Family Practice Vol. 21, No. 2, 146-149
Family Practice Vol. 21, No. 2 © Oxford University Press 2004, all rights reserved.
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Patients' use of GPs and community pharmacists in minor illness: a cross-sectional questionnaire-based study
The Parklands Surgery, Parklands Road, Chichester PO19 3DT and a Centre for Health Care Research, University of Brighton, Falmer Site, Brighton BN1 9PH, UK
E-mail: timmond{at}aol.com
Received 19 May 2003; Revised 22 October 2003; Accepted 3 November 2003.
Hammond T, Clatworthy J and Horne R. Patients' use of GPs and community pharmacists in minor illness: a cross-sectional questionnaire-based study. Family Practice 2004; 21: 146–149.
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Abstract |
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Background. Despite pharmacists having increased involvement in managing minor illness, many patients continue to attend their GP with problems that could be managed by community pharmacists.
Objective. Our aim was to investigate the prevalence of visits to the GP that GPs felt could be managed by a pharmacist, and to explore patients' reasons for such visits.
Methods. This cross-sectional questionnaire study was conducted at 13 general practices in West Sussex, UK. A questionnaire was given to all patients attending appointments with their GP in these practices over a 1-week period, asking what the presenting problem was and whether the advice of a pharmacist had been sought. If patients had not sought the advice of a pharmacist, they were asked why not. The GP was then asked to indicate whether, in their opinion, the patient's problem could have been managed by a community pharmacist.
Results. The response rate was 94% (3984), representing 87% of all patients consulting their doctor during the week of the study. GPs felt that only 7% (260) of these visits could have been managed by a community pharmacist. The proportion of ‘unnecessary’ visits was significantly higher (P < 0.001) amongst young adults, those presenting with new medical problems and those consulting about a child's health. Skin and musculoskeletal problems were the most common causes of ‘unnecessary’ visits to the GP. The majority of patients making ‘unnecessary’ visits (59%) disagreed with the GP and felt that the pharmacist would not have been appropriate for their problem.
Conclusions. GPs and patients were, on the whole, in agreement over which conditions were appropriate for GP attention. There is, however, a need for education to increase awareness of the roles of pharmacists, aimed particularly at young adults and at those with children.
Keywords. Family, pharmacists, physicians, referrals and consultations.
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Introduction |
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Following the Nuffield Report in 1986,1 the role of the community pharmacist has undergone a period of intense review. The Department of Health, GPs and pharmacists alike have advocated broadening the role of the pharmacist from the traditional dispensing role to include, for example, giving advice on minor ailments and involvement in health promotion.2 Whilst research has shown that patients seeking advice from a GP over minor illness could be transferred successfully to community pharmacist management for specific symptoms,3 the role of the pharmacist can only be expanded optimally if patients independently choose to utilize pharmacists for minor health problems as an alternative to their GP.
Some people already use the pharmacist as a ‘first port of call’ for advice on minor illness.4 Many others, however, continue to seek advice directly from a GP. The prevalence of these ‘unnecessary’ visits to the GP, with complaints that could be managed by a community pharmacist, is not yet clear; nor are patients' reasons for attending a GP in preference to a pharmacist. There is some evidence of a mismatch between GPs and patients as to what constitutes a ‘minor ailment’,5 and studies have identified a number of possible barriers to seeking advice from a pharmacist, including negative perceptions of pharmacists, cost of over-the-counter medications, lack of privacy and poor access.6,7 These studies, however, are based either on patients' retrospective accounts of minor illness or on patients' predictions of their behaviour in response to future illness. The aim of this study is to elicit patients' reasons for seeking advice from a GP in preference to a pharmacist at the time of the consultation.
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Methods |
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The study was conducted in 13 general practices in West Sussex, providing a range of urban, semi-rural and rural practices covering all socio-economic groups. A questionnaire was offered to all patients attending appointments with their GP over a 1-week period. Questionnaires were completed in the waiting room prior to seeing the GP, and were anonymous.
In addition to demographic information, the questionnaire asked what the presenting problem was, whether it was a new problem (i.e. had not been seen previously by a doctor) and whether the patient had sought the advice of a pharmacist. If they had not, a list of six possible reasons was presented. These items were developed around themes generated in previous research,6–8 which included: perception of pharmacists (‘not appropriate for this problem’, ‘did not think of it’), access difficulties (‘difficult to get to’, ‘it was shut’), cost (‘it's cheaper to come to the doctor as I get free prescriptions’) and lack of privacy (‘too embarrassed/lack of privacy’). Participants were invited to endorse as many of the six responses as they felt appropriate, and then add any other reasons.
After the consultation, the GP was asked to rate whether, in their opinion, the patient's problem could have been managed by a community pharmacist on a 4-point scale from ‘definitely could’ to ‘definitely not’. Consultations were categorized ‘unnecessary’ if the GP rated that the patient's problem ‘definitely could’ or ‘probably could’ have been managed by a community pharmacist.
Statistical analysis was conducted using SPSS. Chi-square analysis was used to explore the characteristics of patients making ‘unnecessary’ visits to the GP. Frequency distributions were used to examine the types of conditions presented by these patients and patients' reasons for visiting the GP in preference to the pharmacist.
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Results |
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Sample
Of 4232 questionnaires offered, 3984 were completed and returned (a response rate of 94%). The GPs rated the appropriateness of the visit in 3706 (93%) of these cases. The final sample was therefore 87% of all patients who attended the general practices that week. In this sample, 89% of patients were adults and 64% of these were women. For comparison, the Royal College of General Practitioners statistics for 1998 reported that 84% of consultations were for adults, and 61% of these were for females, suggesting that this is a representative sample.9
Characteristics of patients making ‘unnecessary’ visits to the GP
GPs classified 260 cases (7%) as ‘unnecessary’. Consultations were significantly more likely to be categorized as ‘unnecessary’ if they involved a child patient rather than an adult patient [chi-squared (1, n = 3705) = 40.8, P < 0.001], with 15% of children's compared with 6% of adults' problems being categorized as ‘unnecessary’. For adult appointments, there were no gender differences between those making ‘necessary’ and ‘unnecessary’ appointments [chi-squared (1, n = 3286) = 2.2, P = 0.15]. Younger adults were significantly more likely to make ‘unnecessary’ appointments than older patients [chi-squared (2, n = 3296) = 15.7, P < 0.001], with 10% of appointments for 16–25 year olds categorized as ‘unnecessary’, compared with 7% of those for 26–59 year olds and <5% of those aged 60+. Patients presenting with new problems were more likely to be seen as manageable by the community pharmacist (11%) than those with recurring problems (5%) [chi-squared (1, n = 3632) = 47.4, P < 0.001].
Problems presented at ‘unnecessary’ visits
The problems presented at the 260 ‘unnecessary’ visits were categorized into the groups shown in Table 1. Skin and musculoskeletal problems were the most common causes of ‘unnecessary’ visits to the GP.
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Barriers to using a community pharmacist
Of the 260 people whom GPs believed could have been managed by a community pharmacist, 27 (10.4%) reported already having sought the advice of a pharmacist, whilst 216 (83.1%) had not (17 did not respond). Of the six possible reasons given for not having visited the pharmacist, 155 people endorsed one reason, 38 people two reasons, and three people three reasons. Figure 1 shows the responses given. Contrary to the opinion of the GPs, the majority of patients (59%) believed that visiting the pharmacist would not have been appropriate for their problem.
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Forty-seven additional ‘other’ reasons for not visiting the pharmacist were given by respondents. These were classified by three researchers into six themes (see Table 2). Over a third of the responses fell into the category labelled ‘felt only a doctor was qualified/trustworthy’, but other frequent reasons included a recommendation from a third party to see a doctor; the perception that the problem would require a prescription medication; or that the problem was either occurring during pregnancy, or with a child, when people tend to be more cautious.
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Discussion |
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This is the first large study that has directly compared patients' and GPs' perceptions of the potential for community pharmacist management of minor ailments. The findings revealed unexpectedly high agreement between GPs and patients, with only 7% of GP visits considered by the GPs to be potentially manageable by a community pharmacist. There is, however, still some need for education on the role of community pharmacists. Indeed, if these results could be extrapolated to the UK as a whole, the implications are that each GP in the UK still has 11 consultations per week that (they believe) could have been managed by a community pharmacist (calculated from national consultation rates9).
Young adults were significantly more likely than older adults to attend the GP with problems that were considered manageable by a pharmacist. This may reflect generational differences in attitudes to GPs, with older patients being more reluctant to ‘bother the doctor’. ‘Unnecessary’ visits were also made more often when a child's health was concerned, suggesting parents may believe that only GPs can provide the diagnosis and reassurance they need. If patients were presenting with a new problem (which most minor illnesses would tend to be), the GPs were more likely to think it manageable by a pharmacist than if they were reattending for a previous problem. Contrary to previous suggestions,6–8 cost, poor access and lack of privacy did not appear to be important barriers to visiting a pharmacist. Rather, it was patients' perceptions of pharmacists that appeared most important in their decision to visit a GP instead; the majority of patients making ‘unnecessary’ visits believed that visiting a pharmacist would not have been appropriate for their problem, or simply had not considered it.
One limitation of this study is that the GPs' opinions of what could and could not be managed by a pharmacist was taken as the gold standard, with which patients' views were compared. Although this gave a clear picture of the extent to which GPs believed they were being used unnecessarily, it may be that neither GPs nor patients fully appreciate the roles of pharmacists, and further research needs to be conducted in this area, including whether pharmacists believe that they are being used appropriately to treat minor illness.
One potential bias in the study is that the patient handed their questionnaire to the GP at the start of the consultation. This was done in order to ensure that patients responded at the time of consultation (rather than relying on retrospective accounts) and to maximize the response rate. It could, however, have made patients more likely to select reasons for attending the GP relating to trust in the GP rather than to say, for instance, that they had come for a free prescription.
The findings suggest that, in general, public perceptions of the role of community pharmacists are in line with those of GPs. There is still, however, a need to develop strategies to increase patients' awareness of the qualifications and training of pharmacists and their role in the management of minor illness. These should be particularly targeted at young people and those with children. GPs themselves could help in this by reinforcing the role of pharmacists to patients.
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Acknowledgments |
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We thank Ann Pickering and Bernard Dowling from STaRNet for initial planning and academic support, David Conroy and Lynda Earl who acted as pharmacy advisers, Cherry Harrop for data entry, and Matthew Hankins and Professor Alison Blenkinsopp for helpful suggestions. The study was funded jointly by a research grant from the Proprietary Association of Great Britain and by the Kent, Surrey and Sussex Research Network (KSSnet).
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References |
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1 Committee of Inquiry into Pharmacy. Pharmacy: Report of the Committee of Inquiry. London: Nuffield Foundation; 1986.
2 Department of Health. Choice and Opportunity. Primary Health Care: The Future. London: Department of Health; 1996.
3 Hassell K, Whittington Z, Cantrill J, Bates F, Rogers A, Noyce P. Managing demand: transfer of management of self limiting conditions from general practice to community pharmacies. Br Med J 2001; 323; 146–147.
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6 Evans SW, John DN, Hall RA. Why don't consumers ask community pharmacists for advice on minor ailments? Pharm J 1997; 259: R38.
7 Hassell K, Rogers A, Noyce P, Nicolaas G. The Public's Use of Community Pharmacies as a Primary Health Care Resource. Report for the Community Pharmacy Research Consortium. Manchester: The School of Pharmacy and Pharmaceutical Sciences and The National Primary Care Research and Development Centre, University of Manchester; 1998.
8 Cunningham-Burley S, Maclean U. Pharmacists and primary care: some research findings and recommendations. Fam Pract 1988; 5: 122–125.
9 Royal College of General Practitioners. RCGP Information Sheet: General Practitioner Workload. London: Royal College of General Practitioners; 2001.
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