Patient-perceived benefits of and barriers to using ... - Oxford Journals

Family Practice © Oxford University Press 2001

Vol. 18, No. 2 Printed in Great Britain

Patient-perceived benefits of and barriers to using out-of-hours primary care centres Cathy Shipmana, Fiona Payneb, Jeremy Dalec and Lynda Jessoppb Shipman C, Payne F, Dale J and Jessopp L. Patient-perceived benefits of and barriers to using out-of-hours primary care centres. Family Practice 2001; 18: 149–155. Background. The rapid growth of GP co-operatives has encouraged the development of primary care centres, but little is known about patients’ views and experiences of these new forms of out-of-hours service delivery. Objectives. This study was designed to understand patients’ views, expectations and experiences of attending an out-of-hours primary care centre which was part of an inner London GP co-operative. Methods. Systematic samples of patients using the out-of-hours service received semistructured interviews covering the decision to contact the service, expectations and experience of the service and, if relevant, the experience of travelling to the primary care centre. Interviews were conducted by telephone between 7 and 10 days after patient contact. Results. Interviews were completed with 55.4% (72/130) of sampled patients who were primary care centre attenders, 50.0% (47/94) of those receiving telephone advice and 45.3% (53/117) of those receiving a home visit. Most attenders of the primary care centre said that they were satisfied with the consultation (90.0%, 65) and were able to get all the help they needed (83%, 60). The speed of being seen and the opportunity of having a face-to-face consultation were key benefits identified. For some, this outweighed difficulties experienced in attending the centre, including arranging transport, caring for other children, managing several children on the journey and travelling while ill. The main barriers patients identified for not wanting to attend the primary care centre included feeling too ill to travel, having other dependants to care for or lacking transportation. Conclusions. While primary care centres offer patients speedy access to face-to-face consultations, there are a range of obstacles which are encountered. Those who are socially disadvantaged appear likely to experience greatest difficulty, raising concerns about equity in access to services. Out-of-hours services may need to give consideration to patient transport and a more flexible approach to visiting at home if such inequities are to be avoided. Keywords. General practice, out-of-hours care, patient views, primary care centres.

average, 33% of patients contacting a GP co-operative attend a primary care centre (range 6.3–66.4%). Most co-operative managers reported that they intended to try and increase this proportion.1 Primary care centres appear to offer a less stressful out-of-hours working environment to GPs2,3 that meets with satisfaction from those patients who use them.4–7 However, research is limited about how they are used, their accessibility and the costs incurred by patients who attend. The choice of site for primary care centres appears to be driven more often by operational factors, such as proximity to the administrative base of the co-operative, the costs involved and the availability of alternative sites, rather than the centrality of the location and its accessibility in terms of road and public transport links.8

Introduction The shift in locus of care from the home to primary care centre and telephone consultations is a feature of GP co-operatives.1 A national survey in 1997 found that, on

Received 19 April 2000; Revised 17 August 2000; Accepted 30 October 2000. Departments of aPalliative Care and Policy and bGeneral Practice and Primary Care, Guy’s, King’s and St Thomas’ School of Medicine, Bessemer Road, London SE5 9PJ and cCentre for Primary Health Care Studies, University of Warwick, Warwick, UK. Correspondence to Cathy Shipman, Department of Palliative Care and Policy, Guy’s, King’s and St Thomas’ School of Medicine, Bessemer Road, London SE5 9PJ, UK.

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Latterly, some concern has been expressed about the lack of convenience primary care centres may have for patients.5,6,9 A postal questionnaire survey of patients attending primary care centres attached to small–medium (26–186 GPs) co-operatives found three-quarters to be as satisfied as those receiving home visits, and more satisfied with the time waiting to be seen.7 Our study of a larger inner London co-operative found patients attending the primary care centre to be more satisfied than those experiencing other forms of service delivery,5 but tending to be slightly younger, reporting themselves to be less ill and having easier access to transport than other patients.5 However, little is known about the experiences and expectations of those who attend a primary care centre, and how these compare with those who decline an invitation to attend or receive other forms of out-of-hours care. While there are reports of patients feeling pressurized not to demand a home visit,9 the negotiation process involved in deciding whether a home visit, primary care centre consultation or telephone consultation is required has received little attention. In this paper, we present a more qualitative analysis of the experience of being invited to attend and of using a primary care centre run by a GP co-operative. The setting of the study was a relatively deprived population in an inner city area of South London. A quarter (26%) of residents are from black and minority ethnic groups, many of whom have language differences.10 The GP cooperative was established in April 1996, just over 1 year before the study was undertaken. At the time of data collection, it comprised 288 members and was the largest provider of out-of-hours care in the district. All contacts from patients to the co-operative were made initially by phone and, following assessment, GP telephone advice was offered to 62.1%, primary care centre consultations to 15.5% and home visits to 22.4% of patients making contact.5 This is one of two papers concerning different forms of service delivery provided by the co-operative.11 The aim of this study is to understand patient views, experiences and perceptions of attending the primary care centre.

2368 patients who had made contact with the co-operative between 21 April and 25 May 1997 and had been recruited into a postal patient satisfaction study. Sampling for interviews was undertaken at the same time as random sampling for the postal study, and full details have been reported elsewhere.5 All potential interviewees were sent a letter explaining the reason for and nature of the interview, and given an opportunity to decline consent. All interviews were conducted 7–10 days after their contact with the cooperative to give some control over recall bias. Given the logistical difficulties in receiving information from the co-operative, despatching a letter offering an interview and providing the opportunity to refuse, and conducting the interview within the specified time period, we anticipated that only about half of the sample could be interviewed. A total of 94 patients who had received telephone advice, 117 who had received a home visit and 130 who had attended the primary care centre were invited to participate. An interview schedule was devised based on previous research concerning use of out-of-hours services,12 refined to reflect the new form of service delivery and piloted. This included both closed and open questions on the decision to contact the service, expectations and experience of the service, and the experience of travelling to the primary care centre (Table 1). Interviews were conducted by telephone as this has been shown to be a valid and reliable method of data collection,13 and were tape-recorded and transcribed. Four interviewers were trained to administer the interviews, and reliability was assessed through comparison of tape-recorded sessions. The data were analysed using the Framework approach to develop concepts, categories and major themes from a grid of summarized responses.14

Results The overall interview completion rate was 50.4% (172/341). This comprised 55.4% (72/130) of primary care centre attenders, 50.0% (47/94) of patients receiving a telephone consultation and 45.3% (53/117) of

Methods TABLE 1

Our aim was to undertake in-depth semi-structured interviews with at least 150 patients (or, in the case of children, the parent who had made contact) sampled from those attending the primary care centre, or receiving telephone advice or a home consultation. Sampling was undertaken systematically (stratified by age, sex and time of call), with the aim of gaining a sample that would provide a broad range of patient experience. The sample itself was not intended to be representative of those using the out-of-hours service. The study population from which the interviewing sample was drawn comprised

Major themes of semi-structured interview schedule

Reasons for making the call and previous help sought Expectations and type of help wanted Ease of getting help out of hours Ease of access to primary care centre Telephone call from the doctor Travelling to the primary care centre Experience of the consultation Perceptions of change in out-of-hours general medical services

Patients attending the primary care centre

those receiving a home visit. The response rates reflect the difficulties experienced in trying to conduct a telephone interview within a limited time period after the contact with the out-of-hours service; following repeated attempts, 112 patients could not be contacted for interview within 10 days of the consultation because they either did not answer their telephone or were not at home. A few (four) subjects refused an interview, nine sounded too ill or confused to complete an interview, one had died and one had been admitted to hospital. Fourteen could not be contacted because they had wrong or no telephone numbers, and 28 had repeated answerphone messages, where the interviewer was unable to speak directly to the patient or parent to arrange an interview. Seventy (40.7%) interviews were with parents of children aged under 1 year, and 18 (10.5%) were with patients aged 65 and over. There was no significant difference between the ages of those interviewed or not interviewed. Of those patients for whom interviews were completed, 89 (51.7%) were female and 83 (48.3%) were male; interviewees, therefore, included a significantly greater proportion of male patients than the total sample (Table 2). Attending the primary care centre Sixty-two (86%) of those who attended the primary care centre had not expected to be advised to visit the primary care centre at the time that they called the cooperative, and 35 (48.6%) had wanted a home visit. Most (66.7%, 48) reported travelling to the centre in their own car, with six (8.3%) arranging a lift with a friend or neighbour, seven (9.7%) taking a taxi, three (4.2%) taking the bus and three (4.2%) walking. The mean journey length reported was 20 minutes (range: 4–150 minutes), and 64 (89%) lived within 6 km of the primary care centre. Eleven (15.3%) reported incurring out-of-pocket expenses such as taxi fares, and 14 (19.4%) reported having to make other arrangements to enable them to travel, for example arranging a carer to look after other children. Nineteen (26.4%) said that while they had made the journey, they (or their child) had not felt well enough to travel. TABLE 2

Sex of patients interviewed/subject of interview Female

Male

Total

Received interview

51.7% (89)

No interview

72.2% (122) 27.8% (47) 49.6% (169)

χ2

48.3% (83) 50.1% (172)

= 14.801, d.f. = 1, P = 0.001

Interviewees were asked their views about attending the primary care centre, and the following positive themes emerged. Themes associated with healthcare needs • The centre provided face-to-face contact. This was important for a number of interviewees who preferred to see a doctor as they felt that their attempts to explain the problem over the telephone would be insufficient. Themes associated with the organization of care • The centre generally provided a quick process from initial call to consultation. Many respondents commented with surprise on how quickly they were able to gain a face-to-face consultation with a GP at the primary care centre, and this was often quicker and more convenient than being seen at the surgery within hours. • It provided a back-up to telephone advice, should the patient’s condition worsen. This was felt to be particularly valuable with sick children where anxiety was high and uncertainty over the likely course of the illness considerable. • It provided a quicker and more conducive environment than waiting in A&E. Psychological themes • Attending the centre helped reduce patient’s anxieties about wasting the doctor’s time. • It avoided a wait of uncertain length for a home visit, and the accompanying anxiety. Examples of interviewees’ comments are shown in Box 1. Travelling out-of hours to a primary care centre did, however, pose difficulties for some patients, and the negative aspects concerning this included: Themes associated with healthcare needs • The discomfort and/or risks associated with travelling to the centre. There were indications that the pressing need to get relief from pain could result in patients driving, even when from their clinical state it might have been unwise to do so. Travelling on public transport when ill was also distressing, particularly when the journey was lengthy. Psychological themes • Anxiety about taking an ill child out in the night, particularly if the child had been ill for some time.

Telephone advice

48.9% (23)

51.1% (24) 27.3% (47)

Home visit

62.3% (33)

37.7% (20) 30.8% (53)

PCC attendance

45.8% (33)

54.2% (39) 41.9% (72)

Not significant

151

Social themes • The difficulties of arranging babysitting for other children or dependants in the household, particularly in the middle of the night.

152 BOX 1


Interviewees’ comments on the benefits of attending a primary care centre

• “The speed with which I was able to . . . talk to someone and for someone to understand what was wrong and to be able to give me something to try and correct it . . .” (1096: 51-year-old woman with earache) • “. . . going down to see the doctor was just a confirmation that it was the same diagnosis . . . they were very good. Normally . . . if you ring the doctor’s surgery in surgery hours they’re not going to be in a position to talk to you for ages.” (438: 32-year-old woman with blood in her vomit) • “It was more the experience of being able to see a doctor rather than sitting in the waiting room for 1 hour like at casualty . . . when you’ve got young children its nice to be able to just go to a place and see the doctor straight away.” (440: parent of 1-year-old boy who was vomiting, feverish and floppy) • “Just the knowledge really that there was somebody 10 minutes down the road that you could go and see without causing anybody any fuss or wasting anybody’s time.” (2147: 26-year-old woman with stress related headache)

• Travelling with sick children often required the support of another adult, and this was not always available, particularly to lone parents. The difficulties of managing crying and/or vomiting children were described, which could be particularly problematic if other children in the family had to be brought to the centre as well. • The difficulty in travelling to an unknown area and of finding the primary care centre was described by a number of interviewees. Most attended with another adult to provide support either in terms of transport or in terms of caring for the sick individual. Travelling for people living alone could be particularly difficult, especially if they lacked access to a car. Taxis were not always easy to call quickly, and buses were often unreliable, sometimes involving long waits. • The costs of travelling for those dependent on taxis could be substantial, especially in the middle of the

BOX 2

night, and interviewees described paying up to £20 to attend the primary care centre. Themes associated with the organization of care • The length of time sometimes involved from first making contact with the co-operative to finally getting back home after attending the base. • Having travelled to the centre, then being referred on either to a hospital for tests or to a pharmacist for a prescription to be dispensed. Examples of interviewees’ comments on the difficulties of attending the primary care centre can be found in Box 2. Twenty-five (34.7%) out of 72 interviewees made one or more negative comments about the process of getting to the primary care centre but, for almost all, these experiences did not affect perceptions of satisfaction with the service overall.

Interviewees’ comments on the difficulties of attending the primary care centre

• “Well, at that moment it was kind of a difficult situation because I don’t drive . . . I didn’t have no money at the time, but, as I say, God was willing, and a friend came and dropped me down there.” (1093: parent of 1-year-old daughter with stomach cramps) • “I found it very difficult to find. I found the process of going to . . . immensely frustrating . . . that was the worst part . . . parking problems—and the traffic.” (3743: 32-year-old man with sinusitis) • “She told me I had to bring her (2-year-old child) over to . . . and then I explained to her that I was on my own with a 3-year-old and a 10-week-old baby and a screaming child who is really quite ill. She said ‘well I’m sorry, you’ll have to get a cab’ . . . The money wasn’t a problem . . . it was the fact that I had a 10-week-old baby to carry anyway and to try to carry a 2 year old who is constantly crying . . .” (2725: parent of 2-year-old child with head cold, high temperature, nausea and vomiting) • “It was just the pain I was going through . . . getting there was no trouble . . . but it was going over the bumps . . . potholes . . . especially getting into the car itself, I couldn’t bend down properly it was so painful.” (2149: 29-year-old man with severe back pain) • “I had to drive and I had my son with me . . . my tonsils had an abscess on it and it was swollen . . . like restricting my airway . . . and I didn’t really want to go anywhere in that state . . .” (3745: 27-year-old woman with recurrent tonsillitis)


Once at the centre, almost all patients were satisfied with the consultation (65/66, 98.5%); 64/66 (97.0%) said that they were able to explain their problem fully to the doctor and most were able to get all the help they needed (60/63, 95.0%). For some, it was the urgent need to have a face-to-face consultation and the opportunity offered by the centre that outweighed the difficulties involved in attending (Box 3). Views of patients not attending the centres We asked interviewees who had been given telephone advice and home visits whether they had been asked to attend the primary care centre and, if so, what their reason had been for declining to do so. Nineteen (35.8%) of 53 patients receiving telephone advice said that they had been invited to attend if they felt it to be necessary. Fifteen (25.0%) of 60 patients visited at home had been invited to attend but had refused. The main themes from these interviews are similar in context to those gained from patients reporting difficulty in attendance. For certain patients, however, such difficulties presented an absolute barrier to attendance (Box 4), for example in terms of the experience of illness, lack of resources, and expectations of appropriate provision of care. These interviewees reported: Themes associated with health care needs • Feeling too ill to travel. Psychological themes • Not wanting to take an ill child out at night—a number of parents were particularly concerned about the effects on children of taking them out when they were ill and that this might worsen or prolong the illness. Social themes • Having other children in the household to care for. • Not having accessible transport, for example not having access to a car or not being able to drive. • No money for a taxi—a number of interviewees commented that they did not have sufficient money in the house that night.

BOX 3

153

Themes to do with the organization of care • The expectation that the doctor should visit when the need is urgent. • Not knowing where the primary care centre was or what it was. Examples of interviewees’ comments are shown in Box 4.

Discussion We have found previously that patients attending the primary care centre expressed higher levels of satisfaction with out-of-hours services than those receiving telephone consultations and home visits.5 The interviews conducted for this study reveal, however, that such levels of patient satisfaction masked very real difficulties. There is evidence that some of those who attended travelled in pain or distress, and at some potential danger to themselves, and possibly others (if driving). A range of health, psychological, social and organizational difficulties that patients face when considering the option of attending an out-of-hours centre were identified, including very real practical problems, especially where parents are unsupported, of travelling with a sick child and other children within the family. The pain and discomfort of travelling when ill, as well as concerns about the consequences of taking ill children out during the night, were commented on. A quarter of the patients who received home visits and a third of those who received telephone advice alone had been invited to attend the primary care centre but declined to do so. Barriers to receiving care at the primary care centre appeared insurmountable for some, and these included feeling too ill to travel, having dependent children to care for, difficulty in accessing transport and the expense of travelling. Together with providing face-to-face contact, primary care centres can offer swift access to a consultation in comparison with visiting at home, and this was a factor valued by many interviewees who attended. The centre is also valued because it can provide a back-up to a telephone consultation,4 but this is only possible where patients are able to access the centre. Many patients experienced difficulties with transport,

Interviewees commenting on the need for face-to-face contact

• “We would rather go . . . than not see somebody at all. Obviously all doctors can’t come out for everything, but there are going to be cases where people aren’t going to be able to go to . . . and it is very difficult to get a doctor to come out to you nowadays.” (1690: parent of screaming baby with high temperature and chesty cough) • “I didn’t mind as long as the baby was seen.” (1086: parent of 20-month-old baby with high temperature) • “I really did feel ill and I did feel I needed to see a doctor but I knew I was well enough to travel and that I think I would have been wasting the GP’s valuable time and he could have seen 3 or 4 patients if he’d come and seen me . . .” (3371: 40-year-old woman with bronchial asthma, inhaler not helping)

154 BOX 4


Interviewees’ comments on why they decided against travelling to the primary care centre

Patients receiving home visits • “I have 3 children under the age of 6, by the time he called me it was about 10.30 at night and he asked me if I could go there to be seen there and I explained that I was being rather sick at the time and I had 3 young children . . . and he said ‘oh well in that case I have to come out’ and put the phone down and I was a bit angry at that.” (3630: 36-year-old mother with severe abdominal pain). • “Well it was late at night, I haven’t got a car and I’ve got two other children as well . . . if you haven’t got money for a cab as well you just can’t get nowhere.” (2237: mother of 2-year-old daughter with vomiting and a swollen throat) • “It’s a problem that being so short of breath with my asthma that it means I would have to rely on transport, public transport, which I couldn’t do and I do not know anyone which has got a car around me that could help me out in any way.” (595: 56-year-old man with asthma attack) • “He had a really bad runny nose, his breathing was heavy and its just not right, when your children are sick . . . to take them out. You know you’re dragging them out into the cold air and going out and coming back in, I mean when they’re ill I think they feel more comfortable at their own home.” (2232: parent of 6-month-old child) Patients receiving telephone consultations • “I wanted a doctor to come out and see the baby but he . . . told me to go to (PCC) . . . I didn’t have a clue how to get there . . . he said ‘get a cab’—but I didn’t have no money . . . and went to (local) A&E. (2362: parent of 6-month-old baby with dry cough) • “Well I don’t drive and even if I did drive I didn’t feel up to it which is why I called them in the first place.” (3758: 28-year-old man with viral infection)

suggesting that some may have attended had the option of patient transport been available. This is a particularly important consideration in inner city areas where car ownership is low and public transport out of hours may be lacking. To relieve the strain felt by those travelling when ill, it is also important that primary care centres should be well signposted and provide sufficient parking facilities, together with access to a telephone to enable those travelling by taxi, for example, to return home easily following the consultation. Arrangements should be made for patients to travel to other services, if onward referral is necessary, and to get a prescription dispensed. The study was conducted in a socially deprived inner city area, and the applicability of the findings to other areas needs further study. While the qualitative focus of the study enables a range of key issues to be identified for patients, further research is necessary to state how representative these issues may be for the wider population of users of out-of-hours services. In addition, we do not know how the views of non-responders compare with those of the interviewees, and the views of certain groups, such as those with language differences and the very ill, may have been under-represented.5 Patients appear to prefer face-to-face contact, but a number of respondents commented on the worry of bothering the doctor and calling them out at night. A flexible, socially orientated perspective to care is required if the significant obstacles to care that this study

revealed are to be minimized. However, the costs that this might involve for providers could be considerable. For some patients, the expectation persists that a doctor should visit in an emergency and that travelling when ill outside the home is inappropriate for both adults and children. These findings indicate the importance of outof-hours service providers being aware of the extent of patient needs for information about when it is appropriate to travel when ill. When such information needs are met, patients are then more able to make an informed decision about the appropriate place of care. GP co-operatives have been established largely as a response to GPs’ needs to manage and contain out-ofhours demand. If these new forms of organization are to provide equity in access, then it will be important to consider carefully issues, such as the siting of out-ofhours centres and the provision of patient transport, that will enable patients with fewer resources to access the centres more easily. A cautious approach to the strategic reduction in home visiting rates would also appear important if some patients are not to be asked to overcome unreasonable obstacles and considerable social costs to gaining help. The results of this study suggest that at present, those patients with easy access to resources appear to gain the greatest benefit from the development of out-of-hours centres. There is a need for further debate about the costs and inconvenience it is reasonable for patients to bear in making use of out-of-hours services.


Acknowledgements We are grateful to the patients for their participation, and to the interviewers, research support staff and staff at the co-operative for their support. This study was undertaken as part of the evaluation of an inner London GP co-operative, and was funded by the District Health Authority.

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