, although the majority (24, 67%) were less than 50 years old. Participants were from a range of ethnic backgrounds, with the largest group being of South Asian origin, reflecting the higher proportion of this ethnic group in the Chester and Ellesmere Port area.
Key findings The research identified a number of key findings about the use of health services by residents from Black and Minority Ethnic groups in western Cheshire. •
Participants sometimes had limited information on which to decide which services to access.
vii
•
A perception of the accessibility of a service, as well as the perceived severity of a health problem, appeared to influence the decisions that participants made about which service to approach.
•
GP appointment systems were sometimes seen as a barrier to accessing GP services.
•
Some participants reported communication difficulties with staff, particularly GP receptionists. However, there was little evidence of the use of professional interpreting services, even for participants who did not speak and/or understand English fluently.
•
Services were not always sensitive to an individual’s cultural and religious needs. Participants were appreciative where these could be accommodated.
•
Interviewees sometimes wanted to have a choice of practitioner, particularly women who preferred to see a female GP.
•
Continuity of care and the doctor-patient relationship were particularly important to the participants.
•
Some people were discouraged from using preventative services, such as cervical screening or optician services, because of previous experiences, cost or lack of information about the service and what an appointment might entail.
•
There was little evidence of inappropriate use of services.
Conclusion The findings of the research revealed that residents from Black and Minority Ethnic groups had some very positive experiences of local front-line health care services. Many were knowledgeable about, and broadly satisfied with, the treatment they had received, and with their contact with practitioners. Where there was dissatisfaction, it related primarily to their interactions with particular individuals and, to an extent, to specific organisational systems.
The research also found that interviewees’ expectations of services were based upon both their own and other people’s use of health services in the UK and abroad. This breadth of knowledge and experience brought an additional dimension to the perceptions of the participants in this research. For some interviewees, continued contact with their country of origin also presented an additional source of advice and an opportunity to access services. viii
In many areas of health care, research has shown that whilst there are differences in the experience and views of individuals from different ethnic groups, there are also considerable similarities. Many of the changes to service design and delivery which would meet the expressed needs of the population from Black and Minority Ethnic groups would be likely to impact positively upon patients from all ethnic groups within the community. Other changes, however, which focus on alleviating barriers to communication, and cultural or religious issues that affect the quality of the interaction and/or the use of a service would be of particular benefit to Black and Ethnic Minority groups. Many of the key findings of this research in western Cheshire are consistent with the recently produced report from the Department of Health, No Patient Left Behind, which sets out new approaches to providing a high quality, culturally sensitive primary care service which is accessible to all.
ix
Chapter 1 Introduction 1.1
Background and rationale
The health of Black and Minority Ethnic residents has become a significant issue in the United Kingdom (UK) as the Government seeks to address health inequalities within a diverse population (Johnson, 2007). National research shows that Black and Minority Ethnic residents experience poorer health and often worse health care than the majority White population (Johnson et al., 2004), findings which, combined with the increased migration to the UK in recent years, pose new challenges for public services (Institute of Community Cohesion, 2007). It is therefore timely to explore the health care experiences of this population at a local level. Western Cheshire Primary Care Trust commissioned this research to learn more about the use and experience of primary care and other front-line services amongst local Black and Minority Ethnic residents to better inform service planning.
1.2
Local primary care services
Primary care trusts have three functions. These are, firstly, to engage with the local population to improve health and well-being; secondly, to commission a comprehensive and equitable range of high quality responsive and efficient services within allocated resources; and thirdly, to provide high quality responsive and efficient services where this gives best value (Department of Health, 2006a). The Western Cheshire Primary Care Trust covers a population of approximately 233,000 people who live in Chester, Elton, Farndon, Kelsall, Tattenhall, Malpas, Tarporley, Frodsham, Helsby, Bunbury, Audlem, Wrenbury and the borough of Ellesmere Port and Neston. It provides community health services such as health visiting, district nursing, physiotherapy, chiropody, speech and language therapy, and invests in the care provided by other services including hospitals, mental health services, family doctors, dentists, pharmacists and opticians (Western Cheshire Primary Care Trust, n.d.).
For the purposes of this research, Western Cheshire Primary Care Trust was primarily interested in exploring front-line primary care services. Primary care services are defined as general practitioners (GPs), community and practice nurses, community therapists (such as physiotherapists and occupational therapists), community pharmacists, dentists and opticians. In addition to these primary health care services,
1
the Trust was also interested in the use of accident and emergency (A&E), NHS Direct and antenatal and postnatal care.
1.3
Aim and objectives
The aim of this research was to explore the use and experiences of local front-line health care services amongst Black and Minority Ethnic residents. More specifically, the primary objective of the research was to illuminate the perceptions of these services amongst Black and Minority Ethnic residents within the context of each participant’s health needs.
1.4
Structure of the report
This report is organised into a number of chapters. Chapter 2 explores relevant background literature concerning national and local evidence on the health needs and experiences of Black and minority residents as well as the national policy context. Chapter 3 describes the study design and methodology used in the research. In Chapter 4 profile information on the research population is provided and the findings from the interviews and focus group are presented in Chapters 5 and 6. Finally, in Chapter 7, the findings are discussed in light of the aims and objectives of this study and the literature reviewed.
2
Chapter 2 Health experiences amongst the Black and Minority Ethnic population of the UK 2.1
Introduction
The ethnic composition of the UK population continues to diversify and there is increasing interest in exploring the health of ethnic minority groups and their use and experiences of health care (Johnson, 2007). Long-term migration to the UK almost doubled between 1997 and 2006 leading to population growth and increased diversity in both urban and rural areas which has changed the demand for public services (Institute of Community Cohesion, 2007). Population estimates suggest that these changes have been felt in western Cheshire (ONS, n.d.) and with the shift in government policy towards a health service tailored to the needs of local communities it is timely to explore the experiences of service users.
This chapter reviews the literature concerning the national policy context in relation to health inequalities amongst Black and Minority Ethnic groups. The health needs and experiences of Black and Minority Ethnic residents in the UK are then explored in more detail, within the context of inequalities. Finally, local data is used to explore how applicable these findings are to the Black and Minority Ethnic population of western Cheshire.
2.2
Defining Black and Minority Ethnic groups
There is much debate regarding the definition of the term ‘ethnicity’ within the fields of medical and social care research (Johnson, 2007). Definition of ethnic categories has varied across time and between different groups of people; personal identification with a specific ethnic group may be influenced by a multitude of factors including perception of shared origins, heritage, or culture and can be seen as an ongoing individual or collective process (Johnson, 2007). Investigation into the experiences of specific ethnic groups therefore requires acknowledgement of the fluidity of the categories under discussion. Census categories are the most commonly used framework for classifying ethnic groups and are used in this report to explore the experiences of Black and Minority Ethnic UK residents, although the limitations of these categories need to be kept in mind.
3
2.3
The national policy context
Current government policy in the UK identifies the reduction of health inequalities as a major priority, specifically in relation to improving access, outcomes and experiences of health and social care services (Raleigh & Polato, 2005). The most recent White Paper, Our Health, Our Care, Our Say, outlined the Government’s objective of reducing health inequalities through development of local targets and coordination of health and social care services (Department of Health, 2006b). The shift in emphasis from national to locally determined targets for health care encourages service providers to consider the ‘particular needs’ of the local population, using both epidemiological and general survey data as well as listening to the views of the local population (Department of Health, 2004, p. 11).
Research to understand the underlying causes of health inequalities has a long tradition in the UK and in the early 1980s this research expanded to include investigation into the health inequalities of Black and Minority Ethnic groups (Nazroo, 1997). While tackling race inequalities also ranks highly as a government priority, there is criticism that ethnicity has not been a consistent focus of policies to address health inequalities (Parliamentary Office of Science and Technology [POST], 2007).
In 2004, the Government established national core and developmental standards for the NHS, providing a useful backdrop to understanding the experiences of particular health service users (Department of Health, 2004). These standards are divided into seven domains covering the following areas: 1. patient, staff and visitor safety; 2. clinical and cost effectiveness of the NHS; 3. governance of services; 4. patient focussed services that meet diverse patient needs (for example in the provision of food) and ensure patient dignity; 5. patient choice in relation to care pathway through the creation of accessible and prompt services; 6. service environments, for example services should be delivered in an environment that promotes patient well-being; 7. public health protection through implementation of public programmes and response procedures.
4
2.4
Health inequalities amongst Black and Minority Ethnic groups
Inequalities amongst Black and Minority Ethnic groups in England have been found to exist in relation to health outcomes, access to services, and in the quality of health care received (Johnson et al., 2004). Though some positive differences between health outcomes of Black and Minority Ethnic groups and those of the general population are recorded, the 1999 Health Survey for England found that Black and Minority Ethnic groups fare worse across a range of indicators (Stanner, 2001). In terms of general health, the survey found that South Asian men and women, and Black Caribbean women were most likely to rate their own health as bad or very bad (Stanner, 2001). Prevalence of limiting long-standing illness was recorded as between 30 and 65% higher than the general male population amongst Pakistani, Bangladeshi and Irish men, and between 20 and 45% higher than women in the general population amongst Black Caribbean and South Asian women (Stanner, 2001).
The Health Protection Agency suggest that the large majority (85%) of migrants to the UK will have similar health needs to their counterparts in age and sex in the indigenous population and identify three major determinants of migrant health: individual characteristics, country of origin and the circumstances of migration, and the socioeconomic conditions in the host country (Health Protection Agency, 2006).
2.5
Use of health services by Black and Minority Ethnic groups
While ethnic differences in uptake of health services have been reported, particularly in relation to access to secondary care, use of primary care services amongst Black and Minority Ethnic groups is not clear (POST, 2007). There is evidence to suggest that most Black and Minority Ethnic groups access primary care services at rates as high as the general population (POST, 2007) and there is some evidence to suggest that nonWhite groups consult with GP services more often than White groups (Morris, Sutton, & Gravelle, 2005). Interestingly, there is also contradictory evidence to suggest that there is no difference in the health-seeking behaviour of Black and Minority Ethnic groups as compared to the White population (Adamson, Ben-Shlomo, Chaturvedi & Donovan, 2003).
Despite this, South Asian patients are less likely than White patients to receive coronary revascularisation in relation to need (Association of Public Health Observatories, 2006). Women from Black and Minority Ethnic groups make less use of
5
antenatal services (Petrou, Kupek, Vause, & Maresh, 2001) and are more likely to book late for delivery (Rowe & Garcia, 2003). And women from South Asian groups in particular, are less likely to receive prenatal testing (Rowe, Garcia, & Davidson, 2003). Women from South Asian communities (especially the Bangladeshi community) are less likely to access cervical screening (Rudat, 1994). People from Minority Ethnic groups are less likely to visit the dentist (Nazroo, 1997) or optician (Rudat, 1994) and are also less likely to use NHS Direct (Comptroller and Auditor General, 2002). It has also been suggested that new migrants may be more likely to attend A&E inappropriately (North West Development Agency, 2008).
2.6
Explaining ethnic health differences
There is wide debate within social and health sciences regarding explanations for ethnic inequalities in health; there is evidence to suggest that a range of factors contribute to poorer health outcomes and experiences for Black and Minority Ethnic groups. The information below summarises the main arguments within the literature.
2.6.1
Socio-economic factors
Black and Minority Ethnic groups, especially Pakistani and Bangladeshi communities, are among the most deprived communities in the UK, and much inequality in health and access to services may be attributable to deprivation rather than ethnicity per se (ONS, 2004). Pakistani and Bangladeshi groups have the lowest percentage of their population in “managerial and professional” occupational groups (ONS, 2004). In 2002, Chinese pupils were the most likely to achieve five or more GCSE results A* to C in England (77% of boys and 71% of girls); the lowest level of educational attainment was seen among Black Caribbean, Black African, Other Black and Pakistani schoolchildren (ONS, 2004).
Within the UK population as a whole White Irish, Chinese and Indian groups are most likely to have a higher level qualification, although the proportions of these groups without qualifications are also slightly higher than the national average. Pakistani and Bangladeshi groups are most likely to have no qualifications. Nationally, unemployment rates are higher for people from non-White ethnic groups than those for people from White ethnic groups, a finding that is consistent with the differences in relation to educational achievement. In 2002/03, men from Bangladeshi and Mixed ethnic
6
backgrounds had the highest unemployment rates in Great Britain, followed by Black African, Pakistani and Black Caribbean ethnic groups (ONS, 2004).
Although poorer socio-economic position is considered to be a driving factor in the health inequalities of Black and Minority Ethnic groups (POST, 2007), it is argued that emphasis of this link obscures the impact of a range of other factors (Ahmad & Bradby, 2007). Using The Fourth National Survey of Ethnic Minorities, Chandola (2001) found that the self-rated health of Pakistani and Bangladeshi respondents remained significantly poorer compared to Whites when social class had been accounted for. Using the same model and allowing for a combination of social class, standard of living and area deprivation however, the same study found that ethnic differences in health reduced to non-significance. Chandola (2001) and others (see for example Cooper, 2002) have concluded that material factors are important in explaining ethnic differences in health but that the underclass hypothesis by itself does not explain all of the differences experienced.
Nazroo (1998) has also suggested that material disadvantages do not wholly explain differences in health experiences and that the impact of racism and geographical concentrations of Black and Minority Ethnic populations need to be considered. Jones and Duncan, cited in Chandola (2001) suggest that mechanisms contributing to health inequalities can be understood using four categories: physical environment, such as the impact of pollution; individual interaction with specific cultures where health promoting behaviours may be uncommon; area deprivation, which may impact on the accessibility of services; and social mobility which may be affected by the constraints of the regional employment markets.
2.6.2
Cultural differences
Nazroo urges caution when considering the impact of cultural factors on health as there is little accurate measurement of the impact of such factors (Nazroo, 1998). He argues that attributing significance to these factors, such as diet, without reference to the context in which they operate or clear exploration of their impact on health can lead to victim blaming and racialised understanding of differences.
7
2.6.3
Discrimination
There is evidence that people from Black and Minority Ethnic groups are more likely to experience verbal abuse and discrimination which has been associated with anxiety, worry and depression (Kelaher et al., 2008). There is also some evidence to suggest that discrimination which leads to stress could result in chronic illness (Gee, Spencer, Chen, & Takeuchi, 2007). Using The Fourth National Survey of Ethnic Minorities, Karlsen and Nazroo (2002) concluded that racism in the UK can manifest itself in a variety of ways (violence, institutional racism, socio-economic disadvantage) all of which have a detrimental effect on health. Discrimination has also been shown to exist within the health service itself. For example, a recent study into experiences of cancer services found that Black and Minority Ethnic service users reported a failure on the part of providers to accommodate religious and cultural diversity; the study concluded that institutional racism within services still exists (Elkan, et al., 2007).
2.6.4
Access to information
Health knowledge is thought to be a vital influence on utilisation of health services (Field & Briggs, 2001) and there is evidence of a lack of information and information sources amongst some Black and Minority Ethnic groups (Watts, Merrell, Murphy, & Williams, 2004; O'Donnell, Higgins, Chauhan, & Mullen, 2007). Understanding the health care system also influences patient use of services. A study in a London area with a high proportion of Black and Minority Ethnic residents (40%) identified different service expectations amongst these residents and found that patients with limited English often failed to attend follow-up appointments with their GP and often presented as emergencies in general practice for non-urgent problems (Greenhalgh, Voisey, & Robb, 2007).
There is evidence to suggest that recent migrants to the UK may experience difficulty understanding local health care systems; the bureaucracy involved in registering as a new patient for example, has reportedly deterred some migrants from accessing GP services (Institute of Community Cohesion, 2007). Inappropriate use of A&E and late registration with maternity services has also been reported (Institute of Community Cohesion, 2007). There is a belief that many migrants are unaware of their rights with regard to accessing health care which results in their returning to use services in their home country (Institute of Community Cohesion, (2007).
8
Research into attitudes towards colorectal screening identified that Black and Minority Ethnic groups had less knowledge about the disease than White people; the research recommended that appropriate educational materials should be produced to address the imbalance (Robb, Solarin, Power, Atkin, & Wardle, 2008).
2.6.5
Language barriers
Having limited English language also represents a barrier to accessing services and information (Alexander et al., 2004; Merrell, Kinsella, Murphy, Philpin, & Ali, 2006) and provision of interpreting services in the NHS has been found to be ad hoc (Mehta, 2005). This may, in part, account for why a third of Chinese people do not understand the language used by their doctors (Department of Health, 2006c). Chinese people are also less likely to consult their GP than White people, and may also under-use other health services (Gill, Kai, Bhopal, & Wild, n.d). Over half of South Asian people attempt to see GPs who speak their language (Department of Health, 2006c).
Greenhalgh et al. (2007) emphasise the distortion to communication, as well as the challenge to patient-practitioner trust that language barriers can create. Reliance on friends and family as translators can mean that patients do not get vital information, either because of the limited translation skills of unqualified interpreters dealing with complex medical language or because these interpreters may filter information their family member or friend receives through embarrassment or a desire to protect the patient or control the information they receive (Haslam, 2008).
Following a review of migrant health in the UK, the Health Protection Agency (2006) recommended that migrants should have access to culturally appropriate and language-supported health services within primary and secondary care, a suggestion supported by others (Astin, Atkin, & Darr, 2008). Patel, et al., (2007) identified a need for provision of targeted support for Black and Minority Ethnic communities in preventative health care from the positive response received to a community screening programme for cardiovascular disease using interpreters.
2.6.6
Satisfaction with services
There are inconsistent findings regarding rates of satisfaction with NHS services amongst Black and Minority Ethnic groups. A recent report on the National Patients Survey examined the self-reported views of NHS patients from different ethnic groups
9
(Department of Health/Healthcare Commission, 2008). This survey adopted a quantitative approach to look at the five domains of access and waiting; safe, high quality co-ordinated care; better information, more choice; building closer relationships; and clear, comfortable, friendly places to be. The findings of the research presented an inconsistent picture with ‘a range of variations between black and ethnic minority groups and their White counterparts’ (Department of Health/Healthcare Commission, 2008, p.2). Whilst in some of the domains patients from Black and Minority ethnic groups were less likely to report a positive experience, in others there was no difference and a few showed a positive difference for minority groups. The report suggests that a range of factors, including differing expectations and perceptions of services, may influence the findings.
Other research highlights that rates of dissatisfaction with NHS services are higher among some Black and Minority Ethnic groups than their White British counterparts (POST, 2007). For example, South Asians report poorer experiences as hospital inpatients according to the Healthcare Commission’s patient surveys (POST, 2007). A comparison of South Asian and White patients’ GP consultations indicated that GPs spent less time giving information to South Asian patients than to White patients, regardless of language proficiency (Neal et al., 2006). White patients were also seen to have more emotional consultations (Neal et al., 2006).
2.7
The local Black and Minority Ethnic population
The population in the Chester and Ellesmere Port/Neston area is predominantly selfclassified as of White ethnicity, and the area has a lower proportion of residents from non-White ethnic groups than the national average (ONS, 2001). Chester has a higher proportion of residents of non-White ethnicity than Ellesmere Port/Neston. The largest non-White ethnic groups in the area as a whole are Chinese and Indian, followed by Black African and groups of mixed ethnicity. In England overall, Indian is the largest Minority Ethnic group (ONS, 2001).
Using population estimates for mid-2004, 11% of the UK population is from a nonWhite ethnic group (ONS, n.d.). For the Chester and Ellesmere Port areas the figures are lower, at around 4% and 2% respectively. Table 2.7.1 illustrates the breakdown of the Chester population by ethnic group. Table 2.7.2 illustrates the breakdown of the Ellesmere Port population by ethnic group (ONS, n.d.).
10
Table 2.7.1
Estimated resident population by ethnic group, mid-2004 (Chester)
Ethnicity code
Number (,000)
Percentage
111.7
93.9
White: Irish
1.2
1.0
White: Other White
2.4
2.0
Mixed: White and Black Caribbean
0.3
0.3
Mixed: White and Black African
0.1
0.1
Mixed: White and Asian
0.3
0.3
Mixed: Other Mixed
0.2
0.2
Asian or Asian British: Indian
0.7
0.6
Asian or Asian British: Pakistani
0.3
0.3
Asian or Asian British: Bangladeshi
0.3
0.3
Asian or Asian British: Other Asian
0.2
0.2
Black or Black British: Black Caribbean
0.2
0.2
Black or Black British: Black African
0.2
0.2
Black or Black British: Other Black
0.0
0.0
Chinese or Other Ethnic Group: Chinese
0.4
0.3
Chinese or Other Ethnic Group: Other
0.4
0.3
118.9
100.0
White: British
Total
11
Table 2.7.2
Estimated resident population by ethnic group, mid-2004 (Ellesmere Port and Neston)
Ethnicity code
Number (,000)
Percentage
White: British
77.9
96.2
White: Irish
0.8
1.0
White: Other White
0.9
1.1
Mixed: White and Black Caribbean
0.1
0.1
Mixed: White and Black African
0.1
0.1
Mixed: White and Asian
0.2
0.2
Mixed: Other Mixed
0.1
0.1
Asian or Asian British: Indian
0.2
0.2
Asian or Asian British: Pakistani
0.1
0.1
Asian or Asian British: Bangladeshi
0.1
0.1
Asian or Asian British: Other Asian
0.1
0.1
Black or Black British: Black Caribbean
0.0
0.0
Black or Black British: Black African
0.1
0.1
Black or Black British: Other Black
0.0
0.0
Chinese or Other Ethnic Group: Chinese
0.2
0.2
Chinese or Other Ethnic Group: Other
0.1
0.1
Total
81.0
100.0
Since 2004, England has seen increasing migration from new European Union (EU) countries, especially from Poland but also from the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Slovakia and Slovenia. This inflow is likely to change in coming years as opportunities in other EU countries increase. Worker registration has been required of all immigrants from Accession 8 countries (those countries which joined the European Union in 2004) since 2004. The data show that 1,679 worker registrations were recorded in the Chester local authority area between May 2004 and December 2006 (Border and Immigration Agency, Department for Work and Pensions, HM Revenue & Customs, & Communities and Local Government, 2007). There were 393 registrations in the Ellesmere Port and Neston local authority area for the same period (Border and Immigration Agency et al., 2007). Information has also recently been published on National Insurance (NI) registrations. In Cheshire in 2006/07, there were 5,500 NI registrations by non-UK nationals, compared to 1,700 five years previously (Northwest Development Agency, 2008).
12
The Family Health System (FHS) records information on country of birth for persons registering with a general practice. However, there are concerns about the quality of these data, which are incompletely recorded and do not show how long a person has been living in the area. Nevertheless, a 2007 snapshot of the FHS register in Chester and Ellesmere Port showed that the largest group of non-UK born residents came from western Europe; eastern Europe contributed the next largest number of foreign-born residents, with the majority of these coming from Poland (Western Cheshire Primary Care Trust, 2007). Smaller numbers came from Slovakia, Lithuania and other new accession countries. In third place came South Asia, of which the largest number were born in India, followed by Pakistan and Bangladesh. According to this information, there are now more local residents of Polish origin than of Indian origin. Next comes Southern Africa, of which the largest number were born in South Africa, followed by Zimbabwe and Zambia. There are also significant numbers of local residents who were born in the United States of America and Canada.
The profile of the local Black and Minority Ethnic population can be further explored using data from the 2001 Census. This showed that the proportion of the non-White population living in the wards containing the top 10% most deprived Super Output Areas (SOAs) (in terms of health deprivation and disability) was higher in both Chester at 40% (compared with 32% of the total population) and Ellesmere Port and Neston (36% compared with 35% of the total population). One socio-economic indicator, that of educational qualifications, showed that across the whole of western Cheshire, almost every Black and Minority Ethnic group had a higher proportion of people aged 16 to 64 years with higher level qualifications than the White British population. And one health indicator, limiting long-term illness and disability, showed that whilst 18% of the White British population in Chester had a limiting long-term illness or disability, this applied to 13% of the Black and Minority Ethnic population: the comparable figures for Ellesmere Port and Neston were identical with 19% of both groups having a long-term illness or disability. At the time of the 2001 Census, 7% of the Black and Minority Ethnic population of Chester described their health as ‘not good’ compared with 9% of the White British population: the comparable figures for Ellesmere Port and Neston were that 11% of residents of Black and Minority Ethnic origin described themselves as being in poor health compared with 10% of the White British population.
13
2.7.1
Use of services at a local level
There is little research published on the health needs and health care experiences of the local Black and Minority Ethnic population, but local studies suggest that many of the national issues affect the local population in much the same way. In a small-scale county council survey on residents’ quality of life, Black and Minority Ethnic respondents scored their health as ‘good’ or ‘very good’ for their age; this was in line with findings from Cheshire’s White residents (Cheshire County Council, 2005a). However, a number of Black and Minority Ethnic respondents reported that racism in the area impacted negatively on their health (Cheshire County Council, 2005a). A 2002 survey of the health and social care needs of Minority Ethnic residents in western Cheshire by Chester Asian Council found that almost two thirds of the 331 respondents relied on friends or family as interpreters in order to access public services (Chester Asian Council, 2001). The respondents, 89% of whom were drawn from the Chinese and Bangladeshi communities, reported a preference for health information in their own language, though literacy was identified as a problem among older people from the Chinese community.
2.8
Conclusion
Understanding ethnic differences in health remains an under-theorised area of social and health science research (Nazroo, 1998) rendering the task of tackling health inequalities a difficult one for health care commissioners. The health of the Black and Minority Ethnic population is affected by a range of factors, some of which are not yet fully understood. There is evidence, however, that some aspects of the services provided by the NHS negatively affect the experiences of Black and Minority Ethnic groups and that changes to practices and behaviours can improve quality of care. The evidence suggests that many of the issues experienced nationally are relevant to the growing population of Black and Minority Ethnic residents in western Cheshire and exploration of their health care experiences is timely.
The background information on the health and health care experiences of the UK Black and Minority Ethnic population and data on the local population provide the starting point for understanding the experiences of residents in western Cheshire. The next chapter will move on to describe the methodology employed in the fieldwork for this research.
14
Chapter 3 Methodology 3.1
Introduction
This was a small-scale study designed to explore the use and experiences of front-line health services within the Western Cheshire Primary Care Trust area amongst residents belonging to Black and Minority Ethnic groups. More specifically, the primary objective of the research was to illuminate the perceptions of these services amongst Black and Minority Ethnic residents within the context of each participant’s use of each service and their health needs. A qualitative approach was adopted for the study as the aim was to explore perceptions and capture experiences. The study received ethical approval from the Faculty of Applied and Health Sciences Research Ethics Committee at the University of Chester in March 2008.
3.2
Sampling strategy
A purposive, multi-stage sampling strategy was adopted for this research. The first stage was to identify areas of health deprivation in western Cheshire and the second stage was to identify a diverse group of Black and Minority Ethnic residents who lived in these areas. The health deprivation and disability domain on the Index of Deprivation 2004 (Cheshire County Council, 2005b) was used to identify areas of disadvantage. This ranks the SOA within the top 10% of Cheshire SOAs in terms of health deprivation and disability. The wards in Chester and Ellesmere Port which have SOAs in this category are Blacon Hall, Blacon Lodge, Boughton, City & St Anne’s, College, Hoole All Saints, Lache Park, Newton St Michael’s, Central, Grange, Pooltown, Rossmore, Stanlow and Wolverham, and Westminster. Black and Minority Ethnic residents living in these wards were the population from which the sample was drawn.
There was no sampling frame that included all Black and Minority Ethnic residents living in the identified areas of Chester and Ellesmere Port; the researchers therefore used a number of different routes to access the target population. Few community organisations established for, or working with, Black and Minority Ethnic residents exist in western Cheshire and contact was made with the Cheshire, Halton and Warrington Racial Equality Council and the Chester Asian Council. Given the time constraints of the project and the difficulties anticipated in recruiting individuals via the limited number of local voluntary organisations, it was decided that recruitment via the Racial Equality
15
Consultation Panel would provide sufficient number and diversity of research participants. The sample of panel members was refined through consultation between Racial Equality Council staff and the researchers to exclude people who lived outside the areas of health deprivation identified and to maximise the diversity of the sample with regard to geographical distribution, ethnic group, age, sex, disability, and level of spoken English.
Following successful recruitment using the Consultation Panel, it was decided to further diversify the sample, particularly in respect of people who were less proficient in English. A further six participants were therefore recruited via Chester Asian Council.
The Consultation Panel sample contained a number of participants who were related, which may have limited the sample slightly in terms of variety of experience. Although some repetition was identified within the interview responses, discussion focussed primarily on personal experiences, which limited the impact of participants’ relationships.
3.3
The recruitment process
A procedure for contacting potential research participants from the Consultation Panel was established following detailed discussion with the Racial Equality Council. An information sheet (Appendix 1) produced by the Centre for Public Health Research (CPHR) was sent with a covering letter produced by the Racial Equality Council to all members of the Consultation Panel living inside the research sampling area. As the Racial Equality Council had had some prior contact with panel members, they were confident that all recipients of the letter had sufficient English, or could access help from family members with sufficient English to read the letter. It was made explicit in the letter that information could be translated on request and that interpreters could be made available for interviews. The Racial Equality Council followed this up with a phone call, as per their usual procedure. Once verbal consent had been gained by staff at the Racial Equality Council, they were asked to book participants into interview slots pre-agreed with the researchers. It was arranged that written consent would be requested by the researchers at the interview stage; the consent form is shown in Appendix 2.
16
The Consultation Panel members received payment for their time and expenses under the Racial Equality Council’s standard procedures so it was necessary for the researchers to adhere to this practice. While it is sometimes argued that payment of participants can introduce a bias to research, there is a strong argument to suggest that payment facilitates recruitment and can even help address the power imbalance that can exist between researcher and participants (Thompson, 1996).
The second part of the sample was drawn through contact with the Chester Asian Council. Given the sizeable population of Chinese people in the area and the limited number of Chinese participants recruited to the study through the first stage of fieldwork, it was decided that people of this ethnicity should be purposively sampled. Following discussion between the researchers and staff at the Chester Asian Council, contact was made with a local Chinese interpreter who agreed to approach several people about participation. The interpreter contacted people known to her who were living within the sampling area and who had limited spoken English. Following the advice of the interpreter, the information sheet was interpreted verbally to participants and initial consent taken verbally by the interpreter. Written consent was taken at the interview where the consent form was translated by the interpreter. Through liaison with the researchers, the interpreter arranged an interview time for participants.
Researchers were also invited to attend an English conversation class run by a member of the Chester Asian Council’s staff at a local primary school to ask if the class members would like to participate in the research. At this session, the class facilitator from the Asian Council worked through the information sheet verbally in English with participants who had some knowledge of the language. The class was given the opportunity to ask questions and individual class members were invited to attend an interview or focus group with the researcher the following week, immediately after their weekly conversation class. The class made a joint decision to attend a focus group. Written consent was taken at the focus group with the help of the class facilitator.
As Consultation Panel participants had received payment for their participation, it was decided that, for equity, participants recruited via Chester Asian Council should be treated similarly.
17
3.4
Methods of data collection
One-to-one, semi-structured interviews were conducted with members of the Consultation Panel and participants recruited via the Chinese interpreter. Semistructured interviews have a ‘loose’ structure consisting of open-ended questions that define the area to be explored, but allow the interviewer or interviewee to diverge in order to follow up particular areas in more detail (Britten, 1995). The final interview schedule used for the research was more structured than originally anticipated to ensure consistency as it was necessary to use four researchers from CPHR to carry out the interviews.
All of the fieldwork took place during April 2008. Interviews with Consultation Panel members were conducted on the premises of the Racial Equality Council in Chester city centre, or at Ellesmere Port library, depending on the preference of each interviewee. Interviews lasted between ten minutes and an hour, and with the permission of each interviewee, were audio recorded. If the interviewee was not agreeable to this, notes were taken during the interview and were written up after the interview.
Interviews with the Chinese participants were conducted at Ellesmere Port library as they requested. Communication in the interviews was facilitated by the interpreter’s prior relationship with two of the participants and the existence of a mutual acquaintance with the third participant. Further to this, the interpreter’s background, working in the field of health promotion amongst Black and Minority Ethnic residents locally, and her experience of interpreting in medical settings facilitated her understanding of interview responses.
The focus group with members of the conversation class was run at the same venue as their classes. Focus groups are particularly effective for exploratory work and for securing depth of information about experiences (Puchta & Potter, 2004). This method was also considered appropriate for this group because of their similar levels of English and the pre-established nature of the group. The class facilitator was present at the focus group to assist with communication. Her prior knowledge of the women and their circumstances enabled her to help them with expression in English. The class members also helped one another with language.
18
At the beginning of each interview and at the focus group, participants were asked to provide demographic information in order that the researchers would be able to contextualise the responses. Participants who stated that their first language was not English were also asked to rate their own English language proficiency using a four point scale (Oldham Social Services Department, 1998). Participants were also asked about any dependants or any long-term health need or disability which might have affected their use or need for health services. In addition, participants were asked to rate their own health and any changes in their health over the last year, using a five point scale (adapted from the General Household Survey, 2005). The interview schedule for these interviews, which was adapted for those interviews conducted via the Chinese interpreter, and for the focus group, can be found in Appendix 3.
3.5
Analysis
Data from each interview and the focus group were transcribed verbatim into text. The transcripts of interviews with the interpreter recorded only the English spoken. Thematic analysis of the transcripts was conducted using NVivo software. Thematic analysis allows the reseacher to move back and forth between the data and emerging themes, in an effort to gain an accurate picture of the views of the study popluation.
3.6
Conclusion
This chapter has described the methodology adopted for the research. The recruitment of a diverse group of participants was a challenge for the researchers, particularly in an area where there are a limited number of organisations from which a sample could be drawn. A profile of the people who participated in the research is presented in the following chapter.
19
Chapter 4 Profile of the sample 4.1
Introduction
This chapter presents demographic information about the research participants and their health needs which have informed the analysis of their use and experience of health services. This background information is also useful for contextualising descriptions of their use and experience of front-line health care services presented in Chapters 5 and 6.
4.2
A profile of participants
A total of 36 people took part in the research; 24 participants were female and 12 were male. Diversity was achieved in the sample with regard to age, although the largest numbers of people (24, 67%) were aged under 50 years. Table 4.2.1 illustrates the breakdown of the interviewees by age and sex.
Table 4.2.1
Participants by age and sex Age (in years) Under 20
20-29
30-39
40-49
50-59
60-69
70+
Total
Female
1
8
6
3
4
1
1
24
Male
0
4
2
0
3
0
3
12
Total
1
12
8
3
7
1
4
36
Participants were from a range of ethnic backgrounds, although a large number were of South Asian origin, reflecting the higher proportion of this ethnic group in the Chester and Ellesmere Port area. Table 4.2.2 shows the breakdown of participants by ethnic group.
20
Table 4.2.2
Participants by ethnic group
Ethnic group
Number of people
White: Other White
1
Mixed: Other Mixed
2
Asian or Asian British: Indian
10
Asian or Asian British: Pakistani
4
Asian or Asian British: Bangladeshi
8
Asian or Asian British: Other
5
Black or Black British: Black Caribbean
1
Black or Black British: Black Other
1
Chinese or other ethnic group: Chinese
4
Total
36
4.3
Area of residence
Although efforts were made to ensure that participants were recruited from the top 10% SOAs of health deprivation in Cheshire, the information collected from interviews revealed that a small number of participants from Chester lived outside of the specified wards. Overall, 23 participants lived in Chester and 13 lived in Ellesmere Port. The majority of participants had lived in western Cheshire for 5 years or more (22, 61%), though some people were very new to the area. There were a number of people who had moved to the area within the last year (5, 14%) whose knowledge and experience of services was quite limited. The length of time people had lived in the area is shown in Table 4.3.1
Table 4.3.1
Length of time in area
Time in area
Number of people
Less than 1 year
5
1 to 2 years
5
3 to 4 years
4
5 to 9 years
6
10 years or more
16
Total
36
21
Whilst a number of people had lived only in Chester or Ellesmere Port, others had moved from elsewhere in the UK. Some participants had moved from their home country and lived elsewhere in the UK prior to moving to Chester or Ellesmere Port; a number of people mentioned that they had lived in cities such as London and Liverpool, for example, before moving to Cheshire.
4.4
Language
From the overall sample, 13 people said that their first language was English and 23 people reported another language. Participants spoke a variety of different languages, including Hindi, Bengali, Gujarati and Cantonese, and several participants reported that English was not spoken in the home. Participants whose first language was not English varied in age, as Table 4.4.1 illustrates, and although the largest number of interviewees who said English was their first language were under 40 years old, 11 of the people in this age group did not speak English as a first language.
Table 4.4.1
Participants’ first language English as a first language
English not first language
Total
Under 20 years
1
0
1
20 to 29
4
8
12
30 to 39
5
3
8
40 to 49
0
3
3
50 to 59
1
6
7
60 to 69
0
1
1
70 years or older
2
2
4
Total
13
23
36
Age
The majority of participants whose first language was not English reported having a good level of English listening and speaking comprehension and this remained the same across all age groups, as Tables 4.4.2 and 4.4.3 show. The person who said that she did not understand English at all when it was spoken to her was one of three people who were interviewed via an interpreter. She did, however, report that she spoke English ‘slightly’.
22
Table 4.4.2
Self-rated level of English listening comprehension
Age
Fluently
Fairly well
Slightly
Not at all
Total
Under 20 years
0
0
0
0
0
20 to 29
6
2
0
0
8
30 to 39
0
2
1
0
3
40 to 49
0
1
1
1
3
50 to 59
4
2
0
0
6
60 to 69
1
0
0
0
1
70 years or older
1
0
1
0
2
Total
12
7
3
1
23
Table 4.4.3
Self-rated level of spoken English
Age
Fluently
Fairly well
Slightly
Not at all
Total
Under 20 years
0
0
0
0
0
20 to 29
6
1
1
0
8
30 to 39
0
2
1
0
3
40 to 49
0
1
2
0
3
50 to 59
3
3
0
0
6
60 to 69
1
0
0
0
1
70 years or older
1
0
1
0
2
Total
11
7
5
0
23
4.5
Caring responsibilities
In addition to their own experiences, participants with dependants were asked to describe the experiences they had of health services involving someone in their care. A total of 13 participants had children under the age of 16 years and one couple interviewed were expecting a baby; these participants were asked to provide information about their experiences of antenatal and postnatal services. Other participants had adult children and were generally less involved in their children’s health care experiences at the time of the research. Several participants reported that they had caring responsibilities for elderly relatives which resulted in additional contact with health care services on their behalf.
23
4.6
Self-rated health status
The majority of participants described their health as ‘good’. Several younger participants reported that it was excellent and few participants overall reported that it was poor. Table 4.6.1 shows the self-rated health of participants by age.
Table 4.6.1
Self-rated health of participants by age
Age
Excellent
Good
Fair
Poor
Total
Under 20 years
0
1
0
0
1
20 to 29
3
8
1
0
12
30 to 39
0
4
2
2
8
40 to 49
0
1
1
1
3
50 to 59
0
4
2
1
7
60 to 69
0
0
1
0
1
70 years or older
0
2
2
0
4
Total
3
20
9
4
36
A total of 15 participants reported that they had a long-term illness or disability, 10 of whom described their current health status as fair or poor. These individuals were fairly evenly spread across all age groups. Table 4.6.2 shows the age of participants with a long-term illness or disability.
Table 4.6.2
Participants with a long-term illness or disability
Age
Long-term illness or disability
Under 20 years
0
20 to 29
2
30 to 39
4
40 to 49
1
50 to 59
3
60 to 69
1
70 years or older
4
Total
15
24
During the interviews, participants spoke about their experience of a range of illnesses, ranging
in
severity
from
short
to
long-term
problems;
these
included
heart/circulatory/blood problems, lung/respiratory problems, stomach/digestion/dietary problems, kidney/bladder/urinary problems, leg/feet/mobility problems, eye/sight problems, ear/hearing problems, glandular problems, back/torso problems, skin problems, and mental health/emotional difficulties.
4.7
Conclusion
This chapter has presented a profile of the people who took part in the research: it illustrates the diversity of the sample in terms of their demographic characteristics, language and communication skills and health status. Chapters 5 and 6 move on to describe the use and experience of health care services of these 36 participants.
25
Chapter 5 Findings relating to primary care services 5.1
Introduction
This chapter presents the findings from the interviews and focus group that related to primary care services. This consists of all aspects of the GP practice, including out-ofhours services and services provided by practice and district nurses, health visitors, community therapists, pharmacists, dentists and opticians. All quotations have been anonymised and coded.
5.2
Use of GP services
Interviewees were asked about their use and experience of their general practice. Responses were interrogated at the organisation level to explore experiences of general practice features and systems and at the practitioner level to explore participants’ interactions with staff at the practice, including GPs, practice nurses and non-medical staff.
Thirty-one of the 33 participants who were interviewed had seen their GP within the previous 12 months, either for themselves or with someone else; it was not possible to identify the extent of service use for each of the three focus group participants but they had all accessed the service at some time. Within the last 12 months, 4 participants had seen their GP once, 10 had seen their GP on two or three times, and 17 had seen their GP on more occasions than this. Two interviewees, both with two children under the age of 3 years, said that they had seen their GP up to four or five times a month for their children’s health. Interviewees who reported seeing their GP on a monthly basis generally had long-term health conditions which required monitoring by their GP. Two people said that they had not used their GP at all during the last 12 months; both were new arrivals to the UK (within the last 7 months) who reported that they had not experienced any health problems. Twenty-three people talked about an experience of using the practice nurse, either for themselves or with a friend or relative. Whilst some interviewees had regular contact with the practice nurse, others had accessed the nurse only once, or not at all, during the last year.
26
5.2.1
Making the decision to use the service
Several people reported that their use of GP services was preventative and that they usually made appointments for routine health checks either for an ongoing health condition or due to their age. One participant said, ‘I just thought that I’m 50 years old and I needed to have an overall check-up’ (01-001-KP). Another participant reported that he had been advised to see the GP for regular checks, but reported that he did not always get round to making the necessary appointments, as the following interview extract shows: Interviewer:
Why did you decide a GP was the right place to take that particular health issue?
Participant:
Just a general, general health. I went for tests because of, for Hep B status and also we’ve got a family history of heart disease so I should get my cholesterol checked every year but I only ever go now and again.
Interviewer:
Okay.
Participant:
And for just blood tests.
Interviewer:
So does that involve you, I mean the cholesterol tests, do you get called in or …?
Participant:
No, no, no. I should go and book in yearly but I don’t do it, I’m terrible at keeping appointments so it’s my own fault. (07-003-KP).
Other interviewees reported they had seen their GP for routine vaccinations, either for their young children or for themselves before travelling abroad. One participant, who was new to the UK, reported that she had not seen her GP, but had registered as she had been required to do so as an international student at the local university.
Some people said that they saw their GP for specific complaints. One parent of a young child, for example, reported that she would treat her child with over-the-counter medicines for minor illnesses but that for symptoms such as a very high temperature she would see her GP. Other parents reported that they saw the GP for common childhood illness like chicken pox and ear infections. A number of interviewees reported that they had seen the GP following complications after an accident or as a result of a long-term health condition. The participant in the extract below was concerned about headaches following an accident, as she describes:
27
‘Then, near to my car accident, I [was] getting headache all the time, you know, badly [bad] headache and stuff, so I had to go for my MRI and stuff like that.’ (07-003-MT). Other conditions for which people had consulted their doctor included a water infection, an eye infection, and routine pregnancy check-ups.
Some people suggested that their GP was the most authoritative source for dealing with medical issues, one participant saying ‘I wouldn’t have got a medical opinion elsewhere so I needed to see the doctor’ (03-002-FW). Others reported that their GP was their first port of call for medical care; some people reported that they used the GP as a triage service, preferring to take a referral from their GP rather than going elsewhere first. Similarly, one interviewee reported making appointments specifically in order to obtain a referral to a specialist.
In contrast, a number of participants suggested that they would only see the GP if they wanted a prescription, for example, if they perceived that over-the counter medicines were insufficient for their needs, as the following quotation shows: ‘Because my kids are two and three they’re at the doctor’s stage. They need a doctor’s prescription; I can’t get it over the counter.’ (07-003-FW). A small number of people had been referred to their GP either by a practice nurse, or in one participant’s case, by the company nurse following a dizzy spell while at work.
Some interviewees were hesitant about accessing their GP. A number of participants expressed a fear of wasting their GP’s time, and reported that this influenced their decision to contact their GP about a health issue as the following extract shows: Participant:
I can’t think of a specific example but, I’m sure there have been times when it’s been sort of like, I thought, oh maybe I should go to the doctors with this, and then I’ve just sort of not. I’ve decided I think it’s minor, it’s not an issue really and it’s turned out not to be.
Interviewer:
It’s not anything specific that’s put you off going or …?
Participant:
No, it’s more sort of not wasting my time and someone else’s time really. (03-003-FW).
Others talked about needing a good reason to go to the GP and suggested that they might only see their GP if a problem persisted or if self-help and other medical
28
alternatives had failed, as the quotation below shows: ‘I thought I’d kind of sprained my foot, I thought it was fine ... it’ll fix itself, so I spent a week hobbling at work and it wasn’t really getting much better and it got to the stage where, I think it got to the eighth or ninth day and I kind of, I got fed up and I went to the GP asking for a walking aid. And I’d bought some bandages from the chemist and I just asked him if he could recommend any other additional support to help fix itself. And he looked at it and he told me that I’d torn a muscle and so that was one other trigger for going. So, normally it takes, I wait for the symptoms to go themselves or I try and fix myself before I go to the GP so that’s how I tend to … so it’s when things are lingering and they’re not disappearing, that’s my trigger for going.’ (03-002KP). The availability of appointments also deterred some people from seeking help from their GP. There was concern about the lack of weekend appointments and the difficulty of obtaining an appointment in busy surgeries. The early morning booking system requiring patients to call on the day of an appointment also deterred some people from attempting to make an appointment. These issues are discussed in more detail below.
Another reason why people did not see their GP was because they perceived that they would not get the help they needed. For example, one participant had come to the conclusion that visiting her GP was a waste of time as the medications prescribed were usually available and cheaper over the counter. In another instance, a participant reported that she had not considered approaching her GP for help dealing with depression and considered with hindsight that it might have been helpful to do so, as the quotation below shows: Interviewer:
Do you know if your practice does offer anything like that [relaxation therapies]?
Participant:
I don’t think so, I don’t know.
Interviewer:
You don’t think so. Okay.
Participant:
But I was never offered anything like it so.
Interviewer:
Was that something you talked to your doctor about, not feeling well and stressed and down?
Participant:
No, I didn’t to be honest.
Interviewer:
No. Would you normally think about going to see your …
Participant:
For this, no I wouldn’t. But looking back I think I should. You know because it got to the stage I was really, really down. 07-001-MT).
29
One person, who had recently arrived in the UK, reported that she was unsure as to whether she was registered with a GP as the process had been handled by staff at the university with which she was registered. She perceived that this would be a problem if she fell ill as she anticipated that ‘everywhere you go, I think they ask for a GP, right?’ (01-003-KP). Another participant reported that her mother-in-law, who had limited English, would return to her country of origin if she needed to see a doctor as she perceived that dealing with things in her own language would be more convenient.
People had seen the practice nurse for a number of different reasons including cervical smear tests, blood tests, requests for contraception and vaccinations. A number of interviewees had seen the nurse annually for ’flu vaccinations for which they were invited by letter. Others saw the nurse regularly to monitor long-term health conditions, such as diabetes and high cholesterol, and some interviewees had been referred to the practice nurse by their GP for procedures such as blood tests. Some interviewees mentioned that they would request to see a nurse rather than a GP at their practice for less serious health problems. Two participants said that it was the procedure at their practice, in some instances, for nurses to see patients for a screening appointment before a referral to the GP: some patients therefore requested an appointment with a nurse in the first instance for more ‘minor’ issues (03-003-FW). Another patient reported that she made an appointment with the nurse about her eczema when she was told that her GP was unavailable and one participant said that she had been given a telephone appointment with the practice nurse to assess who she needed to see as reception staff had been unable to direct her.
5.2.2
The practice as an organisation
During the course of the interviews, participants talked about how easy it was to use their GP practice. The majority of the interviewees were happy with the location of the GP surgery they attended. Several people said that their GP practice was close to home, for some people, within walking distance. One participant had recently moved house to the other side of Chester which meant that his surgery was no longer convenient, but he had not tried to change doctor, suggesting that the location was not a problem for him. Ease of use was also determined by a number of other factors including practice opening times, appointment waiting time and the systems in place at the practice for booking appointments. These aspects of the service are explored in more detail below.
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5.2.2.1 Appointment systems Participants expressed frustration about the restricted opening hours of their GP surgery. One interviewee said that he avoided seeing his GP as an appointment would require time off work, which he anticipated his employer would not allow. This, combined with the cost of prescriptions, meant that the patient delayed seeking treatment until absolutely necessary.
For others, the lack of weekend appointments was a cause of concern and one older participant perceived that it was particularly problematic for elderly patients to wait all weekend with urgent health needs for an appointment to see their GP. One patient reported that a Saturday service at his local practice in Ellesmere Port had been cancelled which made it difficult for him to see his GP during the week as his place of work was quite far from home.
Some participants expressed annoyance that it could take up to a week to get an appointment with their GP. Participants at the focus group indicated that this posed a problem if their child was experiencing a fever. Other people had experienced a wait of 2 or 3 days for an appointment, with which they were quite satisfied. One participant said: ‘Only that truthfully from what I hear that I think I was prepared for wait[ing] times to be much longer, for it to be harder for me to get to see a GP. I was prepared for it to be a lot worse, you know obviously you hear all the horror stories about people waiting, you know for basic services for a long time. So I was pleasantly surprised at how quickly I’ve usually been able to get an appointment at the GP’s surgery. It was a bit better than I anticipated.’ (07-001-KP). One participant suggested that it was only because his health problem was a ‘major issue’ that he was able to get an appointment easily (01-002-SA). Although other people reported that they were able to get appointments ‘immediately’ (01-002-KP).
One participant, who had approached a GP practice as a visiting patient in another part of the country, expressed frustration that she had been unable to see a GP immediately and was referred instead to the practice nurse. The nurse advised her to use over the counter treatment and see the GP the following day if her symptoms persisted but the patient perceived that she needed antibiotics immediately and contacted a relative in her country of origin who was a doctor. The participant reported that her aunt prescribed medication over the phone which was delivered by courier the
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following day. While the participant’s experience occurred outside of western Cheshire, this highlights the reliance some people placed on services in their country of origin when they were dissatisfied with services they received from local health services.
For many people, their major concern with their GP practice was getting past the reception staff to get an appointment with the GP. Several people perceived that their chance of securing an appointment was dependent on the member of reception staff with whom they spoke. One participant reported that she was more likely to see her practitioner quickly if she spoke to someone on reception who knew her. Similarly, other participants talked about ways of getting round the booking system, such as informing the reception staff that they have been referred following advice from NHS Direct.
One participant expressed frustration that she had been repeatedly referred to the practice nurse by reception staff for a condition which she felt required consultation with a GP. As the nurses were unable to prescribe the required medication, the patient then experienced a delay before being able to see the doctor; she said, ‘you don’t get who you need to see basically’ (03-001-KP).
Many people reported that the appointment booking system in their GP practice required them to call the surgery between 8:00am or 8:30am and 9:00am in order to secure an appointment on the same day. In many cases, interviewees suggested this system had been relatively recently introduced and this was perceived to be to the detriment of the service. Some interviewees said that this was the only booking method at their surgery and it was not possible to book an appointment days in advance. This was reported to be problematic, particularly in relation to providing advanced warning to employers about time off work. One participant described this system as ‘random’, stating that she perceived it as benefiting the doctors rather than patients, particularly patients who work. She said: Participant
The way their system of appointments run … they don’t take advance [bookings] … If I want to see someone today, this morning, I should ring at 8 o’clock and try and see them. They don’t say, “Okay, in a fortnight’s time,” …. “Okay in a fortnight’s time, I’ll come and see them” – that’s not possible.
Interviewer:
So how convenient is that system for you?
Participant:
It’s not convenient. It’s convenient for me, I’m retired but it’s not a convenient thing for anyone working. It’s convenient for the doctors. (03-001-MT). 32
It was a common experience for interviewees to have had experienced difficulty with this appointment system. Several people reported that the telephone lines to their surgery were extremely busy at this period requiring patients to spend a long time trying to get through, a factor which was described by one participant as ‘added stress’ to their health situation (07-001-KP). A number of people stated that this system was impractical for them because they were unable to get to a phone at this time of day. One 18 year old participant, who was a college student, reported that her mother had made appointments on her behalf as she was unable to make a call if she had classes to attend; others stated that work commitments prevented them from calling, while several parents of young children reported that the period between 8:00am and 9:00am was very busy getting children to school. Some people reported that attending the surgery in person was the only way of securing an appointment with this system.
One person reported that if they were unable to get through to the surgery at this time, they missed the chance of an appointment for that day, as the quotation below shows: ‘You have to be sharp early morning to get your appointment otherwise you miss out and then you have to do it the following day, the same thing.’ (07-002-FW). There was also a concern that if all appointments were taken for the day, it was not possible to see the GP in an emergency. Some people stated that the appointment booking system deterred them from going to the doctors. One participant, who was prone to spells of depression, described the booking process as ‘draining’ and reported that she would not go to the doctors unless absolutely necessary because of this. She said: ‘Well, I think when it comes to myself trying to get to the doctors, I wait until I actually lose the plot and then I have to go because I can’t sort it out myself. But it takes a lot out of me, you know, because you have that system of trying to get to the doctors and you don’t get there, so that, I think, it’s weird because you go to the doctors and you get more iller trying to get to the end result …’ (07-003-FW). Although some people reported that the same-day booking system was acceptable to them, these participants perceived that there was an element of luck in securing an appointment using this system.
Obtaining appointments with the practice nurse was seen to be less problematic. In one instance, a participant had been able to see a nurse by dropping into her local
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practice and another person, as the following conversation illustrates, said that the early morning telephone booking appointment system for his GP did not apply to appointments with a practice nurse: Participant:
I think for a routine, like, you know, your blood tests and your cholesterol test, I think you can just book them but it’s just an appointment with your doctor can be difficult to get.
Interviewer:
Okay. So do you see the practice nurse for those tests?
Participant:
Yeah.
Interviewer:
Yeah, okay rather than your GP, yeah. I mean is that generally a little bit easier to access or…
Participant:
Yeah, yeah. You can get regular appointments with the nursing staff. When I had to have injections for when I went abroad a couple of years ago, it was easy to go through them and they just asked what injections I wanted and why I needed them. (07-003-KP).
5.2.2.2 Referrals to other services A number of interviewees had been referred to specialist services by the GP. For some people, this had been a straightforward process and they were satisfied with the way the referral was processed by their GP. Several people reported that they were pleased that the referral had been handled entirely by their GP and in two cases participants praised the way that intervention from their GP had speeded up the referral process. One elderly participant described how her GP had organised for her to be seen privately after a 6 week wait for a knee operation, in order to minimise further waiting in acute pain, while another patient described how her GP’s chasing up a referral to the local hospital on her behalf had relieved the stress she was experiencing. She said: ‘They did all for me because I said, “Look I can’t do this, all the time I’m ringing, ringing” … and Dr [name of doctor] said, “Okay, you don’t need to, I can do for you”, and I said, “Okay then.” That was it, yeah, then when I come back from Bangladesh I said, “Look, am I still on the waiting list?” Then he said, “Okay, I am ringing them again” and they did.’ (07-002-FW). Others described less satisfactory experiences of referrals made by their GP. One participant considered that her referral to mental health services had been poorly handled and in another instance, the GP had given the patient out-of-date information about the location of a service. One interviewee described how a referral made by her
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GP to counselling services had gone astray, causing a delay in her access to the service. The quotation below shows one patient’s frustration: ‘Well initially it was in Ellesmere Port, now they’ve moved it to Chester and I think that’s where the problem lies because ... the GP people didn’t realise that the service had moved so they referred me to the one that they originally knew and I was telling them, “No, it doesn’t exist there”, so I ended up feeling more paranoid, thinking, “Look, I know what I’m talking about because I’ve tried to get there”, and they’re like, “No, they are there", so it’s a bit, they didn’t seem to leave the lines of communications with what the services around here are actually doing so it’s a bit weird because it’s like I can figure it out quicker than they can kind of theory.’ (07-003-FW). Another participant described how an administrative error at her GP practice meant that her elderly mother had received instructions to contact the hospital about an urgent referral for suspected cancer before the hospital had received any information about her case. The problem was resolved by the GP surgery but the participant reported that the incident had caused additional anxiety in an already stressful situation.
Some interviewees reported experiencing difficulty obtaining a referral for further investigation and treatment and there was a perception that GPs sometimes failed to identify problems through insufficient investigation. One participant had anticipated that she required a referral to A&E for a persistent urine infection but was advised by her GP to wait and see the nurse in a few days time. The participant had returned to her country of origin for a pre-arranged visit where she went to the emergency services at the hospital and was immediately taken for surgery. The participant perceived that her health would have been put in danger had she remained in the UK which indicates the dependence some participants placed on services in their country of origin.
5.2.2.3 Collection of test results Comments were made about the length of time it took to receive test results. One patient commented that reception staff were not informed about the procedure for collecting results, even though she had been advised by the doctor to contact them about the issue, leading her to conclude that ‘internal staff communication was all over the place’ (01-002-KP).
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5.2.2.4 Local out-of-hours services When asked about their general practice, several participants talked about their experience of using out-of-hours services. Two participants had had a visit from an emergency doctor at home and two participants had accessed a doctor at an out-ofhours surgery. Whilst for one of these people the occasion was a number of years ago, the second person was someone who regularly used the local out-of-hours service. This was in contrast to the vast majority of the other interviewees who did not mention this service.
The interviewee who used the out-of-hours service suggested that the appointment booking system and opening times fitted in with her work and personal commitments. If one of her children, for example, needed to see a doctor, she was able to collect them from day-care when she had finished work and get them to the out-of-hours service for an appointment she had made on the same day. On at least one occasion, the interviewee had taken her son to the out-of-hours surgery a few hours after an appointment with her GP, when his condition had deteriorated. This person was also very positive about the nature of her interaction with the doctors at the out-of-hours surgery and contrasted the process there with the ‘conveyer belt system’ at the GP practice where she was registered (07-003-FW).
5.2.3
The quality of interaction with the GP
Participants discussed a range of issues which affected their interaction with their GP. Establishing rapport with the practitioner, continuity of care and the attributes of the practitioner were all identified as factors affecting this interaction.
5.2.3.1 Communication Some patients who experienced difficulty communicating in English reported that they encountered difficulty explaining their symptoms to their GP and understanding instructions for treatment. Some participants said that they found their GP’s efforts to communicate helpful, reporting that if it was recognised that the patient had not understood, their GP would use alternative wording or ‘speak very slowly and try explain it to him’ (29-02-KP) or that it was ‘okay’ because ‘the medical representative is aware of our background so he tries to interact with us in gentle language’ (01-002MT).
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Despite these efforts, some people reported that they could only describe ‘general problems’ to the GP and were unable to go into ‘depth’ (29-02-KP). One participant estimated that he understood only half of what his doctor said to him and when referred to a consultant for a specialist issue, reported that his understanding decreased to only a third of what was said (29-02-KP). Another participant reported that she had misunderstood instructions for prescriptions on a number of occasions, as the following quotation from an interview conducted via an interpreter shows: ‘Like prescriptions, she was told to take the ones daily, but she get it wrong and took a few tablets a day, her experience is she get a prescription, which is cream I think, for a cream to use for the lips, and then she eat it.’ (29-002-KP). Several participants reported that they would write down their symptoms in English, at home using a dictionary, for use during the GP consultation. Others said that they would take a relative to the appointment to help with interpretation. Participants who reported that they interpreted for other people however, said that this was sometimes inconvenient if they had to take time off work to attend an appointment with a friend or relative. Some members of the focus group relied upon their children for interpretation at the doctors and it is possible that these methods may be inadequate and not always appropriate. Some people reported that their GP practice did not have interpreting services or that it had never been offered and one participant, who had difficulty communicating with her GP, said that she did not want to waste NHS funds by requesting an interpreter for GP appointments but she perceived it would be necessary for specialist consultations at the hospital, suggesting that the severity of the problem determined the necessity of an interpreter for her.
Language and communication, however, were not static issues. As one interviewee described, her experience of communicating with her GP had changed over the 6 years that she had lived in the UK, saying that at first she was ‘really scared of what I might say’ (07-002-FW) but that she now feels more confident in her level of English and in asking her GP to explain anything that she does not understand.
Other people considered it important that their GP communicated all available information. For example, one participant reported the stress he had experienced because his GP had not informed him of the reasons for some tests he was undergoing, saying:
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Participant:
I wasn’t very happy about it, no, because … I was kept in the dark by having the blood sample. [After] a week’s time, I see doctor to get another blood sample, and after I get the blood sample, after that, I refused to give [another] blood sample until I see a doctor. And after that the doctor told me, “We didn’t want to tell you because we’ve been investigating and trying to see if it is negative or positive [result], so we don’t want to scare you.” But all, there had been a scare …
Interviewer:
Because you’re not spoken [to] …
Participant:
Yes, yes. (03-001-SA).
5.2.3.2 Rapport with the GP Establishing a good rapport with a GP was identified as important by a large number of patients. Many participants reported that they found it easy to talk to their practitioner about health issues and they identified a number of attributes which they thought facilitated a good patient-doctor relationship. Several participants referred to the effective listening skills of their GP and reported that they were always made to feel that their GP had time to see them. One participant said: ‘When I goes to him I feel that half of my illness has gone, you know, because he talk nicely, he listen to you, he gives you the time, you know. He’s a very marvellous doctor he is.’ (07-001MT). Participants reported that it was important to feel that their GP cared about their needs and that they were valued at the practice. One patient expressed satisfaction with the service she had received from her GP following diagnosis of an early miscarriage; she was impressed with the way her GP identified her shock at the diagnosis and arranged a follow-up appointment for her. She was also appreciative of the GP’s direct manner in informing her about her health issues. She said: ‘She listened and she just basically said, “Oh this could be your problem”. And then she asked for a follow-up interview because she realised that I was a bit shocked at what the actual … it was actually that I had a miscarriage and I didn’t actually realise I did. So she just … said what needed to be said, which I appreciated rather than skirting around issues. And then she gave me a follow-up interview to actually say, well you know, “Is everything okay – this, that and the other,” which I appreciated.’ (07-001-KP).
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There were some examples of patient dissatisfaction with the way in which interactions with their GP had been conducted. A number of people reported instances where they perceived that their doctor had trivialised a health condition, as one participant said: ‘I had a basic sports injury from running and he sort of alluded to the fact that women are hypochondriacs so it probably wasn’t really that big of a deal but that I was making a much bigger deal out of it (laughs). So I was not so thrilled with that.’ (01001-SA). Others cited examples of late diagnosis which were attributed to the failure of the doctor to ask questions or spend time listening to the patient. Some people reported that they avoided certain doctors within their surgery following a poor experience; following diagnosis of his wife’s cranial arthritis, one participant concluded that ‘some doctors are better at understanding her illness’ (03-001-MT).
Whilst some interviewees suggested that their doctor spent a good length of time with them, others talked about the speed with which consultations were conducted. One participant said: ‘It’s like a conveyer belt system, it feels like it’s just like in-out and you’ve not really got the opportunity to find out what’s wrong with you.’ (07-003-FW). Other participants were clearer about the source of their feelings of being rushed through a consultation; one person specifically stated that her doctor’s manner made her feel unwelcome in the surgery, as the quotation below illustrates: ‘I felt the doctor was quite cold … didn’t have good manners in terms of doctor-patient manners. I didn’t feel quite welcome. It was almost as if it was to come in and just, you know, “this is what you need to do, go!” There wasn’t very much interaction there so he kind of made me feel a bit cold.’ (03-002-FW). Another participant, born outside the UK, voiced frustration that she was repeatedly asked about her eligibility for health care by a number of different doctors at her practice, despite having established the fact at registration.
Although generally satisfied with her relationship with her GP, one female Muslim participant reported that aspects of her GP’s procedures for diagnosis of a gynaecological problem had made her feel uncomfortable. She described how her GP’s suggestion that she take a test for Chlamydia, was ‘embarrassing’ and offensive to her:
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‘[The doctor] explained it. Well I said, “Well listen, you know, I’m a Muslim woman, I’m not going to be, you know, sleeping around or my husband will not be doing that”. She said “Well no, it’s just a process of elimination” sort of thing. But to me it was like an honour thing (laughs) it’s like … “are you questioning my, our chastity?” sort of thing, you know, but I don’t know whether that’s just old fashioned but that’s how it felt … maybe I am a bit Bangladeshi there (laughs). Too many Hindi films, you know, “Are you questioning my honour?” sort of thing.’ (07-001-KP). Another participant perceived that her GP had not been very understanding or helpful when she had requested an alternative to the medication her GP had prescribed; she anticipated that her GP could have helped her to find an alternative, as the quotation below shows: ‘The iron tablets which I was taking, they had alcohol inside them so I wanted the pharmacy to change it for me to a different type of iron tablet and he said I need to go to the doctor. When I went to the doctor I told her about that and she said, oh she doesn’t know a different one because this is the one which they normally prescribe and there is only a small amount. It’s not about the amount, but I know there is not only one kind of iron tablet, you know.’ (07-001-MT).
5.2.3.3 Continuity of care A number of participants reported that it was important for them to develop a relationship with their GP and for this reason, many preferred to see the same GP each time they visited their practice. Some participants reported that it was not always possible to get an appointment with their own GP however, and said that if they did want to see a particular doctor, they might have to wait longer for an appointment or take an appointment time that was less convenient for them.
For some people, it was important that their GP knew their health history. Participants perceived that seeing a doctor who had treated them before, someone who knew what they had ‘been through’, improved the service that they received (03-002-FW). Some people said that this made them feel that the service was more personalised, as the quotation below illustrates: ‘He’s brought up times when I’ve seen him in the past and related those visits to my current visit and that assumption that he’s seeing so many people, and that I’m just another number, I’m not getting that from them.’ (03-002-KP).
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Although some patients were happy to see any of the GPs at the surgery because they all had access to the same computerised records, one patient explained why he perceived that this was insufficient to ensure continuity of care: Participant:
It is easier to see the same doctor. Okay, they all look up the notes, they don’t remember anything, they have to…
Interviewer:
The notes on the computer?
Participant:
Yeah, computer, they’ll have to read the notes to see. So basically they would, should come to the same conclusion. I’m afraid that doesn’t always happen. One doctor reading his own note will do better than another doctor reading somebody else’s notes. So I don’t think it’s totally satisfactory. (03-001-MT).
In addition, a number of participants suggested that they received a more holistic service if their GP also treated their family members. Some people talked about a preference for seeing their ‘family doctor’ (01-001-MT) and considered that treating members of the same family gave the doctor a more informed understanding of their lifestyle and their needs, as the following quotation highlights: ‘But the good thing, he knows the context of what our family is like and everything so that’s a good thing. Yeah so in that respect he knows our family set-up and how things are working and why.’ (07-001-KP). An established relationship was also seen to have helped improve participants’ sense of trust in their GP. Participants appeared to consider that the history they had with their doctor, and the GP’s involvement with their family made the doctor more accountable for their treatment. The quotation below highlights the preference some people expressed for the opinion of their own GP: ‘Well, I try and see my preferred doctor … ’cos they’re the ones I trust, but if I can’t then obviously I’ll go to an alternative doctor but then it’s ’cos I don’t know them that well I wouldn’t really trust what they’re saying.’ (01-001-MT). One participant reported that she was always satisfied when she saw her own GP but suggested that she received a less thorough consultation from other GPs. Some people reported that they would specifically request to see their own GP for more ‘serious’ (01-001-MT) or ‘personal’ (03-001-KP) issues.
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Participants also perceived that the service they received from a doctor with whom they were familiar was improved by their own comfort discussing health issues. One interviewee said that his interaction with locum doctors was ‘not great’ compared to those with his own GP and he questioned how valuable these consultations were (03002-KP). Another participant said that he used to fear going to his GP surgery, but said that this diminished as he got to know the doctors better and developed the confidence to ask for the information he needed. A mother with young children reported that it was easier for her children to see the same GP as they became used to him/her, which made the consultation more straightforward.
A number of participants for whom English was a second language reported that they found it easier to communicate with a specific doctor and so requested to see the same doctor each time. Sometimes this was because the doctor spoke the patient’s native language, in other instances it was because the doctor had known the patient longer.
Several participants had no preference for a particular doctor. One participant, who was happy to see any of the five doctors within his practice, said that this was because to him, ‘they’re all specialist’ (03-003-SA). These people reported that they were happy to discuss their health issues with any of the doctors in their surgery. One participant perceived that continuity of care was achieved with different doctors because of the use of computerised patient records.
5.2.3.4 GP attributes Several women reported that they preferred to see a female GP and some women said that they would only specifically request a female doctor for gynaecological issues. One participant said that as a Muslim woman it was particularly important to her to see a female doctor. She stated that she would see a male GP if circumstances meant she was unable to wait for an appointment with a female doctor but said that she felt more comfortable discussing her health issues with a female doctor.
While most participants found that their practice were accommodating about this preference, it was reported that the limited number of female GPs working within most practices sometimes made it difficult to get an appointment with a female doctor. Some participants who felt more comfortable talking to female doctors said that they were prepared to wait for an appointment rather than see a male, but many women said that they would see a male doctor if their health problem could not wait. The interview
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extract below shows the decision-making process many women used when booking appointments: Interviewer:
How easy is it to make an appointment with [the female doctors]?
Participant:
... sometime I have to wait for around a week or maybe a couple of days.
Interviewer:
... would you delay the appointment and see the woman …
Participant:
Yeah.
Interviewer
… rather than see the man?
Participant:
See the man, yeah.
Interviewer:
Right, more quickly.
Participant:
But if I need to desperately then I can go but if I can think I can wait for maybe two or three days extra then I can wait. But if I have no choice I can see any of them you know. (07-003-MT).
Although faith was not a matter raised by the majority of the interviewees, one Muslim participant was particularly satisfied with a consultation she had had with a locum GP who was of the same faith, which suggests that continuity was of lesser importance to this participant. She reported that this GP was able to provide advice with reference to her faith, which she found particularly helpful: Participant:
He identified the fact that I was Muslim … [He told me] like the medical things that you do to make yourself better. But he also told me bits about from our religion like what the Prophet used to do and things like that to make me better, you know, which I thought that was a great service because…
Interviewer:
Was that more practical advice or spiritual advice or …?
Participant:
No. Like, say for example, to stop yourselves from having like, colds and things like that, have honey, you know, like one honey a day. It’s practical advice in that respect but he said, “Well if you have it because, as a believer then that would be probably [be] a bit more beneficial for you” … I thought that was pretty good.
Interviewer:
Was that just a one off?
Participant:
That was a one… I don’t know whether he was a locum or something but he just … because it’s quite, it’s not very multicultural down this area so he must have, he might have just been happy to see (laughing) oh, a fellow Asian. (07-001-KP) 43
Another participant, whose first language was not English, reported that she had previously had a Chinese GP with whom she was able to communicate in her own language. Although she had developed a method for communicating with her new GP, she wanted to find her former GP, who she knew had relocated locally, as she felt that communication had been more effective with this doctor.
5.2.4
Quality of interaction with the practice nurse
The majority of participants who talked about an experience with the practice nurse were satisfied with the service they received. Most people reported that their encounter with the nurse had been fine and that they experienced no problem discussing health issues with him/her.
5.2.4.1 Communication Another participant reported that, due to language problems, she was unable to understand the nurse when she had a cervical smear test. Although the participant said that this was not a problem, it did limit the discussion that took place during the consultation, as the following extract from an interview conducted via an interpreter shows: Interviewer:
Have there been any issues communicating with the nurse?
in
Participant:
It’s no problem at all, because they know she doesn’t really understand what they say and she cannot really express what she wants, so actually they don’t ask her so many questions!
Interviewer:
But do you feel like you know what’s going on?
Participant:
It’s okay! (29-001-KP).
5.2.4.2 Rapport with the practice nurse Several people reported that their encounter was pleasant; one participant saying that the nurse she had seen was ‘friendly’, ‘approachable’ and ‘positive’ (01-002-SA). Others reported that they found it easy to talk to the nurse and described friendly interactions that had taken place.
Other people said that they appreciated the frankness with which the nurse had dealt with them and perceived that the nurse had ‘explained everything quite fully’ (03-00244
FW). By contrast, one participant was disappointed that a nurse was unable to answer his questions during a routine blood test. He said the following: ‘I thought OK, while she’s here I’ll ask her a couple of questions, and I asked, “OK, so these pains I’m getting, you know, so the blood you’re taking, it’s there to test for some stuff and so can you tell me where the kidneys are or where the liver is, because I’m not quite sure because this is where the discomfort is.” And she goes, “I’m not sure really.” So then she rummaged through some books and I think she looked, she was a bit flustered, because she couldn’t find the right page, and then she went online and she managed to find this website and pretty much said, “Oh, if you go on this website they’ll be able to answer your questions” and then she said “I think it’s, I think it’s this” and it just didn’t really, I don’t know, it didn’t, it wasn’t great.’ (03-002-KP). There were several instances where participants perceived that the nurse’s manner had negatively affected their interaction. One participant described an experience where she perceived that the practice nurse had been rude to her about a mix-up over the availability of tests for sexually transmitted infections. She said: ‘My GP gave me like, did tests for like, like Chlamydia and stuff like that, she just did that as a routine thing and then I went back again to the doctors and they [the practice nurse] like basically told me off and said, “We don’t do that here”, and I said, “Well, I’ve come here before”, and they were like really snotty with me and then they went, “No, you’ve got to go to the hospital”, and they were just really horrible … I think she thought like I was wasting her time or something.’ (03-001-KP). Another participant had been annoyed when a practice nurse raised concerns about her weight during a routine ’flu vaccination: the participant perceived that the nurse’s suggestion that she take her body mass index was unnecessary and unhelpful, as the following quotation illustrates: ‘She was saying that you needed to get a weight and mass and all that thing, I was thinking, “Look, look at me, I’m overweight, you don’t need to know anymore, and just let it lie,” because I know they needed that for another form of statistics or whatever but I didn’t, I don’t partake of that because I don’t, you already know when you’re overweight you don’t need the vital numbers.’ (07-003-FW). In one instance, a participant had been invited by letter to attend an asthma clinic but had been unaware of the purpose of the appointment when she arranged it. She perceived that the nurses were annoyed with her for attending the clinic without her medication, and consequently did not attend the second session. The participant said 45
that she had too many other commitments to attend the second session but also said that she did not go back as the first session ‘didn’t feel right’ (07-003-FW).
5.2.4.3 Continuity of care One participant who visited the practice nurses several times a year reported that he always saw a different nurse and, whilst this caused him no problem, he would prefer to see the same nurse. Other people reported that they knew the nurses at their practice quite well, either through having attended the same practice for years or through another connection outside of the surgery, and that this improved the service they received. One participant described how knowing the staff at the surgery made using the practice easier: ‘I went to see the doctor, right, and she said, “Oh we haven’t got any appointment today.” So, and without saying anything to her, I went downstairs and I knocked the door to the nurses and I said, and luckily I know so many nurse there now because they all come to us or they come to keep fit with me and stuff like that, and I said, “Can you do me a big favour? I got my sample with me, can you check it please?” So they said, “Oh my God, you’ve got a kidney infection, there’s bleeding as well inside”, you know, she found the blood … so she said, “I’ll write a note, go upstairs to [the] GP first and see them today”.’ (07003-MT).
5.2.5
Quality of interaction with other practice personnel
A number of interviewees spoke about their contact with non-medical staff at their GP practice, such as reception staff and other administrators. These interactions, such as when setting up appointments or arranging to collect test results, were reported to impact on participants’ experiences of using their GP practice. One patient had dealt with the practice manager to make arrangements for her father-in-law, who was visiting from abroad, to have blood tests during his visit. The participant had found the practice manager ‘really helpful’ in making the necessary arrangements and responding to her questions (01-002-KP).
Several participants reported that they disliked the manner in which they had been dealt with by the reception staff. Their manner was perceived to be ‘short’ by one person (03-002-KP) and another participant described the staff she had dealt with as ‘awful’:
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‘The receptionists are just horrible in there, I think they’ve probably been told to say certain things but the way they go about it isn’t the best and they just seem a bit snappy.’ (03-001KP). This person reported that the manner of the reception staff influenced her feelings towards the surgery as a whole: Participant:
Yeah, she’s great the actual doctor, like I hate, I don’t like the actual surgery…
Interviewer:
The practice?
Participant:
Yeah, I don’t like that, ’cos the receptionists are horrible but I like my actual doctor, she’s really nice and she’s good; she’s good at what she does. (03-001-KP).
Some people had encountered a particular problem with an individual member of staff and reported that they made efforts to avoid this person, which was not an easy task, as one participant described: ‘But it’s very, very bad. If you’re standing in a queue to see them at reception and your turn comes and she’s there, you say [to the person behind you] “Would you mind going”, you know.’ (07-001-MT). Another participant reported that she had difficulty communicating with one particular member of staff, which she attributed to the receptionist’s unwillingness to listen to her needs, as the quotation below shows: ‘There is a particular person who doesn’t seem to understand whatever I ask her … I always had a problem with her. Every time she seems to change what I say to something else and it’s just going round and round in circles … And the other people are quite okay, it’s just this one … I don’t think it’s my English to be honest but she just has a very limited view and she just wouldn’t open up I think.’ (07-001-KP).
5.3
District nurse
Only four of the interviewees spoke about contact they or a family member had had with the district nursing service: two people spoke about visits received by their mother and mother-in-law.
Two people talked about visits made by a district nurse following surgery. Whilst one person was happy with the service she received, the other was unhappy about the fact
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that it was not the same nurse who came on each occasion and about the time slots that were given for each visit. He said: ‘They say I’m coming from 9 o’clock to 12 o’clock, or 12 o’clock to 5 o’clock and you have to wait. They don’t give you a precise time, so a lot of people, they get fed up, even if they are housebound, they get fed up from waiting, because they can’t do anything else apart from waiting for the district nurse.’ (03001-SA). One of the interviewees had made a request to the GP that his disabled mother have a ‘full check-up’. Following this request, a district nurse visited his mother at home. Although he was happy with the contact, saying that ‘they are good, experienced nurses and they do as we expect; a good job’, the interviewee argued that the checkups should have occurred as part of a routine service rather than in response to a specific request.
5.4
Community therapists
The research included questions that were designed to find out about participants’ use of community occupational therapy and community physiotherapist services. During the interviews it was apparent that some interviewees were speaking about services that they had received in a hospital rather than in a community setting or at home, and one person appeared to be referring to home care services which had provided personal care when she had a broken shoulder. A total of eight participants, however, spoke about their experience of occupational therapy or physiotherapy services.
5.4.1
Decision to use the service
The use of physiotherapy or occupational therapy services often followed referral from a GP, although in one instance the referral was made by a midwife. One person who talked about receiving private treatment from a physiotherapist was also referred by his GP.
Physiotherapy and occupational therapy services had been accessed for a range of complaints. These included treatment following a knee operation, after being hurt in an accident, following a diagnosis of osteoarthritis, for muscle or ligament problems during pregnancy, for back problems, a foot injury, and regular physiotherapy received by one participant’s disabled mother. The treatment had variously been received in hospital and community settings and at home.
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5.4.2
Quality of care
The majority of the interviewees were happy with the referral process and the service received from occupational therapists and physiotherapists, and there were no complaints about location of the service, whether it was provided in hospital, in a community setting or at home. It was perceived that therapists provided a good service that met the needs of the individual patient as they ‘understood [patients’] requirements’ (07-002-KP). One participant described how her occupational therapist had tailored the therapy to her own needs: ‘She was first asking me what my hobbies are and things I do. I used to do gardening, I still do it. I said gardening and sewing I think. Then she was showing me how to hold the scissors, a special kind and how to hold a kettle. She gave me some sort of mats, to open the lids of jars and something you can put on the handle of the cooking foods and tins.’ (03-002-MT).
Some participants expressed satisfaction with the progress that therapy had helped patients to achieve; one participant suggested that the service provided may have prevented the need for a hospital admission. It was also reported that the help given to patients benefited those friends and relatives supporting them too. For example, one interviewee spoke positively about the physiotherapy that his disabled mother had received at home, describing the therapist as ‘exceptional’; he perceived that the service was of great benefit in alleviating frustration for both the family and his mother because the person ‘listens more … if it’s a doctor or physiotherapist’ (07-002-KP).
There was, however, some concern about longer than expected waiting times for the service and the impact this may have had on the injury or medical complaint. One person suggested that the time between referral and the appointment should be reduced as conditions may deteriorate during the waiting period, she said: ‘Rather than recover fast you’re getting worse and worse and worse. Same with my knee; I’d been telling them that I was getting worse, worse and worse.’ (07-003-MT). The prospect of a long waiting time for the service had persuaded one participant to pay for private physiotherapy. He perceived that the delays often caused a lot of suffering:
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‘That’s my major bugbear with the NHS unfortunately … what stood out was the fact that I paid a bit of money and I was seen practically immediately … I know the NHS is really, really stretched at the moment, but the current structure just means that some patients that are really suffering out there, are really sidelined aren’t they?’ (03-002-KP).
5.5
Health visitor
Nine of the interviewees spoke about contact with their health visitor. In the majority of cases, this contact appeared to have been relatively brief, limited to routine home visits or age-appropriate assessments for their pre-school age children which took place at the local clinic.
5.5.1
The use of the health visiting service
Three interviewees, however, said that they had initiated contact with the health visitor. In one instance, this was following a visit to the clinic for her baby to be weighed and in two cases, the mother had rung to speak to the health visitor about various concerns (including their baby’s hearing, crying, teething and contraception). Only one of the interviewees described regular contact with a health visitor for advice on a range of child health and developmental issues: other interviewees suggested that they would contact other health professionals, primarily their GP, if they had any concerns about their child.
5.5.2
Quality of care
The limited contact the interviewees had had with the health visiting service was generally seen in a positive light, although continuity of contact with the same person was mentioned as an issue by one parent: ‘I think it was [useful], yeah, quite useful but a couple of times I had different health visitors coming and I’d prefer just to have the one that I liked, like I mean, the one that you start with, you know what I mean, because that lady would probably know more about than if you had separate health visitor.’ (01-001MT). One interviewee, whose youngest child was now 12 years old, had contact with the health visiting service a number of years ago and said he thought that the health visitors had ‘an air of coming to inspect your house’. More recently, however, this father
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had work-related contact with the service, and said that he was impressed by what they do (03-001-FW).
One mother was less sure about the quality of her recent contacts with the health visitor. She did not see the health visitor as a first port of call as a result of her experience of contacting the service: ‘I’d call, like my initial point would be going to the GP with saying, maybe that’s a health visitor thing so I’ll attempt to contact the health visitor, she’ll come about a month later and it’s just more of hassle so, no, I don’t, I’m not impressed with the health visitor … I’ve not figured out what her role should have been or is but apparently she’s still covered until they’re four or something?’ (07-003-FW). Two interviewees mentioned the difficulties that they had in communicating with a health professional when their babies were young because of their level of English.
5.6
Pharmacist service
Participants were asked about occasions when they might have accessed advice from a pharmacist. Other pharmacy services were not investigated. Most of the discussion centred on the circumstances in which people might use this service.
5.6.1
Use of the pharmacist
Twenty of the interviewees talked about one or more occasions when they had been to a pharmacist to ask for advice about treatment or suitable medication. These included visits for themselves and for other family members, particularly their children. Eight of the interviewees said that they had not been to a pharmacist for advice, although there was no suggestion that they did not know it was an option that was open to them. Others made no reference to this service.
5.6.2
Making the decision to use the service
The interviews revealed the range of ways that pharmacists were used. Some participants suggested that a consultation with a pharmacist helped them decide whether they needed to go to see their GP, others sought advice from a pharmacist because they were unable to get an appointment with their GP (or not able to get an appointment soon enough) whilst a number of interviewees had seen their GP and not been prescribed medication, so went to the pharmacist to purchase over-the-counter 51
remedies. Whilst most interviewees suggested a choice was made between seeing a pharmacist or their GP, one person said that they first approached either NHS Direct or the pharmacist for medical advice in a non-emergency situation.
Advice from the pharmacist was often sought in conjunction with GP services. In some instances, advice was sought from the pharmacist when symptoms persisted following consultation with a GP. For example, one mother stated that on one occasion, she was still worried about her child’s high fever after seeing the GP and so approached her local pharmacist, suggesting that this source was often seen as useful additional support to parents. Some people perceived that the pharmacist could only offer limited help and reported that a GP consultation had sometimes been needed following ineffective treatment from over-the-counter medicines suggested by the pharmacist. One interviewee was frustrated that the pharmacist always referred her back to the doctor as they were unable to prescribe the medication she required, she said, “they can’t give you anything, you know” (07-001-MT).
Participants spoke about making a judgement as to how serious the symptoms were before deciding whether a visit to a pharmacist was an appropriate course of action. People frequently said that they would seek advice from a pharmacist on ‘minor issues’ and one person said: ‘If the symptom is severe symptom, now you have to go and see doctor. If it’s kind of a mild symptom, you just take advice, I will go to the chemist.’ (03-001-SA). The most common examples of illnesses for which interviewees had sought advice from a pharmacist were coughs, colds, sore throats and ’flu: also mentioned were skin irritations, hay fever, stomach upsets, ear ache, a water infection, chicken pox, the morning-after pill and conjunctivitis. Others who took prescribed medication had also consulted pharmacists about which over-the-counter medications did not conflict with prescription medicines; pharmacists were also generally seen as a source of advice about the best product for their symptoms.
Some people said they ‘would not bother the GP’ with minor illnesses (29-003-KP) and others suggested it was a better use of NHS resources to seek advice from a pharmacist for some sorts of complaints. One person expressed this in the following terms:
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‘I suppose it’s a more effective use of the health service really because they are very minor things.’ (03-003-FW). Some interviewees said that they had only recently been made aware of the full extent of pharmacy services and had not realised that the pharmacist provided a source of advice. Two of these participants had been made aware of the services by chance, and one person, who had received information through attendance at a health consultation event concluded: ‘They haven’t really advertised their services that well’ (07-001-KP).
Some interviewees who said that they would not seek advice from a pharmacist suggested that if they needed medical attention, their GP was the person they would go to for advice. For example, one person said: ‘I’d rather go to the doctor than the pharmacist because I believe in [GP’s name] … whenever I’ve got a problem I go to the doctor and that’s it.’ (07-005-MT). Another person said they would always go to the GP rather than their pharmacist because they would need a prescription for any medication that they needed.
5.6.3
Quality of care
Speed and convenience were two factors which encouraged the interviewees to go to a pharmacy for medical advice. Particular reference was made to the convenience of having chemist counters in the supermarkets, which were also open later than GP surgeries, and it was perceived that speaking to a pharmacist was ‘quicker’ than seeing a doctor (03-003-FW). The majority of the interviewees said they were happy to go to the most convenient pharmacy rather than trying to see the same pharmacist each time, however, one participant perceived that he could be more certain that he was speaking to the most appropriate person if he used his usual pharmacy, as the following interview extract shows: ‘[If] it’s the one currently [which] I will go and see and get my medication, I feel more confidence to talk to them. If it is people like in the supermarket and things, then I don’t feel confident to talk to them, because usually what [who] I’m speaking [to] is the front counter person, it’s not the pharmacist.’ (03-001-SA). The experience of getting what they judged as ‘good quality advice’ (03-001-FW) from pharmacists had encouraged interviewees to use this service on more than one occasion. Pharmacists’ advice was also trusted given the level of their qualifications; one person suggested that pharmacists were well-qualified to offer advice as ‘they’ve 53
got five years training’ (03-001-MT). The availability of written information and advice in some pharmacies was deemed very helpful, as one person said: ‘For example, you’ve got diarrhoea or something, they’ll have cards there saying “Well if that’s your problem, this is your solution”. And that’s all you really want isn’t it? … I find that’s just really helpful, you know, just the little advice corners … and I’ve used them quite a bit, yes.’ (07-001-KP). There was some concern about discussing private health issues in the open environment of the pharmacy and some people said specifically that they would not approach a pharmacist about a personal issue and would instead approach their GP. One person said: ‘All the things that I’ve asked about, again, have been very minor, sort of allergies, things like that, you know, I’ve got a bit of hay fever, something like that, that’s fine. Whereas I suppose if it was anything a bit more personal I wouldn’t like to go to a pharmacy to speak about it.’ (03-003-FW).
5.7
Dental services
There were 28 conversations with interviewees about their recent use of dental services. The majority of the people who were interviewed as part of the research had visited a dentist in the last 12 months, most for routine check-ups but some in response to discomfort they were experiencing. One interviewee had also been referred by her own dentist to the Stanney Lane Clinic as a result of problems with a wisdom tooth.
The majority of the eight interviewees who had not seen a dentist were either not registered with a dentist locally or were unsure if they were still registered as they had not accessed the service for a number of years. None of these interviewees, however, said that they had made any attempts to contact a dentist during the previous year, most frequently saying they would look for a dentist if they needed one; one interviewee also spoke about preferring to use dental services when she made return visits to her country of origin. A further interviewee said that he had not contacted a dentist because he did not have any problems and another said that he had not done so because the majority of his teeth were dentures.
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5.7.1
Quality of care
All of the participants who spoke about visits to the dentist said that the dental surgery they attended was convenient for them, although one interviewee suggested that it would be better if dentists were located in premises alongside GPs.
The majority of the interviewees were happy with the appointment systems operated by their dentists, including one who commented on the value of the telephone reminder a day or so before an appointment. A small number of participants however, were less happy as they perceived that private patients could get appointments more quickly than NHS patients. The participant who was waiting for a dental appointment at the Stanney Lane Clinic was also concerned about the length of time this was taking.
The majority of negative comments about the dental service were concerns about the cost of treatment. Whilst three of the interviewees specifically said that they received private dental treatment, some of the NHS patients suggested that going to the dentist was ‘quite pricy’ (03-002-KP) and that dentists had become ‘too commercial; they’re after your pocket’ (03-003-SA). In one case, an interviewee spoke about her dissatisfaction in relation to being recommended treatment which she was unsure whether it was necessary and in another instance, the interviewee was unhappy because she wanted treatment (cleaning) that the dentist was not offering.
5.7.2
Quality of interaction with the dentist
A number of interviewees said that their dentist was excellent or that they were very happy with the service that they were receiving. The dentist’s manner was reported to affect the quality of interaction at the service and helped to put patients at ease. For example, one interviewee who had recently seen a different person reported that she had previously been afraid of the dentist but that her new dentist put her at ease: ‘I really liked the dentist. I was quite scared of my normal dentist and I’ve had him for years but she made me feel quite easy.’ (03-002-FW). Others were less concerned about the nature of the interaction and spoke about consultations in a more complacent way; one person said ‘they’ve always been nice; I’ve never had a bad experience there’ (080403-001-KP).
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Participants who reported that they used the dentist regularly usually saw the same dentist each time. Only when they had experienced difficulties did they talk about seeing a different dentist, although sometimes this was within the same surgery.
The dentists’ attributes did not appear to be important to participants’ experiences. One interviewee reported that she had expected to have more of a rapport with one dentist at her practice because, like herself, he was Asian, but in reality she described her contact with this dentist as a ‘funny experience’ (01-002-KP), the reasons for which she found it difficult to put into words. It was clear, however, that she was unhappy with his manner and that she did not trust his opinion about the extent of the treatment that he said she needed.
One of the interviewees, who spoke about visits to the dentist with their children, suggested that experience was not a good one for her child. She thought this was because it was a strange environment and the dentist did not seem to be a ‘childfriendly person’ (01-001-MT). As a result, this mother was going to try and see another dentist at the practice because her daughter did not want to go again.
Language or communication issues with the dentist were mentioned by three interviewees. Whilst in two instances, this was a result of the patient’s limited English, in the other case, the interviewee said that she had changed dentist because she found it difficult to understand her dentist’s English, which was spoken with a strong foreign accent.
The interpreter for one interviewee, who had said that she understood spoken English only slightly, said that for anything other than the most basic treatment the participant asked the dentist for more information so that a family member could later explain to her what was needed: ‘She normally ask the dentist to break down what's her problem, so she can find out when she’s back home, but for ordinary hygiene cleaning then she’s fine unless it’s a problem, then of course she prefer to have an interpreter rather than go by herself.’ (29-002-KP). The organisational systems in the dental practice were also reported to impact on patient experiences. The apparently strict order in one practice was distasteful to one participant who said:
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‘ … they’ve got new people coming in and it’s just, it seems more military, I was just like, “No, this is why I didn’t like the dentist, I’m not coming”… the hygienist person was all right, the main dentist, well, he was a bit scary.’ (07-003-FW). Another interviewee, who said that she had only been to a dentist once in the five years that she had lived in Ellesmere Port area, was put off by the fact that her English was limited. If it was not an emergency, she preferred to wait and go to a dentist when she made return visits to her country of origin.
5.8
Optician
During the interviews, 19 people talked about an experience of using an optician, either for themselves or with a relative.
5.8.1
Decision to use the optician
The majority of people said they saw an optician every year or every two years for routine sight tests. For most people, the appointment was seen as a way to monitor their vision and one participant had decided that his age and recent heart surgery made it necessary for him to start attending check-ups with the optician. The convenience of the optician service was reported to influence the decision to make an appointment; one participant reported that she had used the optician when she noticed the service available in her supermarket. She described how convenient this was for her: ‘I was actually in the supermarket and they were doing … there was an optician there to do eyesights, I needed one so I just had one done, it was like literally pure convenience again. So I haven’t actually got a regular optician in Chester at the moment, I haven’t booked with anybody. But that was just purely convenience again.’ (03-002-FW). The optician was not always the first port of call for participants who experienced eye problems and GPs sometimes acted as a stepping stone to optician services. Some people had been referred to the optician after consulting their GP with eye problems while two participants had been referred, or accompanied a relative who was referred, for tests for glaucoma in relation to diabetes.
There were several different reasons why participants had not attended an appointment with an optician recently; for some people, making the appointment was
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seen as an inconvenience for which they did not have time. In addition, there was some fear about the consequences of attending a check up; one participant reported that she wished to delay a check-up as she anticipated that her eyesight would need correction: ‘Well I know, basically I know I need glasses but it’s just sorting making the appointment and going in, plus I don’t want them either.’ (03-001-KP). A poor experience of primary health services was shown to impact on expectations of other services. For example, one participant, who was in the UK to study for a limited period of time, reported that she had been put off using the optician following a poor experience at her GP practice. She felt inclined to wait until she visited her home country to address a sight problem that she suspected she might have. When asked whether she would use an optician service if it were needed she said: ‘Optician? I don’t know, I’m doubtful. It’s like, I guess after coming here I think I have developed, I’ve got eyesight [problems], but I don’t know. By seeing all these services, I don’t feel like … I was discussing this with my parents, so they were like, “Come, come home to India”. It’s like, “You can meet us and also you can get your eyesight right”, like that.’ (01-003KP). The cost of optician services also presented an obstacle to use. Another participant was more inclined to use optician services in his country of origin because it would be cheaper. Even when participants recognised a clear need for the service, the cost sometimes deterred them from making an appointment, as the following quotation shows: ‘I’ve just avoided it (laughs) I’m not too good am I? But again for the same reasons … for financial reasons as opposed to because I don’t need to see one. But I’ve got to the stage, last time I had an eye … I’m short sighted, okay so the last time I’ve seen one was about 2004, so I really do need to see (laughs) someone.’ (07-001-KP). Several others reported that the impetus for their check-up was a promotional offer for a free sight test.
5.8.2
Quality of care
Most people were happy with the service they had received at the optician. Some people reported that the service they had used was ‘very convenient’ (01-001-SA) as
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it was close to their home or in an accessible area such as a supermarket, which contributed to their decision to use the service initially. The participant who had used the service in her local supermarket reported that she was happy with the service but said that she would prefer to use a ‘regular’ optician, as the following extract shows: Interviewer: So would you use that same service again if you needed to or…? Participant: I’d rather have a regular optician appointment (laughs) that’s what I’m used to, it was just like a one-off but I wouldn’t hesitate to go back there if I couldn’t find another optician. (03-002-FW) Other people used one optician more routinely which might suggest that continuity of care was seen as important; one participant reported that her family had been using the same optician ‘for years’ (07-003-KP). Others reported that they did not always use the same optician service and would be happy to use any service in the city centre, suggesting that they perceived that there was some choice in their area.
Some participants expressed concern about how ‘commercial’ optician services had become and it was reported that the sales staff could be ‘intimidating’ (03-003-SA).
The manner of the optician was reported to be important; one participant said that the ‘friendliness’ of the optician had put his daughter at ease (03-001-FW). Others were dissatisfied with the interaction they had experienced with the optician. For example, one participant perceived that the optician was annoyed by the difficulty she experienced completing some of the eye tests; she explained that this had deterred her from visiting the same optician again: ‘And you know where they puff the air into you, well I just could not keep my eyes open and she was just getting really annoyed with me and I was like (tearful noise) “Okay, don’t shout at me”. So I just then didn’t go after that.’ (07-001-KP). The participant also described the choice on offer with regard to lenses as ‘confusing’ (07-001-KP) and explained that she felt unable to ask for help as she was reluctant to take up any more of the optician’s time. The participant had decided to use an alternative service in a ‘smaller, family’ practice.
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5.9
Preventative services
A number of people reported that they had been contacted to receive screening tests, for example for cancer and routine health checks at their GP practice. Others talked about experiences of vaccinations, which included taking children for childhood inoculations, vaccinations for travel abroad, and receipt of the ’flu vaccination.
5.9.1
Cancer screening
Several people had attended screening appointments for cancer. A number of women reported that they had been invited by letter to attend a screening appointment for breast cancer. Only one male participant reported that he had undergone an examination for prostate cancer when visiting his GP for a routine health check.
A large number of women reported that they had been invited for a cervical smear test and the majority of these women had attended; many women reported that they attended appointments regularly suggesting that the service was seen as routine practice. A number of participants, including those who had recently arrived in the UK, had not yet been invited for a test; one of these participants reported that she would ‘definitely’ attend and that she ‘would like to gain more and more information about these services’ (01-002-MT) suggesting that she had not had access to information about the service at the time of her registration with a GP or come across the information anywhere else. It was suggested that ‘everybody hates smears’ (01-001MT) but some women reported that the nurse practitioner who they had dealt with had made the experience more tolerable, as this extract shows: ‘I’ve gone for like the cervical smear, [the practice nurse] was good because I was very like, “Oh, this is so embarrassing”, you know, sort of thing. And you could tell she was used to all of that so she was very patient and she was, yeah she was actually very good.’ (07-001-KP). There was some criticism of the organisation of testing within general practices. For example, one participant had experienced a delay with her referral for treatment following an abnormal smear test result as her original test result had been lost, requiring her to repeat the test. Similarly, another participant had undergone several repeat tests with no explanation from her GP. Although she said that her GP practice had explained that her first test result was unclear and required a repeat test, she reported that she underwent two further tests without any explanation as to the reason why, despite repeatedly asking staff at the surgery. The delay between her first test 60
and obtaining a result had worried her and she reported that was afraid to take another cervical smear test following the service she had received.
Participants had declined the invitation for a test for variety of different reasons. Some participants appeared to be wary of taking part; one participant reported that she was ‘reluctant’ to attend but was not able to articulate why this was (07-004-MT). Another participant, who reported that this test was not available in her country of origin, explained more explicitly that she was afraid to attend, as the following quotation shows: ‘I used to get letters for that, yeah, but I was a little afraid; I didn’t go because I read on the internet what it is and I’m like, “Oh, I can’t bother to go there, sorry, no!”’ (01-002-KP). Another participant had attended the screening appointment without knowing what a cervical smear test involved. She explained that she was so put off by her first experience, she decided not to attend again: ‘Well it was so military and it was just so, like make you feel, it’s embarrassing enough and it just made you feel even more embarrassed as I said and then you’d have a doctor and then you’d have a nurse and they’d be having like a conversation and you’re like, “Hello, this is not funny”, so it was just too embarrassing, I think if they just did what they were going to do and have the conversation after the even that would be perfect but no, I was put off for life.’ (07-003-FW). There was some concern about the frequency of cervical smear tests in the UK; one participant reported that tests were offered more frequently in her country of origin causing her to fear that testing every three years posed a risk to her health.
5.9.2
Vaccinations
Several people received regular ’flu vaccinations for which they were invited by letter or had been advised to receive by health practitioners. One participant reported that he had experienced difficultly arranging for his elderly mother to receive a ’flu vaccination at home and was frustrated that records were not kept to ensure that she automatically received it.
Parents with children under 16 years reported that they had routinely taken their children for vaccinations. One mother reported that she had been reminded by letter to take her children for vaccinations while another participant reported that she had used
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the information in the ‘the red book’ given to parents at the birth of their child to make decisions about inoculations (29-001-KP). Participants reported that they perceived they had enough information to make decisions regarding their children’s vaccinations.
5.9.3
General health checks
Other people had attended routine health checks with their GP or practice nurse either because of their age or because of a specific health condition. Participants who had received such checks were generally happy with the service they had received, describing them as ‘useful’ (03-001-MT).
The healthy living centre in Ellesmere Port had been accessed as a source of advice and support for weight management; the centre was reported to present a more appealing option to seeing the GP as it was perceived as preventative whereas visiting the GP had connotations with ‘illness’; as one participant said: ‘‘The healthy living centre I found is a nice alternative to like GPs and things. They’re not, you know, they’re not doctors but you don’t feel ill going there (laughs) because you’re doing something proactive to help your … you know, to help you to stay healthy, maintain your health and things like that and yeah, I found that service is very good.’ (07-001-KP).
5.10 Conclusion This chapter described the interviewees’ contact with primary health care services. Chapter 6 explores the participants use and experience of a number of other front-line health services.
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Chapter 6 Findings from other front-line services 6.1
Introduction
In addition to primary health care services, the research also explored the use of accident and emergency (A&E), NHS Direct, and antenatal and postnatal care by residents from Black and Minority Ethnic groups. This chapter describes the interviewees’ experiences of these services.
6.2
Accident and emergency services
Participants were asked about their use and experience of A&E. A number of issues emerged from the findings including interviewees’ knowledge about the service, waiting times, interaction with staff and treatment received from the service.
6.2.1
Use of accident and emergency
The interviews included conversations about A&E services with 25 participants, including people who had and had not used the service. Fifteen interviewees spoke about an experience of using A&E in the last 12 months and seven more people said they had not used the service during the previous year but had done so in the past. Some participants referred to an instance where they had used A&E services for themselves, while others referred to occasions where their spouse, children or friends had used the service. Three of the interviewees said they had not used A&E services in the UK. Whilst one person, who had recently arrived from India, said that she was not aware of A&E services at the hospital, the other two people who had not used A&E did know about the service.
Whilst the majority of the interviewees described a single instance when they had used A&E, four interviewees spoke about more than one visit during the last year. In one case, the patient had gone to hospital two or three times after falling whilst for the other participants, visits to A&E resulted from a range of incidents affecting themselves or other family members.
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6.2.2
Making the decision to use the service
A&E attendances that were referred to during the interviews were a result of a range of medical concerns or incidents including a miscarriage, head and neck injuries, chest and back pains, appendicitis, a severe migraine, difficulty in breathing, falls, cuts and bleeding, and sickness and diarrhoea.
Descriptions of the circumstances surrounding its use showed that the A&E department was not necessarily the first port of call for participants. A number of the people who had used A&E said that they would look to another source of medical help first, particularly to avoid the waiting time they had experienced or anticipated experiencing at A&E. In seven instances, participants had first approached another medical service (their GP, NHS Direct or an emergency doctor) and had been advised to go to A&E or had had an ambulance called for them. One of the interviewees had rung and was waiting for an emergency doctor who did not arrive: following a further conversation with the out-of-hours GP service he went to A&E.
In four cases, the interviewees referred to the fact that they had used the service during the evening, night or weekend and that their GP surgery had been closed. One person was not sure whether their nearest hospital had an A&E department and consequently chose to go straight to the Countess of Chester Hospital when her child had a head injury. On two occasions, participants described incidents that had taken place the previous day and they decided to go to A&E because it was still a problem the following morning.
One person who had not used A&E said that she would be more inclined to approach her GP than use A&E, particularly if help was needed during the week. She said that for ‘major’ incidents, she would go to A&E, but would generally try to ‘hang on’ until she could see the doctor (07-001-FW). Although her reasons were not clear, it seemed that the participant would avoid using A&E if at all possible. Another participant reported an incident where she had gone to her GP for an ongoing problem, anticipating that she would be referred to A&E given the severity of her condition, but was advised to wait and see the nurse in a few days time. The participant reported that she was ‘suffering’ (29-002-KP) and was surprised at the advice. By coincidence, she was returning to her country of origin for a visit two days later, where she approached A&E, suggesting that she felt unable to override her GP’s advice within the UK health system.
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6.2.3
Waiting times
Comments about waiting at A&E included references to the length of time the patient was in the department before being seen as well as their understanding of what was happening during this time.
Some patients reported that they had experienced long waits at A&E, although it was the experience of some interviewees, and the appreciation of others, that the length of the wait was often dependent upon the nature or severity of the patient’s needs. For example, one participant said: ‘I can appreciate that a cut finger is not quite as you know, different as an emergency or say like someone having a heart attack so I don’t … didn’t mind waiting an hour or two or even three but I can understand if you’re waiting longer than that it’s a bit horrible.’ (07-003-KP). One person described three visits to A&E, saying that on two occasions she felt they had been seen very quickly (in one instance she had a bleeding head injury and another time she had hurt her neck); she herself suggested that the other incident was minor and was not surprised that she was not seen as a priority. One person suggested that the waiting times were simply a matter of luck, that is, how many people happened to be there: ‘It wasn’t busy then anyway, it depends how many people are waiting there doesn’t it … If you’re lucky it’s not many there, but if you’re unlucky they’ve got so many queues there.’ (07-003MT). Several interviewees were concerned about the length of time they had waited to be seen at A&E, including one person who went to A&E when her son sustained a head injury. She described how she had waited for so long that she left without being seen and went straight to the emergency appointments session, which happened for the last hour of the surgery each day at her GP’s practice.
One participant, however, was pleasantly surprised by the length of time she waited when she accompanied a friend to the A&E department. She said that she had heard some criticism about waiting times in the media and although they did have to wait, it was not for as long as she had anticipated: ‘I feel that [the overall service at A&E] was okay but the patient feels that she has to wait for a long time … But it’s not that bad. We spent two hours altogether in there so I think well, it’s acceptable, isn’t it?’ (01-001-KP). 65
Some of the interviewees were less concerned about the length of time that they waited at A&E than about the process of waiting itself. Interviewees said they were not clear about what was happening, or why they were waiting, and did not understand why they were seeing a number of different people with a wait between each one, as the following interviewee explains: ‘We saw the triage nurse quite quickly and he just seemed to sort of look at it and said, “Oh well, it doesn’t seem, nothing major but you know, it doesn’t look like it needs stitches and stuff like that”, but it was still hurting on his head so we waited to see the doctor and I think we waited like a good couple of hours to see the doctor … they’d come to see us and … you don’t see them for another half an hour and then they come back just to be told like, “Oh, it’s nothing important”, and I mean, so it’s like you don’t see the doctor like after half an hour or an hour or so you’re waiting for all that time and you don’t see them.’ (01-001-MT). Interviewees also talked about the facilities, both for the patient and for the people who accompanied them to the hospital, whilst they were waiting. One person was concerned about his relative who had brought him to A&E one Saturday evening: ‘My poor sister was in the reception area just waiting for me. So I don’t think it was that pleasant for her and … eventually they called her in so she could just sit with me.’ (03-002-KP). This interviewee was also concerned about the lack of privacy in the cubicles where he could hear other patients’ conversations and people vomiting whilst he was waiting to be attended to.
One interviewee made comparisons between A&E in the UK with the service in their country of origin. She suggested that, judging by the experience of a friend, the waiting times were much longer here and that emergency services were given less priority ‘than back in our country’ (01-002-MT). This interviewee attributed the longer waiting times to a shortage of staff.
6.2.4
Quality of care
The interviewees were generally positive about their contact with staff and the treatment they received at A&E. For example, one person was particularly positive about the manner of the doctor when she took her son to A&E: ‘The person that dealt with him, he was very nice, and he sort of gave the good service to him and made him feel a bit assured because he was scared, you know.’ (07-001-KP). 66
Some participants perceived that the pressure of the A&E ward meant that staff could be ‘terse’ with patients (03-002-KP) and could be heard ‘bickering’ amongst one another (07-001-KP). One participant reported that staff had seemed ‘harsh’ (03-002KP) in their treatment of him when he was admitted on a Saturday night but he attributed this to the timing of his admission which he believed may have led staff to think his problem was alcohol related; he reported that the doctor’s tone seemed to change once the reason for his admission became apparent. This suggests that patients had some understanding of the pressures which shaped their experiences of the service.
A number of the interviewees were disappointed with the treatment they received in A&E. One patient was referred urgently by her GP, who advised her that she needed to be seen that day, but on arrival at A&E was unable to receive treatment as the eye specialist within the hospital was unavailable. The patient was told to return the following day, which she was surprised and annoyed about, given her GP’s earlier concern for her condition. Another participant was surprised that no treatment was given when she attended A&E because her baby was suffering from sickness and diarrhoea. The participant, who had limited English, did not appear to understand why this had been the case suggesting that communication from A&E staff had been poor or problematic.
One participant with limited English reported that communicating with staff in A&E was a ‘big problem’ and that during past experiences, he had had ‘to try to explain himself as much as possible because it’s [an] emergency’ (29-003-KP). This suggests that for patients who experience difficulty communicating in English, emergency situations pose even greater stress. Although the availability of interpreting services in these instances was not made clear in this interview, there is an implication that the responsibility of communication was left with the patient.
6.3
NHS Direct
Interviewees were asked about instances when they had used the NHS Direct telephone line. Discussion centred on knowledge of the service and satisfaction with the outcome amongst those who had used it.
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6.3.1
Use of NHS Direct
Eleven of the interviewees talked about an instance when they had used the NHS Direct telephone service. This included people who had phoned on behalf of someone else or people for whom a call was made by another person. In one case the interviewee said that they had made the call on behalf of a friend because the friend had very limited English.
The calls to NHS Direct resulted from a variety of medical concerns or incidents including an electric shock where someone was burned, a child having a ‘hard time going to the toilet’ (07-001-MT), asthma attacks, shortness of breath, a pregnant relative being sick and having palpitations, a baby with a high fever and the son of a friend having taken some tablets.
6.3.2
Making the decision to use the service
NHS Direct was seen as a first port of call to some people, and was often used to establish whether it was necessary to contact another service. Some people said that they had rung the helpline because they were unsure whether to go to A&E; one person said, ‘I didn’t want to take my mum to A&E for no reason’ (07-003-KP) suggesting that contacting the helpline was seen to constitute a lesser demand on NHS services. Other people had used the service as an alternative to their GP practice when appointments were unavailable, indicating that this service was seen to be more accessible. Some people had called the helpline during the evening or weekend because their GP surgery was closed; one person had used it following information she received from the recorded message at her surgery, which implies that the service is seen as an appropriate source for out-of-hours care. Participants also reported that they contacted the service for medical advice to give them peace of mind, as one participant said: ‘it’s a reassurance thing, isn’t it, and just in case’ (07-003-KP).
When asked about NHS Direct during the interview, six participants who had not used the helpline knew about the service and had a clear view of the circumstances in which they might use it; they suggested it would be for issues that arose outside of GP surgery hours, as an alternative to A&E (where the problem was perceived to be minor) or if they could not get to a pharmacist, suggesting that they perceived other sources as more useful and might only use the helpline as a last resort. Their knowledge about
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the NHS Direct telephone helpline had come from various sources including friends, GP surgeries and, in one instance, from working within the health service.
There was some uncertainty about the purpose of NHS Direct services amongst participants. For example, some people confused the service with out-of-hours primary care services, believing that the service was only for use in the evenings and weekends and one person perceived that as there was a local out-of-hours service available in his area, NHS Direct was not supposed to be used. There also appeared to be some confusion between NHS Direct and the emergency services, as the following quotation shows. When asked about his knowledge of the service, one participant said: ‘If there’s any emergency you need to ring that number anytime and they’ll come to your place if it’s going to be a scene of dead [death] or emergency; they’re really supportive but I don’t know much about it more.’ (01-002-FW). Nine of the participants specifically said that they had not heard of the NHS Direct telephone helpline and some people asked for more information about it. On receiving more information, these participants were largely positive about the service and some said that they may use it in the future. One participant was unsure as to whether she had used this service but reported trying to use a telephone service which sounded similar, without success. She said that she had been unable to communicate with the person on the other end of the phone as they did not speak her language (Cantonese).
6.3.3
Quality of care
Participants were largely satisfied with the service they had received from NHS Direct. People particularly liked the speed with which they accessed professional medical advice; one participant said: ‘The very good thing about it is it’s very quickly answered, that you get through to someone to talk to quite straightaway.’ (0701-MT). Interviewees were particularly positive about the professionalism of the response they received when they rang NHS Direct. They felt that the person they spoke to was wellinformed and they found the conversation and advice they received reassuring. In one instance, a participant was impressed by the authority NHS Direct staff asserted in arranging an ambulance for her friend following what the participant perceived to be a detailed consultation, as the following quotation shows:
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‘Because on the phone she asked me these questions; I just feel they were very professional: “What colour is her skin,” and oh … I asked the lady on the phone, “Should I take my friend to the hospital myself?” and she said, “No, no, no: wait ‘til the ambulance men and paramedics come over” … I found it was very responsible.’ (01-001-KP). In the other case, the interviewee suggested that the advice given to her on the telephone made her feel more confident about her decision not to go to hospital immediately, saying: ‘They were saying if she does, if she’s getting pain then she should definitely go to A&E with the palpitations … because I don’t think she was getting the pain at the time so [the advice] was reassuring.’ (07-004-MT).
Others were less satisfied with the service. For example, one person said that he perceived the interaction with staff on the telephone as impersonal and that he was disappointed with the information he was given: ‘I kind of treated it as a telephone appointment – it was too ‘scripted [and I] probably didn’t get much from there that I couldn’t have picked up from Google.’ (03-002-KP) There was also a perception that the service provided on the helpline was too slow and the process was too long. One participant described how disconcerting she found the process of providing personal information and reported that she doubted the ability of the staff to answer her query, saying: ‘They’d spend lot of time taking a lot of personal information but if you think it’s an emergency you really don’t want to be on the line for very long. You’re almost quite panicked as to what to do because they’re asking for reams of information … I’m not quite sure how qualified they are really and whether they need all the information they’re actually asking for, especially in emergency situations.’ (03-002-FW). Some participants did not think the service was helpful because NHS Direct staff suggested that the patient needed to make an appointment to see their GP. For example, one person reported that she continued to worry after the telephone call ‘because [there was] no action’ and she was still unsure ‘how to handle my children’ (28-KP-FG).
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6.4
Antenatal services
Thirteen of the participants spoke about their experience of antenatal services: 12 of these interviewees had children under the age of 16 years and one was a woman expecting her first child.
6.4.1
Antenatal check-ups and contact with midwives
Ten women spoke about their experience of antenatal check-ups and their contact with the midwifery service. All of these women said that they attended their antenatal appointments and were positive about their contact with individual midwives and felt able to ask any questions they had. Although most of the women did not mind seeing a number of different midwives, one participant was concerned about the lack of continuity and the fact that, in five check-ups, she had not seen the same midwife.
There was praise for the level of care provided by midwives and this was illustrated by one woman’s level of satisfaction with the speed with which she was referred for necessary physiotherapy, saying: ‘I’m actually really excited by the care that you get here because I wouldn’t expect things to happen so quickly in terms of you know, phoning for my physio’. It was within a week and I’d got an appointment. And any other problems I’ve had they’ve been very quick to answer and call up and follow up to make sure everything’s okay with me so … I think the care is excellent, in terms of the midwife-led care.’ (03-002-FW). People often attended antenatal appointments with a friend or relative for support, usually the participant’s husband. In some instances, women had taken someone to the appointment who had a level of understanding of English that was better than their own, to ensure that they understood everything and could ask any questions they may have, as the following conversation illustrates:
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Interviewer: So, those appointments, did you go by yourself or did anyone go with you? Participant: Somebody help me for [because I do] not understand everything. Interviewer: Was that alright? Did you understand things generally do you think? Participant: No; this little bit [I] understand, then no [I don’t] understand, my friend translated for me. Interviewer: So did you feel you got all of the information you needed? Were you able to ask questions that you wanted to ask? Participant: Yes [I was] telling my friend and [she was] telling me. (28-KP-FG).
6.4.2
Experience of antenatal classes
Six of the interviewees said that they had attended antenatal classes – this included two men who went with their wives. One man said that although he went to the sessions to give his wife ‘moral support’, attending was ‘not easy in the beginning’ (03001-SA). He reported that it became easier as the course progressed and that he did find that the classes had been helpful when it came to the birth. In contrast, the explicit view of one male participant who attended an early evening antenatal course with his wife was that fathers-to-be certainly should go to these classes: ‘I found that for both parents it is a necessity. I know some parents who work shifts, they probably would ignore and let all their wives to go alone but I think it’s wrong.’ (07-002-KP). The majority of the women who had attended antenatal classes were happy with the content of the courses they went to: this included three interviewees who attended sessions run by Sure Start local programmes. Women were particularly satisfied with the range of information they received at the antenatal classes covering a lot of different topics. One person perceived that the course content was very comprehensive: ‘Every session was different. So, say for example one was for labour in one session, the other one was feeding, bathing, changing, health and safety. I think they tried to include everything possible.’ (07-001-MT). Others, with more experience of childcare, perceived the information in the classes to be less helpful. For example, one participant, who had nieces and nephews, said that the classes should have focussed more specifically on the birth. She said:
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‘The antenatal classes I went to, I remember she was showing us about things … like what kind of soap powder to use and what things that you could buy for the baby … I didn’t find it that useful, maybe it’s ’cos I knew what to get anyway ’cos of having nieces and nephews and stuff … I thought it was more you know, they should tell me what to do, like breathing exercises and things like that, but it wasn’t like that so what I had of those antenatal classes in my head was not, it wasn’t that.’ (01-001MT). Similarly, two women who had attended antenatal classes when they were expecting their first child said they had not done so during their second pregnancy as they perceived that they had remembered enough information from their first experience. Other women had attended other antenatal services, but had chosen not to attend classes for a variety of reasons. For example, in one instance, classes were fully booked at the hospital and the participant had been informed that they would not be available until 37 weeks into her pregnancy, despite having booked a place in her 26th week. She reported that she hoped to go full term in her pregnancy in order to receive some preparation from the classes, particularly for her husband, who had little experience of childbirth. The participant had been able to go to a privately run antenatal exercise class until a health problem forced her to stop attending.
Other reasons for non-attendance included perceptions that the classes were solely intended for mothers-to-be and that men could not attend. The location of the classes made it difficult for some people to attend and one person said that she had moved into the area late in her pregnancy and missed the classes. One participant had not attended classes as she had not been aware of any during her pregnancy. She attributed this lack of knowledge to her level of English, which she reported had been poorer at the time of her pregnancy.
There was praise for the antenatal services provided at an antenatal drop-in at a local healthy living centre which was reported to be a good facility. One participant said that she perceived this service to be ‘more helpful than the actual official antenatal things’ (07-003-FW).
6.5
Postnatal care
Six women spoke about postnatal care and postnatal classes and one male interviewee said that he had appreciated the information on child development (and gift items) that were contained in the ‘Bounty Box’ (03-001-FW).
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6.5.1
Maternity, postnatal care and check-ups
Whilst interviewees expressed general satisfaction with maternity services, there was some frustration that staff at the hospital had mistaken a patient for a ‘foreign’ visitor. One participant described how a visit to her country of origin, shortly before her pregnancy led to some confusion about her status as a UK patient: ‘I don’t know whether foreign people have to pay or something I’m not sure. But I was like, “No, I’ve just been to Bangladesh for a while, I’ve actually been born here”. So there was a lot of paper work, you know to deal with that … I didn’t know the relevance of it, you know, at the end of the day: deal with my situation.’ (07-001-KP). Although several interviewees mentioned postnatal visits at home immediately after they had their babies, some women were unable to attend a clinic to have their baby weighed as they did not have access to transport.
Only one of the interviewees spoke about the impact of the language barrier when she had her baby: communicating with service providers had posed great difficulty for her. This extract from an interview via an interpreter illustrates the stress the lack of support caused her: ‘She didn’t know how to look after the baby. The midwife came to visit her and they had communication problems. She didn’t know how to ask… because it’s the first baby for her, she felt really, really a disaster. One experience is, when her boy had sickness and diarrhoea and she got the boy to the hospital but the hospital just sent her home. No medications or anything.’ (29-001-KP).
6.5.2
Experience of postnatal classes
Three mothers said they had been to postnatal classes. All of these women lived in Ellesmere Port and two specifically said that the classes were run from the healthy living centre, both mentioning baby massage and breast feeding support. One mother was particularly appreciative of the support at the centre as she had experienced difficulty breastfeeding: ‘It was quite good because with my first son, he never figured out breastfeeding so I had to have an express machine and they did sort it out … it was quite welcoming, it was safe for me to go there on my own. Normally I didn’t really venture very far away at all but I’d make a point to try and get to there because you know, just to see other people with the same scenario and people that would talk back and they weren’t crying, it was heavenly.’ (07-003-FW). 74
Postnatal exercise classes were welcomed by mothers wanting to get back into shape after pregnancy. The short-term nature of the classes however, made it difficult for one Muslim participant to continue exercise in a mixed-sex environment. The participant reported that she found it difficult to exercise due to the lack of available facilities which catered for her religious/cultural needs: ‘It was okay while the health visitors were there because it was a closed environment and only those people were allowed but then after that, three months or what have you, then you have to join the proper gym and that means anyone can go … the woman’s time is when you’re working … I’m constantly having to try and find alternative ways to keep healthy. Although things are out there they’re not accessible for a Muslim woman. Not because Islam says it’s not, it’s because the facilities aren’t [suitable].’ (07-001-KP). One of the interviewees said she was not aware of any postnatal classes but would have been interested in knowing more about them.
6.6
Hospital services
Although the interview schedule only covered the aforementioned services, some participants mentioned experiences of local hospital services and this impacted on their overall impression of local health services. Concerns were raised about the cleanliness of the Countess of Chester Hospital, the cost and availability of parking facilities and waiting times for an appointment: this was of concern to a large number of participants who had experienced what one described as waiting for an ‘overwhelmingly long time for the appointment’ (01-001-SA). As a result, some participants had chosen to go privately for treatment to avoid waiting.
There was, however, praise, from some participants, for the manner in which consultants at the hospital dealt with patients, in particular for their willingness to provide comprehensive information. One participant said: ‘Recently I went to … The Countess [of Chester Hospital] and the consultant was amazing and so good … You know there was a time when doctors were, “I’m a doctor; I’ll tell you whatever you need to know and no more”. But nowadays the doctors tell you so much they … even without asking sometimes, they tell you what actually is happening with you, what are the causes. So then it helps you to prevent in the future something to happen.’ (07-002-KP).
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By contrast, there was also a perception that some consultants at the hospital did not deal with patients as individuals. For example, although he did not provide specific examples about his experiences, one participant reported that he perceived that patients lost all rights to dignity when they went into hospital, as the following quotation shows: ‘Consultant[s], some of them good, some of them bad, but I think the problem is with dignity. It’s when you [get] to hospital: you sign your dignity off … So that means you’re being treated not as a human being, as a piece of equipment, piece of machine.’ (03-001-SA).
6.7
Conclusion
This chapter shows that the interviewees had accessed a range of other health services. Chapter 7 now explores the key findings of the research and discusses their implications for the provision of front-line health services.
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Chapter 7 Discussion 7.1
Introduction
The previous two chapters of this report have illustrated how a sample of residents from Black and Minority Ethnic groups who lived in Chester and Ellesmere Port have used specific front-line health services. It also described their personal experiences of the contact they had with these services. This chapter moves on to discuss, with reference to the literature, the key findings of the research and considers the implications for future service design. It first explores issues related to the impact of the research design and to the profile of the Black and Minority Ethnic population of western Cheshire. It then examines the implications of the choices that interviewees made in their use of health services, their experience of organisational processes and their interaction with health personnel. The chapter concludes by reflecting on their overall levels of satisfaction with front-line health services.
7.2
The research design
The research was designed to explore the views and capture the experiences of a sample of residents of western Cheshire who are of Black and Minority Ethnic origin. The research adopted a purposive sampling approach with the aim of selecting a diverse group of people who lived in areas of health deprivation within Chester and Ellesmere Port. The interviewees, therefore, included residents from a number of different Black and Minority Ethnic groups, males and females, of a range of ages, with a variety of health needs and different levels of speech and comprehension of English.
The research was not designed to present a representative picture of all residents of all Black and Minority Ethnic origin in western Cheshire. In keeping with qualitative research, it illuminates the views and experiences of research participants from which some broader conclusions about the experiences of other residents of western Cheshire and those from Black and Minority Ethnic groups in particular, can be understood.
7.3
The Black and Minority Ethnic population in western Cheshire
The comparatively small size of the Black and Minority Ethnic population in western Cheshire and its changing nature means that it is difficult for local service providers to 77
know with some accuracy the size and profile of this population. It is also apparent that the Black and Minority Ethnic population of western Cheshire is not a homogeneous group but there is considerable diversity in the population in terms of ethnic group, gender, cultural and religious backgrounds, country of birth, fluency in English, and socio-economic group. These differences were also reflected in the profile of the interviewees who took part in this research. Although the research aimed to select interviewees on the basis of living in areas of health deprivation, with the multiple differences in the characteristics of the population it can be difficult to disentangle the extent to which the choices people made about their use of health services and their experiences of health care have been shaped by virtue of their ethnic origin, by other personal characteristics or a combination of these things.
7.4
Making choices about services
Interviewees had used a range of services, including both traditional points of contact such as GPs and A&E, and newer services, such as NHS Direct and seeking advice from pharmacists. The interviews revealed something of the processes that people employed before making a decision to access a health service.
Whilst for a minority of participants, the GP was viewed as the person they would always approach if they had a health issue, there was some evidence that the majority of people made choices between different services. These choices about which service to access appeared to be influenced by a number of criteria including their level of knowledge about the service; their perception of the severity of their illness; advice received from another health practitioner; their desired outcome; the convenience of the location and ease of access; and their level of satisfaction with their previous contact. The fact that ‘choice’ is not necessarily a linear or rational process and that a range of factors influence the process for each individual means that there can be no single solution to maximise the number of patients accessing what local health services view as the most appropriate point of contact on each occasion.
Previous research (for example, Field & Briggs, 2001), has suggested that knowledge is a vital influence on the use of health services. The findings from this research indicated that an individual’s level of knowledge about health services was likely to be drawn from their own contact with the services and information gained verbally from family members, acquaintances and practitioners. Written documentation appeared to be less important, although it was suggested that highly visible promotional materials
78
for the less traditionally used services such as NHS Direct and pharmacists providing advice, were useful. The research shows that people were content to use these services in certain situations if they were sure about what was offered and in what circumstances it was appropriate to use them.
Despite the influence of underlying knowledge, however, this research found that even when someone did not know about particular health services, they often had a rationale for accessing another service and that whatever the interviewee’s depth of knowledge about the range of services available, there was little evidence of them using services inappropriately. However, knowledge appeared to be but one piece of the jigsaw in relation to influences on how services were used.
The research revealed a number of instances when interviewees had not accessed front-line health services when they thought that they needed to. In some cases, people spoke about their use of services when they made return trips to their country of origin, telephone conversations where they sought confirmation of advice they had received, or the acquisition of medicines via mail order. Whilst previous research (see for example, Institute of Community Cohesion, 2007) has referred to recent migrants using services in their country of origin because of a lack of awareness about their rights in the UK, this does not appear to have been the underlying reason for the interviewees who took part in this research. They were more likely to compare the services in their country of origin favourably with one they could have accessed in the UK, particularly in terms of the cost, the speed of being seen and treated, familiarity with the practitioner and ease of communication. The implication of these findings is that some people were not relying on NHS services for all their health care needs but looking more broadly at the alternatives that were available to them.
There was evidence to suggest that people made good use of preventative services such as screening programmes and vaccinations. Where people had little knowledge about a preventative service however, (either about its purpose or what it would involve) there was reluctance to make use of it. The research also shows that cost sometimes acted as a deterrent to using preventative healthcare services, particularly in relation to sight and dental checks.
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7.5
Experience of organisational processes and systems
The research found that there were organisational processes which influenced people’s perception of whether the service they had received was a good one and whether it could meet their needs.
Appointment systems were a major concern, particularly those in operation at a number of GP practices. Whilst some interviewees expressed frustration about the restricted times that GPs were available and some mentioned the length of time they had to wait, the greatest expression of dissatisfaction was in relation to the system of only being able to make an appointment early in the morning for that day. Whilst on most occasions, patients pursued this route despite the inconvenience, and sometimes the stress it caused, it had resulted in some people being deterred from attempting to make appointments and seeking advice from alternative services.
A further concern that was raised during the course of the research was the role of ‘gatekeepers’. There was a perception that ‘gatekeepers’ included reception staff at the GP surgery, the person answering the telephone at NHS Direct, or reception and nursing staff at A&E, and that they prevented patients from being able to see or speak to a doctor, or to see them as quickly as they wanted to.
Although waiting to receive a service was something that people would rather not do, it did not in itself appear to be viewed as a particular problem. There was some acceptance that, with A&E services in particular, patients needed to be prioritised: the frustration that existed was often a result of a lack of understanding about why they were waiting and when there was a perception that allocation processes were inequitable.
Organisational processes and systems such as these have implications for the whole population but these may be exacerbated when understanding and communication in English are more limited. This research suggests that these factors have resulted, in some circumstances, in residents from Black and Minority Ethnic groups looking for alternatives, including accessing services in their country of origin, whilst in other cases they are ‘accepted’ as something that has to be endured because they are part of the local health care system.
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7.6
Interaction with health practitioners
Despite the views expressed about the organisational systems and processes, the factor which had the greatest impact upon the individual’s satisfaction with their experience of health care appeared to be the nature of their interaction with the health practitioners that they saw. This was particularly the case for GPs who the interviewees were more likely to have seen more frequently then other staff. Patients often wanted to see the same general practitioner. This desire for continuity and familiarity was explained in terms of the practitioner having a greater awareness of the individual’s history and needs and the building of a trusting relationship. In some cases, contact over a period of time was perceived as leading to enhanced communication where language difficulties may have otherwise occurred.
Communication in English was not easy for a number of the interviewees and, even when some people said that they spoke and understood English ’fairly well’, consultations involving medical terminology could present particular difficulties.
The
majority of interviewees with limited English, however, suggested that they had developed techniques for dealing with these situations. These included taking a family member or friend along to an appointment; using a dictionary and making notes beforehand; asking a practitioner to write things down so they could take them home; and requesting during the consultation that the practitioner repeat things that they did not understand using different words or speaking more slowly. Some of the interviewees had themselves accompanied by friends and family members as an interpreter or translator and were also able to describe their experiences in this role.
Where interviewees did have difficulty in expressing themselves or understanding English, there were a number of potential consequences. This included a lack of clarity in explaining health issues and a failure to understand elements of the diagnosis and treatment; not asking questions that they would like to have asked; a reliance on taking family members (including children) to appointments which may be inconvenient and/or inappropriate; and not accessing a health practitioner at all. But despite the difficulties that interviewees had experienced, only one person spoke about their use of a professional interpreter, and she was selective about when she accessed the service, suggesting it would be too expensive to ask the NHS to provide interpreters for less ‘serious’ appointments.
Some of the female interviewees wished to see female practitioners, especially within the GP practice and for specific health issues. This was a particular desire of a number 81
of the Muslim participants on religious grounds. The appointment systems, however, that operated within some GP practices and the availability of women GPs, meant that this was not always possible.
There were also instances where religious or cultural considerations had determined whether an interviewee felt able to access a service or receive a particular treatment and how they felt about particular consultations. This was mentioned in relation to participation in antenatal and postnatal exercise classes, the receipt of medication for anaemia and gynaecological examinations. Where cultural and/or religious needs had been overcome, it resulted in a particularly positive view of the service: where they were not, the interviewees reported considerable dissatisfaction and suggested that they would not use, or would hesitate to access the same service in the future.
The expressed desire for continuity and consideration of the personal attributes of the practitioner (usually ethnicity, gender and language spoken) usually related to GPs, although there were some comments in relation to district nurses, midwives and dentists. These are practitioners who patients are likely to see more than once or over a prolonged period and with whom they wished to feel comfortable. However, the appointment systems operated in many GP practices may mean that patients have less choice about which person they see as slots are booked up quickly at the beginning of each session. In addition to issues of personality and sex – which may be a consideration for the wider population – cultural and religious needs and issues relating to communication may mean that the impact of this system disproportionably affects residents from Black and Minority Ethnic groups.
7.7
Key findings
The research identified a number of key findings about the use of health services by residents from Black and Minority Ethnic groups in western Cheshire. •
Participants sometimes had limited information on which to decide which services to access.
•
A perception of the accessibility of a service, as well as the perceived severity of a health problem, appeared to influence the decisions that participants made about which service to approach.
•
GP appointment systems were sometimes seen as a barrier to accessing GP services. 82
•
Some participants reported communication difficulties with staff, particularly GP receptionists. However, there was little evidence of the use of professional interpreting services, even for participants who did not speak and/or understand English fluently.
•
Services were not always sensitive to an individual’s cultural and religious needs. Participants were appreciative where these could be accommodated.
•
Interviewees sometimes wanted to have a choice of practitioner, particularly women who preferred to see a female GP.
•
Continuity of care and the doctor-patient relationship were particularly important to the participants.
•
Some people were discouraged from using preventative services, such as cervical screening or optician services, because of previous experiences, cost or lack of information about the service and what an appointment might entail.
•
7.8
There was little evidence of inappropriate use of services.
Conclusion
The findings of the research revealed that residents from Black and Minority Ethnic groups had some very positive experiences of local front-line health care services. Many were knowledgeable about, and broadly satisfied with, the treatment they had received and with their contact with practitioners. Where there was dissatisfaction, it related primarily to their interactions with particular individuals and, to an extent, to specific organisational systems.
The research also found that interviewees’ expectations of services were based upon both their own and other people’s use of health services in the UK and abroad. This breadth of knowledge and experience brought an additional dimension to the perceptions of the participants in this research. For some interviewees, continued contact with their country of origin also presented an additional source of advice and an opportunity to access services.
In many areas of health care, research has shown that whilst there are differences in the experience and views of individuals from different ethnic groups, there are also considerable similarities. Many of the changes to service design and delivery which would meet the expressed needs of the population from Black and Minority Ethnic
83
groups would be likely to impact positively upon patients from all ethnic groups within the community. Other changes, however, which focus on alleviating barriers to communication, and cultural or religious issues that affect the quality of the interaction and/or the use of a service would be of particular benefit to Black and Ethnic Minority groups. Many of the key findings of this research in western Cheshire are consistent with the recently produced report from the Department of Health, No Patient Left Behind, which sets out new approaches to providing a high quality, culturally sensitive primary care service which is accessible to all (Department of Health, 2008).
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Office for National Statistics. (2001). Neighbourhood statistics. Retrieved May 19, 2008, from, http://neighbourhood.statistics.gov.uk/dissemination/ LeadHome.do;jsessionid=ac1f930dce6512c276e3a5d4346a6bacc4f378fd4dd.e 38OaNuRbNuSbi0LchaOahmQaN8Me6fznA5Pp7ftolbGmkTy?bhcp=1 Office for National Statistics. (2004). Focus on ethnicity and identity. Retrieved May 19, 2008, from http://www.statistics.gov.uk/downloads/theme_compendia/ foe2004/ Ethnicity.pdf Office for National Statistics. (n.d.). Population estimates by ethnic group 2001-5, tables EE1-EE6 – England and LADs 2004.xls, EE6. Retrieved May 20, 2008, from, http://www.statistics.gov.uk/StatBase/ Product.asp?vlnk=14238 Oldham Social Services Department. (1998). The ethnic minority social and health needs project: a study of the social and health needs of members of the Pakistani and Bangladeshi communities in Oldham. Unpublished manuscript. Patel, J. V., Gunarathne , A., Lane, D., Lim, H. S., Tracey, I., Panja, N. et al. (2007). Widening access to cardiovascular healthcare: Community screening among ethnic minorities in inner-city Britain – the Healthy Hearts Project. BioMed Central Health Services Research, 7, 192. Retrieved May 28, 2008, from http://www.biomedcentral.com/1472-6963/7/192 Petrou S, Kupek E, Vause S, & Maresh M. (2001). Clinical, provider and sociodemographic determinants of the number of antenatal visits in England and Wales. Social Science and Medicine, 2001, 52, 1123-1134. POST (Parliamentary Office of Science and Technology). (2007). Ethnicity and Health. Retrieved January 31, 2008, from http://www.parliament.uk/documents/upload/ postpn276.pdf Puchta, C. & Potter, J. (2004). Focus group practice. London: Sage. Raleigh, V., Polato, G., (2005). Evidence of health inequalities. Retrieved February 4, 2008, from http://www.healthcarecommission.org.uk/ _db/_documents/ 04017601.pdf Robb, K. A., Solarin, I., Power, E., Atkin, W., & Wardle, J. (2008) Attitudes to colorectal cancer screening among ethnic minority groups in the UK. BioMed Central Public Health 2008, 8, 34. Rowe, R. E., & Garcia J. (2003). Social class, ethnicity and attendance for antenatal care in the United Kingdom: A systematic review. Journal of Public Health Medicine, 23 113-119. Rowe, R. E., Garcia J., & Davidson, L. L. (2003).Social and ethnic inequalities in the offer and uptake of prenatal screening and diagnosis in the UK: A systematic review. Public Health 2003, 118, 177-189. Rudat K. (1994). Black and Minority Ethnic groups in England: Health and lifestyles. London: Health Education Authority.
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Stanner, S. (2001). Health Survey for England 1999: the health of minority ethnic groups. British Nutrition Foundation Nutrition Bulletin, 26, 227-230. Retrieved February 4, 2008, from http://www.blackwellsynergy.com/doi/pdf/10.1046/j.1467-3010.2001.00138.x Thomson, S. (1996, Autumn). Paying respondents and informants. Social Research Update. 14. Retrieved May, 13, 2008, from Y:\lit\Paying participants\Social Research Update 14 Paying respondents and informants.htm Watts, T., Merrell, J., Murphy, F., & Williams, A. (2004). Breast health information needs of women from minority ethnic groups. Journal of Advanced Nursing 47, 5, 526–535. Western Cheshire Primary Care Trust. (2007). [Family Health System data]. Unpublished raw data. Western Cheshire Primary Care Trust. (n.d.). What do we do? Retrieved 13 May 2008 from http://www.wcheshirepct.nhs.uk/
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Appendix 1 – Participant Information sheet
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Centre for Public Health Research:
Experience of local health services
Information sheet for people taking part
We are inviting you to take part in an interview. Before you decide it is important for you to understand why it is being done and what it will involve. Please read this sheet and discuss it with others if you wish. Ask if there is anything that is not clear or if you would like more information.
What is the research for? The research is being done to find out about the experience of Black and Minority Ethnic residents when they use local health services. The information will be used to help Western Cheshire Primary Care Trust when they are planning local health services.
Who is organising and funding the research? Western Cheshire Primary Care Trust has paid the Centre for Public Health Research to carry out the work on their behalf.
Why have I been chosen? You have been asked to take part in an interview because you are live in Chester or Ellesmere Port and are from a Black or Minority Ethnic group. We would like to find out about your views and experiences. The interview will last about 45 minutes.
Do I have to take part? Taking part is voluntary. If you do not take part it will not affect the health service you receive in any way. If you decide to take part you will be asked to sign a form to say you have had this information about the research. Even if you decide to take part, you can stop at any time and you do not have to give us a reason.
What are advantages and disadvantages of taking part? You may like the chance to share and discuss your experiences and to put forward your views. We do not think there are any disadvantages in taking part in the interview.
Will my taking part be kept confidential? Taking part in this interview is anonymous and no names or details that could identify you would ever be used in any written or verbal reports.
What will happen to the results? A report will be written and that will go to Western Cheshire Primary Care Trust. We can send you a summary of the report if you would like one.
What if something goes wrong? If you wish to complain or have any concerns about any aspect of the way you have been approached or treated during the course of this study, please contact Professor Sarah Andrew, Dean of the Faculty of Applied and Health Sciences, University of Chester, Parkgate Road, Chester, CH1 4BJ, 01244 513055.
Who can I contact if I want more information? If you would like to know more about the interview you can ring the researchers at the University of Chester – the researchers are Fiona Ward (01244 512027) and Katie Powell (01244 512058).
Appendix 2 – Consent form
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Study Number: 076
CONSENT FORM
Title of project: Your Experience of Local Health Services
Name of Researchers:
Fiona Ward and Katie Powell
Please tick each box
1. I have had and understand the information sheet about the research and have had the chance to ask questions.
2. I understand that the interview will be taped.
3. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason.
4. I agree to take part in the experience of local health services research.
---------------------------------------------------- -------------------------------Name of Participant
Signature
---------------------------------------------------- -------------------------------Name of Interviewer
---------------Date
----------------
Signature
Leave one copy with the participant and interviewer takes the other
Date
Appendix 3 – Interview schedule
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Interview schedule USING LOCAL HEALTH SERVICES – APRIL 2008 The interview Interview number Interview location Interview date Interview time Interviewer (+ others present) Western Cheshire Primary Care Trust has asked us to do this research. The aim of the research project is to find out about the experience of residents from Black and Minority Ethnic backgrounds when they use local health services. The information we collect will be used to help Western Cheshire Primary Care Trust when they are planning local health services. Read consent form and ask person to sign it. The interviewee - ask Sex Age
Ethnic group
Postcode
male / female under 20 20-29 30-39 40-49 50-59 60-69 70+ Bangladeshi Indian Pakistani Asian other (please state) Chinese Black African Black Caribbean Black British Black other (please state)
Mixed background (please state) White British White Irish White other (please state)
First of all, I would like to ask you a few background questions that will help us to understand how and why you might have used different health services:
1. Firstly, can you tell me which language you would say is your first language? If first language is not English, a. How well do you consider that you speak English? Would you say fluently, fairly well, slightly or not at all? b. How well do you usually understand English when it is spoken to you? Would you say fluently, fairly well, slightly or not at all? If English is not spoken fluently, c. Do you think there is a difference is speaking and understanding English in everyday situations compared to situations when you are talking about health and illness with a doctor, nurse etc? 2. Which area of Chester/EP do you live in? How long have you lived in this area? If not all their life, a. Where did you live before then? 3. Thinking about other people that you might use health services with - do you have any caring responsibilities, for children, disabled or elderly relatives, for example? If have children, a. How old are your children? 4. Now thinking about your own health, compared to people your own age, would you say that your own health over the last 12 months has, on the whole, been excellent good fair poor very poor 5. Over the last year, would you say your health has got much better better is the same worse much worse 6. Do you have a long term limiting illness, disability or health condition? If yes, a. Could you tell me the nature of this disability or health condition?
I would now like to ask you about a number of different health services that you might have used, either for yourself or with someone else, over the last year
First of all, your GP or family doctor a. Could you tell me if you have seen a GP in last 12 months yes/ no/ dk
b. How often seen in last 12 months Once 2 or 3 times more often
c. Had you used this service before the last year
If not last 12m: d. Have you ever used this service
yes/ no/ dk yes/ no/ dk
7. Could you tell me a bit more about your experience of using this service a. Why did you decide to see the doctor rather than go somewhere else? b. Did you see them for yourself or with someone else? c. Would you say that this service was convenient for you to use? (probe: the time it took to see or speak to someone and where you saw them) d. If contact more than once, did you see the same person each time? How did you feel about discussing your health issues with the person you saw? e. Were you satisfied with the service provided? Do you think it could have been better? If not, What do you think could have been done differently? (probe length of appointment, what happened as a consequence) At any of these appointments, did the doctor refer you on to another service? If yes, f. Who did they refer you to? g. Have you had this appointment? If yes, Did this service meet your needs? If English is not spoken fluently – h. Which language was spoken when you saw the doctor? i. Were you comfortable with this? j. Did this present any difficulties for you? If yes, were they/how they were resolved?
Next, a district nurse or practice nurse a. Could you tell me if you have seen a DN/PN in last 12 months DN - yes/ no/ dk PN - yes/ no/ dk
b. How often seen in last 12 months Once 2 or 3 times more often
c. Had you used this service before the last year
If not last 12m: d. Have you ever used this service
yes/ no/ dk
DN - yes/ no/ dk PN - yes/ no/ dk
8. Could you tell me a bit more about your experience of seeing a (DN or PN) a. Did you request this service or were you referred to it? b. Did you see them for yourself or with someone else? c. Would you say that this service was convenient for you to use? (probe: the time it took to see or speak to someone and where you saw them) d. If contact more than once, did you see the same person each time? How did you feel about discussing your health issues with the person you saw? e. Were you satisfied with the service provided? If not, What do you think could have been done differently? (probe length of appointment, what happened as a consequence) At any of these appointments, did the nurse refer you on to another service? If yes, f. Who did they refer you to? g. Have you had this appointment? If yes, Did (this service) meet your needs? If English is not spoken fluently – h. Which language was spoken when you were with the nurse? i. Were you comfortable with this? j. Did this present any difficulties for you? If yes, were they/how they were resolved?
Community therapists (including physiotherapists and occupational therapists) a. Could you tell me if you have seen a community therapist in last 12 months Physio - yes/ no/ dk OT - yes/ no/ dk
b. How often used in last 12 months Once 2 or 3 times more often
c. Had you used this service before the last year
If not last 12m: d. Have you ever used this service Physio - yes/ no/ dk OT - yes/ no/ dk
yes/ no/ dk
9. Could you tell me a bit more about your experience of using this service a. Did you request this service or were you referred to it? b. Did you see them for yourself or with someone else? c. Would you say that this service was convenient for you to use? (probe: the time it took to see or speak to someone and where you saw them) d. If contact more than once, did you see the same person each time? How did you feel about discussing your health issues with the person you saw? e. Were you satisfied with the service provided by the nurse? If not, What do you think could have been done differently? (probe length of appointment, what happened as a consequence) At any of these appointments, did (this service) refer you on to another service? If yes, f. Who did they refer you to? g. Have you had this appointment? If yes, Did (other service) meet your needs? If English is not spoken fluently – h. Which language was spoken when you were dealing with the service? i. Were you comfortable with this? j. Did this present any difficulties for you? If yes, were they/how they were resolved?
Have you sought advice from a pharmacist? a. Could you tell me if you have asked a pharmacist for advice last 12 months
b. How often done so in last 12 months Once 2 or 3 times more often
c. Had you asked a pharmacist for advice before the last year
If not last 12m: d. Have you ever asked a pharmacist for advice
yes/ no/ dk yes/ no/ dk
yes/ no/ dk 10. Could you tell me a bit more about your experience of using this service a. Why did you decide to use this service rather than go somewhere else? b. Did you see them for yourself or with someone else? c. Would you say that this service was convenient for you to use? (probe: the time it took to see or speak to someone and where you saw them) d. If contact more than once, did you see the same person each time? How did you feel about discussing your health issues with the person you saw? e. Were you satisfied with the service provided? If not, What do you think could have been done differently? (probe length of appointment, what happened as a consequence) At any of these appointments, did the pharmacist suggest you contacted another service? If yes, f. What did they suggest? g. Did you follow this up? If yes, Did (other service) meet your needs? If English is not spoken fluently – h. Which language was spoken when you speaking to the pharmacist? i. Were you comfortable with this? j. Did this present any difficulties for you? If yes, were they/how they were resolved?
Optician a. Could you tell me if you have seen an optician in last 12 months
b. How often have you seen an optician in last 12 months
c. Had you seen an optician before the last year
If not last 12m: d. Have you ever seen an optician
yes/ no/ dk
Once 2 or 3 times more often
yes/ no/ dk
yes/ no/ dk
11. Could you tell me a bit more about your experience of using this service a. Why did you decide to go to an optician rather than go somewhere else? b. Did you see them for yourself or with someone else? c. Would you say that this service was convenient for you to use? (probe: the time it took to see or speak to someone and where you saw them) d. If contact more than once, did you see the same person each time? How did you feel about discussing your health issues with the person you saw? e. Were you satisfied with the service provided? If not, What do you think could have been done differently? (probe length of appointment, what happened as a consequence) At any of these appointments, did the optician refer you on to another service? If yes, f. Who did they refer you to? g. Have you had this appointment? If yes, Did (this service) meet your needs? If English is not spoken fluently – h. Which language was spoken when you were with the optician? i. Were you comfortable with this? j. Did this present any difficulties for you? If yes, were they/how they were resolved?
Dentist a. Could you tell me if you have seen a dentist in last 12 months yes/ no/ dk
b. How often used in last 12 months Once 2 or 3 times more often
c. Had you used a dentist before the last year
If not last 12m: d. Have you ever seen a dentist
yes/ no/ dk
yes/ no/ dk
12. Could you tell me a bit more about your experience of using this service a. Why did you decide to go to the dentist rather than go somewhere else? b. Did you go for yourself or with someone else? c. Would you say that this service was convenient for you to use? (probe: the time it took to see or speak to someone and where you saw them) d. If contact more than once, did you see the same person each time? How did you feel about discussing your health issues with the person you saw? e. Were you satisfied with the service provided? If not, What do you think could have been done differently? (probe length of appointment, what happened as a consequence) At any of these appointments, did the dentist refer you on to another service? If yes, f. Who did they refer you to? g. Have you had this appointment? If yes, Did (other service) meet your needs? If English is not spoken fluently – h. Which language was spoken when you were with the dentist? i. Were you comfortable with this? j. Did this present any difficulties for you? If yes, were they/how they were resolved?
Accident and emergency a. Could you tell me if you have used A&E in last 12 months yes/ no/ dk
b. How often used in last 12 months Once 2 or 3 times more often
c. Had you used A&E before the last year
If not last 12m: d. Have you ever used the A&E service
yes/ no/ dk yes/ no/ dk
13. Could you tell me a bit more about your experience of using this service a. Why did you decide to go to A&E rather than go somewhere else? b. Did you go for yourself or with someone else? c. Would you say that this service was convenient for you to use? (probe: the time it took to see or speak to someone and where you saw them) d. How did you feel about discussing your health issues with the person you saw? e. Were you satisfied with the service provided? If not, What do you think could have been done differently? (probe length of appointment, what happened as a consequence) At any of these appointments, did (this service) refer you on to another service? If yes, f. Who did they refer you to? g. Have you had this appointment? If yes, Did (other service) meet your needs? If English is not spoken fluently – h. Which language was spoken when you were at A&E? i. Were you comfortable with this? j. Did this present any difficulties for you? If yes, were they/how they were resolved?
NHS Direct telephone helpline a. Could you tell me if you have used NHS Direct in last 12 months yes/ no/ dk
b. How often used in last 12 months Once 2 or 3 times more often
c. Had you used NHS Direct before the last year
If not last 12m: d. Have you ever used NHS Direct
yes/ no/ dk
yes/ no/ dk
14. Could you tell me a bit more about your experience of using this service a. Why did you decide to call NHS Direct rather than go somewhere else? b. Did you call for yourself or for someone else? c. Would you say that this service was convenient for you to use? (probe: the time it took to speak to someone) d. How did you feel about discussing your health issues with the person you spoke to? e. Were you satisfied with the service provided? If not, What do you think could have been done differently? (probe advice given, what happened as a consequence) Did NHS Direct suggest you used another service? If yes, f. Who did they suggest? g. Have you had this appointment? If yes, Did (other service) meet your needs? If English is not spoken fluently – h. Which language was spoken when you were on the phone? i. Were you comfortable with this? j. Did this present any difficulties for you? If yes, were they/how they were resolved?
If service not used ever, Do you know about this service? If yes, Are there any circumstances that you would use it? (probe)
For interviewees who have children under the age of 16: The primary care trust is particularly interested in people’s use of antenatal and postnatal services (may be different experience for different children if have more than one – check whether living in Chester or Ellesmere Port when had children (Q2 and Q3)) 15. When (you were/your partner was) pregnant, did you have any check-ups? If yes, a. Where did the check-up(s) take place (hospital, health centre or GPs surgery, at home, Sure Start centre)? b. Was this location convenient for you? c. Did you go to all of the check-ups? d. Did anyone go with you? e. Did you think that these check-ups were useful? f. Did you feel able to ask any questions? If English is not spoken fluently – a. Which language was spoken when you were dealing with the service? b. Were you comfortable with this? c. Did this present any difficulties for you? If yes, were they/how they were resolved? If no, a. Was there a particular reason why you did not have any antenatal check-ups?
16. Did you go to any antenatal classes? If yes, a. What sort of classes were these? b. How did you find out about the classes? c. Where did they take place? Was that convenient for you to get to? d. Did you go on your own or with someone else? e. How did you feel about attending the classes? f. Did you think they were useful? If English is not spoken fluently – d. Which language was spoken when you were dealing with the service? e. Were you comfortable with this? f. Did this present any difficulties for you? If yes, were they/how they were resolved? If no, a. Was there a particular reason why you did not go to antenatal classes?
17. Did you use any health services or go to any postnatal classes in the days and weeks after your baby was born? (prompt, includes Sure Start, NCT etc) If yes a. Which services or activities were these? b. How did you find out about them? c. If classes, what attracted you to the class(es)? d. How did you feel about your contact with this service/activity? If English is not spoken fluently – a. Which language was spoken when you were dealing with the service? b. Were you comfortable with this? c. Did this present any difficulties for you? If yes, were they/how they were resolved? If no, a. Was there a particular reason why you did not use any postnatal services?
18. Health visiting is a service provided for all parents of young children. Did you remember having a visit from the health visitor soon after your child/children were born? a. Did you ever contact your health visitor about your child’s health or speak to your health visitor at a baby clinic? If yes, b. Where did you see them? (prompt at home, clinic, doctors, sure start centre) c. How do you feel about your contact you had with the health visitor? If English is not spoken fluently – a. Which language was spoken when you were dealing with the service? b. Were you comfortable with this? c. Did this present any difficulties for you? If yes, were they/how they were resolved? If no, Was there a particular reason why you did not contact the health visitor?
For all interviewees 19. Have you been contacted to attend any screening appointments or routine health checks, for example, vaccinations, breast screening, cervical smear or bowel cancer screening? a. Have you attended any of these appointments? If yes, a. How did you feel about the service you received? If no, a. Why didn’t you go?
20. Thinking back further than the last year, have you had any particular experiences when you have used health services, either good or not so good, that you would like to tell me about? (prompt – check whether service was in Chester or EP) 21. Are there any health services that you think you may have needed or thought about using but haven’t accessed? If yes, a. Which service(s) was this? b. Why didn’t you use this service? c. Would anything have made a difference and encouraged you to use the service? 22. Is there anything else you would like to say about your experience of using local health services?
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