Family Practice Vol. 20, No. 1, 41-47
© Oxford University Press 2003
Clinical Research |
The provision of ‘same-day’ care in general practice: an observational study
Division of Primary Health Care, University of Bristol, Cotham House, Cotham Hill, Bristol BS6 6JL, UK.
Correspondence to Dr Chris Salisbury; E-mail: c.salisbury{at}bristol.ac.uk
Stoddart H, Evans M, Peters TJ and Salisbury C. The provision of ‘same-day’ care in general practice: an observational study. Family Practice 2003; 20: 41–47.
Received 13 March 2002; Revised 31 July 2002; Accepted 9 September 2002.
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Abstract |
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Background. Surveys suggest that general practice is perceived to be inaccessible, with long delays before it is possible to be seen by a doctor. Although there is demand for rapid access to care, this has the potential to decrease continuity of care, which research consistently shows to be valued by patients but stressful for doctors.
Objective. Our aim was to investigate the provision of ‘same-day’ care and the characteristics, treatment expectations and priorities of patients attending for ‘routine’ and ‘same-day’ appointments.
Methods. The uptake of same-day and routine appointments was determined from appointment system records. A self-completed questionnaire survey of people attending 362 same-day and 362 routine appointments at 15 general practices in Avon and Gloucestershire enabled comparisons with respect of patient characteristics and consultation experiences, patients’ preferences for rapid access, seeing a known practitioner or seeing a doctor rather than a nurse.
Results. The uptake per 1000 practice population per day was 7.6 [95% confidence interval (CI) 7.1–8.1] for routine appointments and 3.8 (95% CI 3.5–4.2) for same-day appointments. In univariable analyses, use of same-day care was greater by people who were younger, non-white, in work and with educational qualifications. They had attended the practice less often, waited less time to see a doctor previously, had their current problem for a shorter time and were more likely to expect a prescription. From multivariable analyses, only age, speed of previously obtaining appointments, expecting a prescription and having the problem for a short time were independently associated with receiving same-day care. Rapid access to care was rated as more important than seeing a known doctor for two clinical scenarios.
Conclusions. Much care is provided currently on the day it is requested in general practice. The use of same-day care was related to acute illness and expectations but was not associated with deprivation or patient characteristics apart from age.
Keywords. General practice, same-day care.
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Introduction |
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There currently is much emphasis on improving patient access to primary care. The NHS Plan proposes that all patients should be able to see a primary care professional within 24 h and a GP within 48 h. These proposals are partly a response to the perceived inaccessibility of GPs, supported by a national survey which highlighted delays that patients experienced in obtaining an appointment.1
All practices have systems for managing patients who wish to be seen on the same day, such as reserving some appointments for urgent cases, seeing patients after routine surgeries or providing ‘open’ surgeries. However, GPs find that providing care for patients on the same day is stressful.2 The use of terms such as ‘extras’3,4 to describe these patients implies that this demand is beyond the normal service provided. Previous research has suggested that demand for same-day care is more related to social factors than medical need, being associated with younger age, lower social class, single mothers, minor self-limiting illnesses and when making an appointment was considered inconvenient.4–6
Possible ways to improve access include involving nurses in assessment and treatment, and organizational changes such as the recently promoted ‘Advanced Access’ model.7 However, more rapid access potentially could reduce continuity of care from one health professional, which is related to patient satisfaction and possibly improved health outcomes.8 It is unclear whether patients give higher priority to speed of access or continuity of care.9
This study investigated the proportion of care currently provided on a same-day basis within general practice in the UK, and compared the characteristics of patients attending for ‘routine’ and ‘same-day’ appointments. We also examined patients’ expectations and the priority they give to rapid access versus continuity of care, and to seeing a doctor rather than a nurse.
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Methods |
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Sampling and data collection
Fifteen GP practices in Avon and Gloucestershire were selected purposively to provide a range of settings in terms of geographical area, population characteristics and practice size. A questionnaire was distributed to a sample of ‘same-day’ and routine patients attending these practices. ‘Same-day’ patients were defined as those who saw the doctor on the day they made the appointment. Some practices used nurses to manage patients with minor illnesses, and these consultations were included. ‘Routine’ patients were defined as those who had booked a routine surgery appointment before the day of attendance. Same-day patients did not include patients who requested a routine appointment and were given one on the same day, for example because of a cancellation. Treatment room appointments and special clinics, such as diabetes or antenatal clinics, were excluded. For each practice, on two randomly sampled consecutive weekdays, the target was to approach the first 15 routine and 15 same-day patients per day and request that they self-complete a questionnaire whilst at the surgery. Each weekday was sampled an equal number of times. The age and gender of all those approached was recorded. Practice appointment records were examined to ascertain the uptake of same-day and routine appointments in the study period.
Questionnaire
Following an initial qualitative phase of 20 interviews with patients on the day of consultation and piloting, a questionnaire was finalized covering socio-demographic status, past experience of seeking appointments and details of the current appointment. Same-day patients were asked their reasons for requesting a same-day rather than pre-booked appointment. Treatment expectations and preferences were explored by asking patients to respond in three ways to two illness scenarios, one describing an acute illness (sore throat) and one a chronic illness (back pain) (Box 1
). First, patients were asked what sources of help they would consider in response to each scenario. Secondly, they were asked the extent to which they agreed or disagreed with statements relating to seeing a doctor quickly, seeing a doctor they knew and seeing a doctor rather than a nurse, using Likert-type scales. Thirdly, they ranked these three issues in order of importance. With patients’ consent, their medical records were examined at a later date to ascertain whether a prescription was issued, if secondary care referral was made and the number of consultations in the previous 12 months. Diagnoses were obtained from the medical records and classified independently by ME and HS according to the body system affected.
| Box 1 Scenario 1: "Imagine you have had a cold for a couple of days. During the night you noticed that your throat was very sore and you had a temperature." Scenario 2: "Imagine you have had back pain for the last couple of years. It comes and goes and the doctor has said it’s probably arthritis. For the last week it’s been painful again."
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Statistical issues
Ignoring clustering effects, 183 patients in each group would yield 80% power to detect as significant at the 5% level a difference of 15 percentage points in the proportion of patients expecting a prescription (50 versus 35%). Allowing for clustering and non-response (assuming intra-practice correlation of 0.02, 60 patients per practice and 10% non-response) increased this to 450 routine and 450 same-day care patients, which meant 15 practices were required.
Univariable and multivariable relationships between type of appointment and patient characteristics were investigated using descriptive statistics and logistic regression with robust standard errors to adjust for clustering effects, using tests for heterogeneity or linear trend as appropriate. To avoid overlooking potentially differentiating characteristics, a 20% threshold for statistical significance was used to select variables for multivariable analyses; otherwise, 5% was used. Patients’ preferences for rapid access, seeing a known practitioner or seeing a doctor rather than a nurse were investigated using logistic regression comparing across appointment type within scenarios, and the Stuart–Maxwell test to compare between scenarios.
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Results |
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Rate of same-day and routine appointments
The average list size of participating practices was 9401 patients (range 4893–15 300). Appointment rates were calculated from all routine and same-day appointments over the 2-day period. This was only possible for 13 practices since in two it was not possible to distinguish when the appointment had been made (one rural, one urban, both with list sizes of ~7500). A total of 1419 patients had been seen per day in the 13 practices (941 routine and 478 same-day). The rate per 1000 practice population per day of routine appointments was 7.6 [95% confidence interval (CI) 7.1–8.1] and of same-day appointments 3.8 (95% CI 3.5–4.2).
Questionnaire survey
Of the 783 patients approached in all 15 practices, 724 (92%) returned a questionnaire. Responders did not differ from non-responders by age, sex or type of appointment. Consent to access medical records was given by 638 responders (88%), with 23 (3.6%) notes unavailable. Characteristics of responders were similar to those in a national study of patients consulting in UK general practice in terms of gender and employment status, but the study sample contained more people aged 17–64 years (68 versus 62%) and more married people (70 versus 60%).10
Reasons for requesting a same-day appointment are shown in Table 1. Needing a prescription, having the problem for ‘long enough’ or having to wait too long for an appointment were cited frequently. Most consultations were with doctors rather than nurses; 90% of 347 same-day and 99% of 350 routine appointments.
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As shown in Table 2
, same-day care was used more frequently by people who were younger, non-white, not retired and those with educational qualifications. Same-day patients were more likely to be working or in the ‘other’ category, which included those studying or caring for children. Unemployment, not working due to illness or disability and receiving benefits (excluding state pension) were not related to appointment type. Same-day patients were more likely to be living with non-related adults. They had problems of more recent onset, but a third had had their problem for a few weeks or more.
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Same-day patients had fewer appointments in the previous year and were more likely to have seen a doctor previously on the same day. They were more likely to expect a prescription and prescriptions were issued more frequently to same-day patients. Although only a small numbers of hospital referrals were made, this was more common for routine patients.
Patients seen on the same day with known diagnoses (n = 291) were more likely than routine patients (n = 296) to have ENT (24 versus 8%) or skin (14 versus 9%) problems, and less likely to have cardiovascular (2 versus 13%), endocrine (1 versus 7%), urinary/reproductive/ obstetric (13 versus 18%) or mental health (4% versus 10%) problems.
Only a few of the characteristics studied were associated independently with the type of appointment in the multivariable model (Table 3). Younger age, previously obtaining an appointment with any doctor quickly, expecting a prescription and having the problem for less than a week were associated with greater likelihood of receiving same-day care.
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Table 4
describes the speed with which participants would seek help for each of the illness scenarios. These decisions were similar by appointment type. For the sore throat scenario, 78% of 354 routine and 72% of 349 same-day patients would deal with it themselves, with 9 and 12%, respectively, visiting a pharmacy and only four people using a walk-in centre. For the back pain scenario, same-day patients were slightly more likely than routine patients to choose to see a doctor today, but this was of borderline significance.
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In the attitudinal questions, routine patients were more likely to stress the importance of seeing a doctor they knew for both scenarios (trend P = 0.004). For the back pain scenario only, routine patients also had a stronger preference for seeing a doctor rather than a nurse (trend P = 0.004). There were no significant differences between same-day and routine patients in the priority they gave to seeing a doctor today (trend P > 0.6 for the two scenarios).
In the ranking exercise, Table 5 shows that being seen quickly was rated as the priority for both scenarios. Seeing a known doctor was more important for back pain, being seen quickly was more important for sore throat, and there was no difference between scenarios for seeing a doctor rather than a nurse.
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Discussion |
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This large and broadly representative study is the first to examine the uptake and characteristics of same-day and routine patients in general practice in England. Although accessing an appointment in primary care is perceived to be difficult,1 about a third of all consultations were actually delivered on the day care was requested, although this did vary by practice (14–65% of all appointments).
Our findings do not support the previous research which suggested that patients requesting same-day care might be seen because of social rather than medical reasons.4–6 Patients who attended on the same day had been seen less frequently in the last year than routine patients, and the decision to consult quickly was related to the patient’s age, recent onset of illness, expectations and previous experience.
The study has several limitations. It is likely that the characteristics of same-day patients are partly dependent on the practices arrangements as well as patients’ choices. A further limitation is that consecutive patients were approached starting in the morning, rather than a random sample. This might have resulted in an over-representation of certain types of patients. Finally, the research was based on a small sample of days from a relatively small number of purposively selected practices.
It is interesting that although many of those seen on the same day had their problem for a very short period of time, a third had experienced it for over a week. Why these individuals decided to be seen on the same day is unclear, and non-medical factors might have contributed.11 Many reported they felt that they had the problem for ‘long enough’, felt too ill to wait any longer, would have to wait too long for an appointment or expected a prescription. The multivariable model suggests that the longer they waited in the past the less likely they were to receive same-day care on this occasion. Since those expecting a prescription were more likely to receive same-day care (adjusted odds ratio of 2 in Table 3
), there might be some potential to modify the demand for such care by patient and professional education about the benefits of medication for minor illnesses and the possibility of alternatively using over-the-counter treatments and advice from pharmacists. The use of same-day care declined with age, which may be related to greater preference for continuity or to more chronic illness.
It is unclear whether rapid access is compatible with continuity of care,8 which has been rated by patients and GPs as being more important than a convenient appointment for serious clinical or psychological problems.12 The findings support the notion that continuity of care is more important for chronic problems, although for both scenarios the most common preference was to be seen quickly. Whether this would also apply to other chronic conditions is unknown. A recent study has also found that only a few patients and GPs valued a personal GP more than a convenient appointment for somewhat similar scenarios (painful knee and severe cough and cold).12
There is considerable patient and political pressure to provide more rapid access to primary care in the UK. However, this study shows that much care is already being provided on the day it is requested. In the current debate about access to primary care, decisions will have to be made about the trade-offs between speed and continuity, between patient demand and clinical need, and about the most appropriate roles for doctors and nurses. The radical re-organization of appointment systems is being heavily promoted currently,7 based on some positive experience but little formal evaluation. The costs and benefits of these changes for all patients, including the elderly and those with chronic illnesses, are unknown.
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Acknowledgments |
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We would like to thank all the practices for their involvement and the patients for completing the questionnaire. This study was funded by the South West GP Trust.
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References |
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1 Airey C, Errens B. National Surveys of NHS Patients: General Practice 1998. London: NHS Executive, 1999.
2 Luthra M, Marshall M. How do general practices manage requests from patients for ‘same-day’ appointments? A questionnaire survey. Br J Gen Pract 2001; 51: 39–41.[Web of Science][Medline]
3 Kendrick T, Kerry S. How many surgery appointments should be offered to avoid undesirable numbers of ‘extras’? Br J Gen Pract 1999; 49: 273–276.[Medline]
4 Virji A. A study of patients attending without appointments in an urban general practice. Br Med J 1990; 301: 22–26.
5 Taylor B. Patient use of a mixed appointment system in an urban practice. Br Med J 1984; 289: 1277–1278.
6 Field J. Problems of urgent consultation within an appointment system. J R Coll Gen Pract 1980; 30: 173–177.[Medline]
7 Murray M. Patient care: access. Br Med J 2000; 320: 1594–1596.
8 Guthrie BWS. Does continuity in general practice really matter? Br Med J 2000; 321: 734–736.
9 Freeman G, Richards S. Is personal continuity of care compatible with free choice of doctor? Patients’ views on seeing the same doctor. Br J Gen Pract 1993; 43: 493–497.[Web of Science][Medline]
10 McCormick A, Fleming D, Charlton J. Morbidity Statistics from General Practice: Fourth National Study 1991–1992. London: OPCS, 1995.
11 Zola I. Pathways to the doctor: from person to patient. Soc Sci Med 1973; 7: 677–689.
12 Kearley KE, Freeman GK, Heath A. An exploration of the value of the personal doctor–patient relationship in general practice. Br J Gen Pract 2001; 51: 712–718.[Web of Science][Medline]
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