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Abstract
Introduction The demand for urgent care is increasing, and the pressure on emergency departments is of significant concern. General practitioner (GP)-led urgent care centres are a new model of care developed to divert patients to more appropriate primary care environments. This study explores why patients with minor illness choose to attend an urban urgent care centre for their healthcare needs.
Methods A self-completed questionnaire among patients aged 18 years or over (N=649) who were triaged with a ‘minor illness’ on arrival to an urgent care centre, colocated with an emergency department in London.
Results Median participant age was 29 years. 58% (649/1112) of patients attending the centre with minor illness during the study period took part. 72% participants were registered with a GP; more women (59%) attended than men; and the majority of participants rated themselves as healthy (81%). Access to care (58%) was a key reason for using the service as was expectation of receiving prescription medication (69%). GP dissatisfaction influenced 10% of participants in their decision to attend. 68% did not contact their GP in the previous 24 h before attending.
Conclusions We found that the GP-led urgent care centre was similar to walk in centres in attracting healthy young adults, who were mostly registered with a GP and used services because of convenience and ease of access rather than satisfaction levels with their GP. This group may benefit from being seen as part of routine general practice care to provide opportunities for education and promotion of self-management.
- primary care
- emergency department
- practitioners
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Key messages
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What is already known on this subject
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Responding to increasing demand for urgent and after-hours care, the UK has created nurse-led walk-in centres, minor injury units and general practitioner (GP)-led urgent care centres, some colocated with an emergency department. Studies of walk-in centres have shown that most users are registered with a GP and attend due to speed of access and convenience.
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What this study adds
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At this GP-led urgent care centre, most patients are registered with a GP and are influenced to attend by decisions of convenience and ease of access. Despite being triaged as having a minor illness, many patients are anxious and believe their problem to be serious.
Introduction
Urgent care has been defined as ‘the range of responses that health and care services provide to people who require or who perceive the need for urgent advice, care, treatment or diagnosis’.1 The demand and associated costs for urgent care is increasing in the UK and elsewhere.2 ,3 A UK-based patient survey at an emergency department found that over half of attendees were triaged with having a minor illness or injury and could have been treated elsewhere.4 A variety of models including walk-in centres, minor injury units and general practitioner (GP)-led urgent care centres have been developed in an attempt to divert patients to more appropriate environments.
Studies have explored patient behaviour when accessing urgent care with primary care problems.5 However, there are inherent difficulties in making international comparisons due to the variations in definition of an ‘inappropriate’ attendance, type of urgent care facility and the healthcare system being examined. For example, unlike some other countries where such research has taken place, the UK offers universal access to primary care services at no cost to patients.6
Several UK studies have focused on the use of NHS walk-in centres in reducing demand for emergency care.7 ,8 They found that patients using these centres compared with their usual primary care provider were more likely to be home owner-occupiers, have further education, live locally and, in contrast to international research, were registered with a GP. The main reasons for attending were ‘speed of access’ and ‘convenience’.
To our knowledge, there are no UK studies that have examined why patients choose to attend GP-led urgent care centres, especially those colocated with an emergency department. Our aim was to examine why patients triaged as having a minor illness choose to attend the centre, in preference to their own GP. We describe the demographic and socioeconomic backgrounds of this patient group; investigate access and attitude towards their usual GP, and whether this influenced their decision to attend; and further explore their reasons for attending the centre.
Methods
Setting
The urgent care centre in which this study took place is colocated with Charing Cross Hospital's emergency department in London. It opened in September 2009.9 ,10 The centre offers a new model of healthcare that comprises two types of service: open access urgent care services with no appointment necessary and normal GP services with planned appointments for local residents. The urgent care facility is open 24 hours a day for 7 days a week and staffed by GPs and emergency nurse practitioners. On arrival and following registration, patients are triaged by a GP streamer who decides on the most appropriate healthcare ‘stream’ for the patient. The streams comprise ‘minor illness’, ‘minor injury’, ‘GP priority’, ‘emergency department transfer’ and ‘see and treat’ in triage. All ambulatory patients presenting to what was previously the entrance to the emergency department are now seen and streamed by GPs working at the urgent care centre.
Study participants
A self-completed questionnaire was given to all patients aged 18 years or over allocated to the ‘minor illness’ stream after their initial consultation with a GP streamer. Patients were excluded if they were less than 18 years old, unable to give informed consent, unable to speak English, not accompanied by an adult who spoke English or if advocacy and telephone language translation were unavailable. The GP streamer gave each patient an information leaflet to read in the waiting room. An identifiable trained study representative was available in the waiting room to answer any questions regarding the survey before potential participants consented.
Questionnaire design and piloting
An original questionnaire was developed as we were unable to identify a validated questionnaire to use in this setting (see online supplementary appendix). With permission, we used parts of existing questionnaires that had been applied in NHS walk-in centres and emergency departments.4 ,7 Our questionnaire consisted of five sections: access to healthcare (nine questions); patient's own health (five questions); the problem for which they attended (five questions); previous experience and attitude towards the urgent care centre (six questions); demographic and socioeconomic data (six questions); and an opportunity for further comments. The question format varied and included yes or no questions, multiple choice stems and Likert rating scales that ranged from 1 to 10. We piloted the questionnaire among 20 randomly selected patients attending the centre. A revised questionnaire was developed that incorporated feedback on the time taken for completion, readability and layout, question wording and overall questionnaire comprehension.
Sample size calculation
We aimed to use the survey results to estimate the population percentages to within plus or minus 4% with a 5% type I error. A sample of 650 patients would allow estimation of a value of 50% plus or minus 3.9%; that is, there is a 95% probability that the true population percentage lies within the range 46.1–53.9%.
Data collection
Data collection took place between 1 June 2011 and 12 August 2011 (over a 10-week period), on Mondays to Fridays between 8:00 and 20:00. Patients were not recruited overnight or at weekends as the option of attending a patient's usual general practice during these times is generally not available. In total, 649 questionnaires were completed, and during the data collection period, a total of 1112 patients were triaged to the minor illness stream; 671 to the emergency department, 1387 to GP priority stream, 1621 to minor injuries and 696 as see and treat. Most patients attending the urgent care centre with a minor illness between 8:00 and 20:00 arrived before 17:00 (73%), while 13% arrived between 17:00 and 18:30, and a further 14% arrived between 18:30 and 20:00. We therefore sampled 58.3% of minor illness patients. Streaming guidelines developed jointly between the emergency department and the urgent care centre guided GP clinical decisions.
Statistical analysis
Results were entered on to a predesigned Access database as they were collected and then analysed using the statistical package Stata V.12. We carried out a descriptive analysis of baseline participant characteristics and used χ2 statistics to examine relationships between categorical variables.
Results
Baseline participant demographic and socioeconomic characteristics
Participants attending with minor illnesses had a median age of 29 years (mean age of 35 years, range 18–84 years) (table 1). More women attended than men (59% vs 41%, p<0.001); 72% of patients were from a white ethnic group and 83% of participants were long-term UK residents rather than visitors. Among participants, 11% had left full-time education at aged 16 years or younger; 65% described themselves as employed; 17% reported that they were currently ‘going to school, college or university’; and 6% were retired.
Baseline demographic and socioeconomic characteristics of participants by age group (N=649)
Seventy-two per cent (n=465) of the survey participants were registered with a GP. Forty-seven per cent were registered with a GP in the London Borough of Hammersmith and Fulham, where the urgent care centre was located, with a further 27% of participants registered with a GP elsewhere in North West London. Ten per cent were registered with a GP outside London. Of the 182 participants that were not registered with a GP, 49% were visitors to the UK.
Health status and GP registration among attendees
Registered patients were older than those not registered by 7 years (95% CI 4 to 9 years) and were more likely to have a long-term illness than those that were not registered (18% vs 6%; p<0.0001) (table 2).
Health status of participants attending the urgent care centre by GP registration (N=649)
Participants were asked to rate their health on a five-point scale from very good to very bad. Eighty-one per cent (518/640) reported that their health was either very good or good. Sixty-seven per cent reported that they took no regular medication. Fourteen per cent (90/638) of participants reported they had a long-term illness or disability that limited their daily activities or work. Among participants registered with a GP, 23% (n=106) consulted with their GP once in the last year; while 46% (n=211) consulted between three and four times in the last year.
Health behaviours and perceptions among attendees
Fifty-three per cent (231/439) of respondents recorded 7 or more on a Likert scale of 10 on the importance of seeing the same doctor when attending their GP surgery, where 10 ranks the highest. Sixty-seven per cent (295/441) were ‘very satisfied’ or ‘quite satisfied’ with their regular GP; 16% (n=71) responded that they were ‘neither satisfied or dissatisfied’; and 16% (70/441) responded being ‘quite dissatisfied’ or ‘very dissatisfied’. Ten per cent of patients who were ‘quite or very dissatisfied’ with their GP reported that this had influenced their decision to attend the urgent care centre (table 3).
Health behaviours and perceptions of participants attending the urgent care centre by GP registration
Sixty-eight per cent (n=456) of attendees did not contact their own GP practice in the previous 24 h before attending the centre. Among participants who did contact their general practice, 44% (64/146) were told that there were no doctor appointments available on that day; 16% had seen a nurse or a doctor that same day, and 19% had been offered an appointment the following day.
Health advice before attending the centre was most commonly sought from a family member or partner, followed by a friend, while 19% (115/615) used the internet. Others sought advice from work colleagues and pharmacists. In terms of self-help, 48% (291/617) had tried medication from a pharmacy before attending; 41% (253/617) had tried ‘bed rest’; while 13% (55/440) already had prescription medication from their doctor. Seventeen per cent (157/930) stated that the action they took was not listed as part of the stem question. Sixty-four per cent (401/625) of participants attended within 7 days of their problem starting while 12% presented on the same day as their symptoms began and 23.7% had experienced the problem for over 7 days.
Participants were asked to rate the perceived seriousness of their presenting condition. Forty-four per cent (274/621) reported that their condition was serious (defined as 7 or more on a Likert scale of 10) and 9% (57/621) described their condition as ‘very serious’ (rated 10). Participants also rated their level of worry about the problem; 56% (352/624) described that they had a high level of concern about their condition, 2% reported that they were not at all worried (rated 1) and 18% (111/624) reported that they were very worried (rated 10). We found a positive correlation between participants’ view on seriousness of the problem and how worried they were (r=0.7349, p<0.001).
Main reasons for attending and expectations among attendees
Access to care was a key reason for attending the urgent care centre, with 58% (359/623) of participants citing the reason for attendance as ‘quicker than getting a GP appointment’ (table 4). The next commonest reason was ‘nearest place to my home or work’ (n=292), while 134 reported that it was the ‘best place for my particular type of problem’, and 125 had the centre ‘recommended by family, friend or colleague’. Eighty-nine participants felt that they had more confidence in advice and treatment given at the urgent care centre than by their own GP. Only 31 participants said that they ‘wanted a second opinion’.
Main reasons and expectations among urgent care centre attenders by GP registration
The commonest expected outcome when attending the centre was to be prescribed medication; 69% (426/620). The next commonest expectation was to see a hospital specialist; 30% (185/620), while 27% (166/620) expected to be given advice only. Sixty-nine per cent (426/620) gave more than one response to this question. Among the 47% (299/634) of participants whom had previously visited the urgent care centre, 88% (255/291) rated their care as either good or excellent (other rating options included fair or poor). We found that among 66% (187/284) of participants, a previous visit strongly influenced their decision to return (score of 7 and above on a Likert scale of 10; p<0.001).
Discussion
Main findings
We found participants attending a GP-led urgent care centre were mainly working young adults, especially women, registered with a GP, and who rated themselves as healthy. Over 80% of participants reported that their usual health status was very good or good. They did not report any long-term illnesses, two-thirds had no requirement for regular medication, and consulted their GP less often than the national average.11 We found that one in five participants did not try any form of listed health-seeking behaviour before attending. Our study differs from international research, which showed that patients were more likely to be unemployed, homeless, lack health insurance or an established healthcare provider,12 but is similar in showing that patients who attended had a low frequency of chronic illness.13
The ability to get a faster appointment than with their GP and proximity to home or work were the most commonly cited reasons for attendance. This is consistent with research undertaken in Italy,14 Canada15 and Brazil16 demonstrating that access to usual primary care services and patient perception of need are central factors governing patients’ behaviour. Other factors include patient preference in relation to trust in medical professionals, or previous experience of a service, and dissatisfaction with usual primary care services. We found that level of satisfaction with usual GP services was not a major reason for attending the centre, but a high proportion of participants had attended the centre before and this had influenced their decision to return.
Although the GP streamer who saw the participants thought that they had a minor illness, a significant proportion of patients thought that their condition was serious and had high levels of worry. The commonest reason for attending was that it was quicker than getting a GP appointment and that it was the nearest place to their home or work, suggesting that access remains an issue for some patients. In terms of expectations of the visit, the most common reason was to be given a prescription, followed by seeing a hospital specialist and then looking for advice only. Fewer participants expected imaging or diagnostics, with approximately 1 in 12 attending because they felt they needed an X-ray and 1 in 20 to have a blood test.
Similar to findings from studies in walk-in centres, most participants attended the urgent care centres soon after their problem began and had not consulted another health professional before coming. We found that participants who attended the urgent care centre had attended their own GP less than the national average of 5.5 times per year. This suggests that they are healthier, but it may also be because they tend to use other ‘walk-in services’ in preference to routine general practice.
Limitations of study
To our knowledge, there have not been any patient surveys of reasons why patients choose to attend a GP-led urgent care centre. We sampled 58% of the total number of patients that were streamed as having a minor illness during the study period. We were unable to determine whether patients that attended and did not participate differed significantly from those that did. Therefore, we need to interpret the results cautiously in terms of generalisability to the general population of patients attending with such conditions.
In terms of access, although the urgent care centre is open daily, 24 hours a day, we chose to survey patients attending Monday to Friday during the hours of 8:00 and 20:00, as many GPs, since 2004, have undertaken extended hours; core hours being between 8:00 and 18:30. We aimed to explore whether there were access issues despite some practices offering this service. However, we were unable to link survey participants with their registered practice and determine if they offered this service.
During the study period, most patients who attended the urgent care centre (between 8:00 and 20:00) with a minor illness did so before 17:00 (73%). We did not record time of arrival of study participants and are therefore unable to determine whether this had any bearing on reason for attending.
We had to develop an original questionnaire as we were unable to identify an appropriate questionnaire from a review of the literature. Although we used some parts of existing questionnaires, further work needs to be done on its validity, as participants could only respond to question stems that we had developed. Approximately one in five participants was unable to respond to the options listed in examining health behaviours and actions. We tried to address this by having several open-ended questions. Another limitation of our survey design was our inability to measure patient outcomes and validate whether participants that were triaged as having a minor illness, really did have a minor illness.
Policy implications
GP-led urgent care centres may provide an alternative for patients to access primary care services. Like walk-in services, the service appears to attract healthy young adults already registered with GPs and ease of access and convenience were key reasons for attending. Further research is needed to understand what interventions will enable patients to self-manage their minor illness. GP dissatisfaction was generally not a reason for attending the centres, but access and convenience were. Arguably, redirecting patients to their GP may offer greater opportunities to help patients self-manage over time. This would require optimisation of existing services rather than providing multiple points of access for primary care problems.
Conclusions
We found that patients who attended the GP-led urgent care centre with minor illnesses are mainly healthy young adults, registered with a GP, and using these services because of convenience of access rather than satisfaction levels with their GP. The centre appears to provide a similar service to walk-in centres. This patient group may benefit from being diverted to routine general practice care to provide education and promote self-management of minor, self-limiting illnesses.
Acknowledgments
We thank the staff of Partnership for Health and staff at Hammersmith and Charing Cross Emergency Departments for their help. We are also grateful to Professor Chris Salisbury for his advice. Partnership for Health is a consortium of London Central and West Unscheduled Care Collaborative, Imperial College Healthcare NHS Trust and Central London Community Health Services. The Department of Primary Care & Public Health at Imperial College London is grateful for support from the NW London NIHR Collaboration for Leadership in Applied Health Research & Care (CLAHRC), the Imperial NIHR Biomedical Research Centre and the Imperial Centre for Patient Safety and Service Quality (CPSSQ).
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online supplement
Footnotes
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Contributors CA, BW and SG were responsible for the study conception and design. SI and FR were responsible for data integrity and analysis. All authors have had full access to study data and take responsibility for the accuracy of data analysis. All authors were responsible for critical manuscript revision and approval. SG is the study guarantor.
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Funding The new service model was funded by NHS Hammersmith and Fulham. The Department of Primary Care & Public Health at Imperial College received funding from the Imperial College Healthcare NHS Trust to help evaluate the new model.
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Competing interests SG, SI, AM and FR are employed by Imperial College London, which received funding to help evaluate the new model of care. TL is an appointed post holder officer of Partnership for Health.
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Ethics approval This study was reviewed and given a favourable opinion (Research Ethics Committee reference number 11/NW/0221) by National Research Ethics Services Committee North West- Haydock Park 12 April 2011.
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Provenance and peer review Not commissioned; externally peer reviewed.
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Data sharing statement Primary data associated with the research paper are available on request to the corresponding author. Further unpublished data are available to researchers on request.