How to get an appointment in routine hours
During routine hours, the main "health service" barrier for patients seeking or obtaining an appointment was the perceived waiting time. This was despite all patients believing they would be seen the same day in an emergency. Often, however, participants were unclear whether symptoms warranted an emergency appointment.
E7 (female; small rural practice) "Well for example [my husband]had a rash on his nose, and one Thursday morning I phoned up and I says to the receptionist, 'I was wanting to make an appointment for [my husband].' 'Is it urgent Madam?' And I says, 'I don't really know – he's got a rash on his nose.' 'Oh,' she says 'If I had a rash on my nose it would be an emergency. Tell him just to come up at 10 o'clock.'"
If an appointment was sought with a preferred doctor, participants who were registered at small, rural practices reported the shortest waiting times for appointments: those at large, urban practices, the longest ones. The waiting time varied from same day to almost two weeks, depending on the practice at which participants were registered. Knowledge of long waiting times for appointments could generate uncertainty about whether to consult, as illustrated in this focus group discussion.
C8 (male; small urban practice)
"There is another aspect here I would think about, is sometimes, well when you phone the doctor, you invariably have to wait a few days and there is this feeling that it is going to go away."
G1 (male at small rural practice) indicates disagreement.
C8
"Not with yours...? Well, sometimes with mine then it is a few days and there is this feeling that by the time you have your appointment..."
D7 (male; large rural practice) "..Aye – it is okay."
Moderator "But if you book this appointment and then you, then it got better, you perceived that it had gone?"
C8
"I just phone and cancel it, that would be OK, yes."
And later:
C8
"I think it depends what it is though. If it was something that you thought was like a ... lump, or a tumour or something like that I wouldn't mind how long it took to go and I would definitely want to go and not have that feeling about that I mentioned earlier. It is only if it was something, like, that you might feel was slightly less – more trivial than – a sore throat or something."
D7
"Just say, this niggly little thing, because it is going to take a few days for you to see a doctor, you put it off?"
C8
"Yes, you could do, yeah"
This extract illustrates two further points. First, indecision about whether to consult was only apparent when symptoms were perceived to be mild (in this instance, the vignette described a dry, irritating cough for three weeks and then some pleuritic chest pain). Second, the urban resident's options included either delaying consulting or booking an appointment, despite believing symptoms to be self-limiting, with a view to cancelling later if symptoms improved. The latter was one of several strategies used by urban participants for obtaining appointments. In this situation the patient thought he had time, and was operating a wait and see approach. In others, when patients wanted a quick appointment, their approach depended on assertiveness.
H30 (male; large urban practice) responding to vignette describing brief intermittent palpitations: "I would be insisting that I get an appointment or somebody come out, I would. I would tell them what it was and insist I get somebody."
One participant had used out-of-hours for a second opinion when not content with his own doctor's treatment.
B22
"I have called out of hours for that, aha, because I have thought 'well, I am no' getting any satisfaction from my own doctor in four years,' I thought, 'I wonder if another doctor...'. And he said 'Go to your own GP. I think you should be referred back'."
In rural areas, participants also used strategies to obtain appointments, but sought to use influence rather than assertiveness. Only one rural patient talked of insisting on an appointment – a previous city dweller – and, even here, her language was less confrontational.
F13 (female; large rural practice) Vignette described possible myocardial infarction at night. She waited to call her doctor the following morning."I'd say 'Can I see you today'. And if they said no, I would explain the situation and say 'Look, I've got to see a doctor today because I'm so concerned about this..."'
More typically and subtly, rural participants believed that their past record of consulting behaviour would be taken into account by their general practice when they asked for an appointment:
G6 (male; small rural practice)
"I'm just judging this personally, but I think they probably grade their patients into those that only ring when there's something wrong – like myself – and those that go a little more often."
D40 (male; large rural practice) ".. I think the doctor must suss them oot o'er a period o' time. Say 'Oh to hell, I have had enough o' you, you bugger!' So that is why she [receptionist]just takes me right away, 'cause I dinnae [don't] pester, ken [you know]?"
Beliefs that patients should use health services responsibly were not restricted to participants from rural areas – statements about this were frequently made in both urban and rural locations – but only rural participants expressed the belief that their general practice would reward this responsible behaviour by seeing them quickly when they needed it. This belief was embedded in the broader theme we mentioned in the introduction – a tendency towards stronger relationships between doctors and patients in rural areas. We have expanded on this previously [
7].
F22 (male; large rural practice)
"And it's one of those things – it's a bit like the old boy network – if you know someone, they know you, they know that you're not playing around and they will take you seriously. Whereas other people – difficult."
Although access to appointments in routine hours was considered good by participants from small rural practices, there were instances where this was countered by a lack of choice, for example when patients did not like their general practitioner's attitude, or were embarrassed:
G21 (female; small rural practice)
"I don't know... I wouldn't want to compromise the position between the two of us by asking him to give me examinations in relation to female problems. Although, when we had our breasts checked, he did that, but his practice nurse was there and I thought, okay, and I'm sure that his practice nurse would always be there anyway, but I wouldn't want to put him in an awkward position with us knowing each other so well."
In these situations, options were limited. They may attempt to see the practice nurse or another general practitioner if there was one, but this could involve waiting or travelling.
How to get seen out-of-hours
The situation out of hours was different. For most participants in the study, out-of-hours care was provided by a centralised service. Many were uncertain about what the formal arrangements were, unless they had experienced them. For most patients, decisions to consult out of hours depended on their assessment of whether or not their symptoms warranted it, but this assessment could depend on their opinion of the service(s) available. Opinions on out of hours services varied. Some were content:
H16 (male; large urban practice) in focus group -Vignette described possible myocardial infarction at night "Yes, well it is the [out of hours service]ain't it at that time – you go straight through to them. I would ask for advice, because you know how busy they are and then, well, whether they would ask me to go up and see them, because they usually do."
But there were also instances, in both rural and urban areas, where participants expressed concern about their local out of hours service and reluctance to use it. A number of reasons were given for this, including a belief they would not be taken seriously, and lack of faith in the person they would speak to.
F22 (male; large rural practice) Vignette described brief intermittent palpitations."..which brings me back to the point of the NHS phone line business. Well I think it's difficult because unless you are medical you could put the emphasis on the wrong thing. Unless the person is going to click in – and are they going to do it every time? How many calls are they going to get for a start? I mean, it doesn't matter, you can keep on top line for a wee while, but you are going to get tired even if you are the super-matron or something on the phone and the rest of it. No it's, ehm, I'm a little dubious on that ringing up the phone. I think they pump things up on the computer screen – don't they? – and I think it works it out for them. But if the person describes the wrong thing, you could be going the wrong way. It's a bit worrying. No, it would depend. If it was someone close to you, that, you would obviously worry more and maybe you may. But I think if that was me, there, I think I would wait till the Monday."
H43 (female; large urban practice) Vignette described possible myocardial infarction at night "...I haven't much faith in [out-of-hours]I must admit. I've heard too many stories about them. So, if it come to the push I probably would just phone an ambulance. I've heard a few stories that weren't very nice...It probably just depends who's on call...No doubt some of them are really good..."
The latter extracts show that patients develop strategies to get around the out of hours service. In some areas, often cited alternatives were to phone 999 for an ambulance, or to go straight to a hospital. The following extracts were responses to a vignette describing symptoms that could have been caused by a myocardial infarction at night. Going straight to hospital was attractive to those who lived near them (including community hospitals in rural areas), but not otherwise, as illustrated in this focus group discussion:
C20 (female; small urban practice) "If it was very severe I would get my husband, if he was there, to drive me to the hospital. To go that one step further, I feel that I would make the judgement that it was flu or something or it was something you know like that. But if I thought it was a heart attack coming on – if I suspected it was something that was actually – I wouldn't phone the [the out-of-hours service]because I would feel to be honest that I would be told 'Oh, it is flu' or 'it is indigestion'. If I felt in myself it was something like that, I would get myself somewhere quickly."
G18 (female; small rural practice)
"That's not a bad idea but then again it would depend on how far you have got to travel."
C20 "I am in [the city]so."
D23 (female, large rural practice)
"Well I am 34 miles."
Calling an ambulance was also less common for patients in rural areas. For many participants, this was because of uncertainty about whether they were allowed to do it – "I didn't realise you could do that!". There was also concern about distances and the time it would take for an ambulance to arrive.
D2 (male; large rural practice) "...Let's see noo...I am sure they have come fae [from] [the town]doon to here. My dad he got his hip joints and he gid awa' [went] to a roup, a farm sale, this afternoon and his hip joint slipped out and he was just in agony. I thought it was [the town]the ambulance come fae. It's ridiculous like, but however...that's the worst of staying out in the wilds out here because they speak abut this nine minutes and stuff o' this kind, but that is impossible staying oot here, like."
For rural participants without a nearby hospital, the only remaining way to avoid calling the out-of-hours service was to wait and call their own doctor during routine hours. This course of action was recounted several times, even when symptoms were perceived to be severe (as in the possible myocardial infarction vignette):
F11(female; large rural practice) in focus group "Eh, no, I would probably have waited until eight o'clock."
Moderator
"Right, okay, why?"
F11
"Because if it had been as I am led to believe for that length of time, I think I would be very, very frightened. Because that's, you know, the first half of that was everything – hanging out of the window to try and get the air and breathe and it is so frightening."
Moderator
"But you are leaving it till eight?"
F11 "Yes because I wouldn't want to disturb the doctor. The doctor I want. Not somebody who is coming from [the town]which is three quarters of an hour away. Well nearly three quarters of an hour away from me."
It is unclear how much this tendency to delay was due to their desire to avoid the other options (out of hours service, travelling to hospital, or calling an ambulance) and how much to their desire to see their own general practitioner. The latter had some influence – rural patients preferred to use their own doctor whenever it was perceived that this was "allowed". For example, one rural patient explained why she would have considered calling her general practitioner even when he was not on duty:
E7 (female; small rural practice) "For example, there was one morning no' so awful long ago, there had been nae electricity or anything about here. The lights and everything went out and we noticed a chap from the two bungalows just out of [village]on the way in. A guy came through the village on his bike and he went up to the back door of the doctor's. And then we noticed [GP] coming out and this was about 7 o'clock in the morning. And the chap next door to him had been having a heart attack. I know that he died anyway, but [GP]he still went to it – you ken [know]what I mean."
Interviewer
"But people would do that in a situation, would go and knock on his door?"
E7 "Aye, just went to his back door and he was just out and into his car and away, you ken [know] what I mean. It's no' as if - [GP]would nae be the kind of folk that would say, 'Oh, we dinnae start 'till..."'
Interviewer
"'I'm not on call just now"'
E7
"No. I'm no' saying he's never said that, but no' that I know of anyway."