Patterns of service use
Participants regarded and used primary care services in a variety of ways. Four patterns were identified and are described below (Box 1). Although we looked for instances, none of the patients who prioritised swift access failed to receive care within 48 hours.
Box 1. Patterns of service use found.
▸ 1. Preference for and success in seeing a named provider
▸ 2. Preference for but not successful in seeing a named provider
▸ 3. Priority given to and success in obtaining swift access to care
▸ 4. Preference for and success in seeing a named provider for some problems; priority given to and success in obtaining swift access to care for others
1. Preference for and success in seeing a named provider
Participants with this pattern of service use included both those who rarely consulted but always chose to see the same GP and those who consulted very frequently and saw the same GP (or practice nurse) for the great majority of their consultations.
Many of these participants were older patients. They identified a particular provider whom they regarded as their ‘own’ and whom they felt had come to accept a personal responsibility for their care. This personal connection was important to them and experienced as personal care, as Mrs A illustrates:
‘Mrs A regarded a personal relationship with her doctor as important and had invested in building it over many years: “We should all know our bank manager,” she said at interview, “and our bank manager should know us. And we should all know our doctor and we made a point of that.” During the study she consulted for a range of chronic and acute problems. For example, in booklet 1 she listed the reasons for consulting as “BP [blood pressure] check, pills needed; discuss possibility of wheelchair; wart to be blasted; itchy rash on top of back.” In each booklet she indicated that she wanted to see one person in particular, her “own” GP. This she managed to do without apparent effort or problem.’
(Mrs A, 81-year-old widow. Sixteen consultations in year: 13 with ‘own’ GP, three with the practice nurse.)
Mrs A's success in seeing her ‘own’ GP was facilitated by a practice culture that recognised her as Dr L's patient, practice policies that enabled her to book regular appointments with him in advance, and a GP who appeared willing to discuss all problems in any consultation. Not all practices made it so easy for patients, however, and where they did not, patients had to work very hard to be able to see their ‘own’ GP. For example, Mrs B had to overcome a number of obstacles, which she identified as arising from the increasing size of her general practice, policies restricting advance bookings of appointments and the attitude of the receptionist:
‘Mrs B had made a conscious decision a number of years earlier to find a GP she liked and to get to know (and be known by) her, but by the time of the study she was finding it increasingly difficult to get to see her. For example, in booklet 4 she described how she had attended the practice for a routine blood test and while there had tried to book an appointment with her own GP regarding a chest infection she had mentioned in an earlier booklet. “The receptionist told me that there were no appointments for at least 2 weeks and that the diary didn't go beyond that. Eventually, after a discussion, she told me to go home and my GP would telephone; which she did at 10:45 giving me an appointment at 11:15. My GP was very efficient and kind as always.” (booklet 4).’
(Mrs B, 67-year-old retired seamstress. Nineteen consultations in year: 11 with ‘own’ GP, four with another GP, four with practice nurse.)
Despite the obstacles she encountered, Mrs B succeeded in seeing her own GP for the great majority of her consultations. Crucial to this was her own determination and the supportive response from her GP who acted on her sense of responsibility for Mrs B as ‘her’ patient. Other patients described further strategies including accepting a long wait to see their own GP and learning when to ring for an appointment, whom to speak to and what to say.
2. Preference for but not successful in seeing a named provider
These patients identified a healthcare professional whom they considered their ‘own’ and whom they wanted to see when they consulted, but were generally not successful in doing so.
An example is Mr C who used both his general practice and a community mental health facility. In both cases he made appointments expecting to see his ‘own’ provider but often found he was seen by someone else:
‘Mr C regarded his relationships with his “own” GP and with the first clinician he saw at the community mental health clinic as important in helping him stay “stable” and in treatment. He booked appointments at the two clinics regularly and always expected to see his own GP at one and his own psychologist at the other. In the last months of the study, however, it was no longer these particular professionals whom he saw. On the first occasion this happened, Mr C noted in his booklet, “I would have preferred my own GP. Partner took GP's place (holiday leave). Fortunately the practice nurse sorted out prescriptions so we didn't have to see alternate GP.” When this happened on two further occasions, he indicated considerable dissatisfaction.’
‘Continuity was even more difficult to sustain in the community clinic, which had a high turn over of staff. He noted in his penultimate booklet: “Five different doctors over the last 8 months is too much for me. It leaves me feeling negative that none of the doctors truly knows me, except for the case notes that they quickly flick through.” (booklet 7). Despite his growing frustration and dissatisfaction, he took no action beyond booking further appointments.’
(Mr C, 42-year-old registered methadone user, unemployed. Practice notes not available; eight consultation record booklets completed over 5 months.)
Patients with this pattern were unhappy with the care they received. They wanted personalised care and commitment from a healthcare professional whom they knew and trusted and, as Mr C illustrates, neither the use of detailed case notes nor the efforts of other members of the team to maintain a consistent approach to management were perceived as adequate substitutes. However, they took no steps to try to see their ‘own’ GP and appeared to expect the practices to arrange this for them.
3. Priority given to and success in obtaining swift access to care
These patients placed a high value on swift access, often in the context of convenient timing, and succeeded in achieving it. Most were young and employed. They consulted largely (but not exclusively) about minor acute problems and did not mind which GP they saw.
Mr D provides an example of a ‘taxi queue’ approach, accepting care from the first health professional available:
‘Mr D regarded health care as a technical activity, accepted medical records as an adequate basis for consistent care and was happy to take the next appointment that came up with whoever was available. For example, in booklet 1 he reported a visit to the local A&E department to deal with “sand and grit in face and left eye”. He wanted immediate treatment for the problem and did not mind whom he consulted as “anyone qualified to give eye treatment” was acceptable. In the second booklet he reported a visit to his general practice for “pain in upper back”. Again he did not mind whom he consulted but wanted to be seen within 2 days and at a suitable time, noting that “I was working late shift at work and required a morning appointment and was given an appointment for the following morning.” His concern for a rapid and convenient appointment was readily accommodated by his large urban practice, which operated an appointment system with a high proportion of 48-hour appointments.’
(Mr D, 36-year-old electrician. Six consultations in year: saw four different GPs; also consulted hospital A&E department.)
For most patients, swift and convenient access to care was achieved at the cost of seeing different healthcare professionals for each consultation. However, this need not necessarily be the case and a small number of patients who prioritised access nonetheless also saw the same GP each time they consulted. Mrs E provides a typical example:
‘At interview Mrs E indicated that she did not mind which GP she saw and she reiterated this in all her consultation record booklets except for a next-day follow-up appointment which she wanted with the same GP. For example, in the first booklet she noted swollen glands and cold sores as her reason for consulting and indicated that she did not mind who she consulted but “I wanted to see someone before I went to work”. Her small urban practice operated an appointment system which could accommodate this (early appointments bookable in advance, late appointments available the same day) and, at the same time, were able to book her appointments with the same GP.’
(Mrs E, 51-year-old office manager. Seven consultations in year: all seven with one GP.)
While these participants regularly saw the same GP, they appeared unaware of this, or unconcerned about it, and did not appear to experience it as continuity of care.
Neither Mr D nor Mrs E looked for a continuing relationship with any particular provider and neither felt they were missing anything as a result of not having one. However, several patients who prioritised speed and convenience of appointments and who saw a number of different GPs quickly expressed dissatisfaction with the care they received. An example is Mr F:
‘At interview he stated he did not want to be restricted to a single GP of his own (although he identified three he preferred), and indicated that “transport problems” would also make it difficult to stay with one GP. In his booklets he noted that the speed or timing of the appointment was most important to him. For example, in booklet 1 he wanted to see someone that day and any of range of people would do, to “get my inhaler changed, trouble with breathing, and to see again if I could get my small finger, left hand, sorted out.” However, at the end of his last booklet he indicated that he was less than satisfied with the consultation and that the GP he had seen would not be his first choice next time. He closed by adding, “I tend to feel like I am on a conveyor belt in a rush to get rid of me”.’
(Mr F, 55-year-old man, on long-term incapacity benefit). Nineteen consultations in year: 11 with four different GPs, eight with four different nurses.)
As Mr F illustrates, patients' priorities may be shaped by practical constraints and achieving them may not always meet their needs.
4. Preference for and success in seeing a named provider for some problems; priority given to and success in obtaining swift access to care for others
Participants with this pattern include young parents who made an effort to see their ‘own’ GP for their own problems but who looked for quick access to any appropriate provider for their children; and patients who made an effort to see their ‘own’ GP for chronic health problems but gave a greater priority to quick or convenient access when they experienced minor acute problems. This could give rise to a large number of consultations with many different practitioners, as Mrs G illustrates:
‘At interview, Mrs G indicated that over the years she had come to regard Dr Y as her “own” GP and preferred to see him whenever she consulted except when she had “women's problems” when she preferred to see the female partner, Dr X. She had discussed this with Dr Y who was happy with the arrangement. The general practice records also indicated that, although Mrs G saw a number of different providers for specific problems, Dr Y reviewed all her problems each time he saw her (and was the only GP who did).’
‘The many concerns and their changing salience which shaped her complex pattern of consulting were evident in her consultation record booklets. For example, in booklet 6 she reported making an appointment for her husband to see “our own GP because he knows our family circumstances really well” and had succeeded as she had made it well in advance “for the day my husband was off work as he cannot take time off at present due to work pressure.” By contrast, three consecutive booklets showed that, in seeking help for her son's sore throat and voice loss she had first asked for and seen her “own” GP for a same-day appointment, then several days later had rung NHS Direct who had advised her to see a pharmacist which she did before finally contacting her practice again. At this point she did not mind whom she consulted for a same-day appointment and saw the trainee GP with her own GP in attendance.’
(Mrs G, 38-year-old mother, off work on sickness benefit. Fourteen consultations in year: five consultations with ‘own’ GP, three consultations with female partner, one consultation with each of four other GPs and two practice nurses. Consultation record booklets also show that she accompanied her son and husband in consulting primary care providers on other occasions, though these consultations were not recorded in her own practice records.)
Continuity of care was facilitated by the commitment of Dr Y, and the support of a large inner-city practice, which had a flexible appointment system, placed a high value on personal continuity, encouraged patients to see the same GP for continuing problems and asked patients which GP they wanted to see.
Despite the complex pattern of consulting which resulted, these patients and their ‘own’ GPs seemed able to accept the contribution of other providers, while still maintaining their mutual commitment to their relationship as the primary one.
