Telephone survey of private patients' views on continuity of care and registration with general practice in Ireland

95% (400/423) of people contacted had attended a GP in Ireland. The main reason for not having seen a GP in Ireland was recent arrival in the country (14/23 (61%)). 309/400 (77%) respondents had attended a GP in the previous year, and 364/400 (91%) in the previous 2 years. Only 10 (2.5%) respondents had not seen a GP in the previous five years. Respondents with a disability or illness were more likely to have seen a GP in the previous year (90%v74%, X² = 10.06, 1df, p = 0.001). The mean number of visits per annum to the GP for all respondents was 2.3 visits. Female respondents attended more frequently then their male counterparts (2.6 v 2.07, F = 5.9, 1df, p = 0.016).

357 (89%) respondents considered themselves to have a regular GP. Table 1 shows older age to be associated with having a regular GP. Regression analysis showed older age and more recent attendance at a GP to be predictive of having a regular GP, accounting for 12% of the variance (p < 0.001). The mean length of time spent with the same GP was 15.6 years. 310 (78%) respondents stated they receive their personal medical care from a regular GP; while a further 72 (18%) respondents receive their care from GPs within the same practice. 85% of respondents considered it fairly or very important to see the same GP at each visit.

The reasons for choosing their present GP fell into two main categories: convenience to home or work and personal recommendation from family or friend. Respondents indicated that they would consider a GP to be their regular GP after a mean of four visits to the same GP.

Interviewees were asked whom they would prefer to receive their personal medical care from. 326 (82%) respondents expressed a preference for their personal medical care to be provided by a regular GP, whilst 54 (14%) opted for a GP within the same practice and only 20 (5%) for care outside of general practice. Regression analysis showed younger age to be most predictive of a preference for care outside of a regular GP practice (p < 0.001). Factors important to respondents in seeing a regular GP are shown in Table 2.

59/378 (16%) respondents had attended a GP outside of their own practice in the previous year. Table 3 indicates that respondents who were younger, female and with poorer health status were more likely to be associated with attending a GP other than their regular GP practice. Regression analysis showed female gender, poorer health status and longer commuting distances to work to be most predictive of attending another GP (p = 0.01). Patients expressing a preference for a GP within the same practice were as likely to see a GP outside of their own practice as patients who expressed a preference to attend any practice (15% v 20%, X² = 1.0, 1df, p = 0.3). The main reason given for attending a GP outside of their practice was that their regular GP was not available (n = 21 (36%)). Other reasons included recommendation from others (25%), convenience to work or home (22%), cost (10%), sensitive medical problem (3%) and problems with their own GP (3%). Only 9 (2%) respondents had attended a GP cooperative and 22 (6%) a GP deputising service in the previous year. 66 (17%) respondents had used an Accident & Emergency Department with the majority of these (71%) only attending once in the previous year. Frequent attendance in general practice was associated with attending these other services (p= 0.009).

When asked about the likelihood of changing GPs in the next 12 months 89% indicated this was very or fairly unlikely. All respondents were asked what drivers would encourage them to change GP (Figure 2). The commonest reasons were the GP leaving the practice due to retirement or death and a change of address.

The majority of respondents (324 (81%)) considered it is important to be officially registered with a GP practice of their choice, with 58% indicating it is 'very important' and 23% 'fairly important'. After prompting with possible benefits of registration (including continuity of care, better knowledge of medical history and invitations to screening programmes) 369 (92%) considered it fairly or very important to be registered with a GP practice of their choice. Table 4 indicates that female patients were more likely to support registration with a GP practice. Regression analysis showed lower educational level to be most predictive of thinking registration would be beneficial (p = 0.002).

We decided to use a telephone survey for this study as it would be relatively rapid and enable us to easily exclude those respondents who did not fit our categories (patients under the GMS scheme). In addition, the response rates are known to be relatively high in telephone surveys. However, telephone surveys have weaknesses including a selection bias in omitting those who do not have phones and those less likely to use a landline or to be at home. In addition, the survey instrument needs careful design to tailor the questions to a telephone survey. We are aware of the possibility of a response bias in answering the questions on patient registration as the concept was not defined to the patient in the survey instrument. In addition, this was a first pilot study looking at continuity of care in Ireland, but could have explored some of the concepts in greater depth than our survey instrument allowed.

The figure of 11% of respondents not having a regular doctor is similar to a previous study in Newfoundland where 15% of the population did not have a regular doctor[13]. A relationship between length of time with a doctor and the value placed on continuity has also been previously established[14]. The mean length of time spent with a GP for this population was 15.6 years and this is reflected in the positive views expressed towards continuity of care. As in other studies younger people were least likely to have adopted attitudes and behaviours supporting continuity of care with a GP[13, 15]. This may be related to a different approach towards healthcare utilisation in this group or may be that as a group they are generally healthier, more mobile and more likely to be consulting a GP about acute episodes of illness.

Previous studies have shown frequent users of services outside of a regular GP for primary care to be a psychosocially vulnerable group[16]. In this study, we found that users of other services, including Accident & Emergency and out of hours GP services were also likely to be frequent attendees at their own regular GP.

Attendance rates for the GP were low at a mean of 2.3 visits per year and may reflect the lack of delivery of preventive services to this population. However, this is consistent with previous studies of GP visiting rates among private patients in Ireland, as is the higher visiting rate amongst female patients[17]. However, the proportion of respondents who had visited a GP in the previous year (77%) is higher than in previous studies (65%)[17]. This may be due to this study being carried out on a more urban population. This study supports previous studies in indicating that the overwhelming majority (97%) of the population have seen a GP in the previous five years.

Patients in this study chose their GP on the basis of convenience and personal recommendation. Important factors to the patient in continuing with the same GP are the GP's knowledge of their medical history, good communication with the GP and trust in their GP; factors similar to other studies[18]. Few patients were intending to change GP. The main precipitant for such a change would be the death or retirement of their GP. This would seem an obvious factor but has not been reported in previous studies[19, 20]. Other reasons including change of address and breakdown of the relationship with their GP are similar to these previous studies.

It is clear from this study that private patients in Ireland have positive attitudes towards continuity of care with a GP. This has implications for proposed changes in the Irish Healthcare system encouraging registration with a primary care team as opposed to a GP practice.

Only 16% of respondents had visited a GP other than their regular GP in the previous year. We sought to characterise this group but could account for only 4% of the variance, explained by female gender, poorer health and a longer commuting distance to work. However, there was no difference between those who expressed the view that seeing a regular GP was important and those who did not in the likelihood of having consulted a GP outside their own practice in the previous year. The reasons given for attending another GP tended to indicate 'one-off' occurrences as opposed to a regular pattern of behaviour. This suggests that there may not be a distinct group of people who use different GPs on a regular basis but more likely a group of circumstances that encourage this[21].

We sought to define a practice population in the absence of universal registration. It appears that this population of private patients behave as a stable GP population, even in the absence of registration. The majority of patients visit one regular GP or practice over long periods of time. The patients who attend a GP outside of their regular GP are not readily characterised. The question remains as to how GPs can identify a practice population in order to institute population based programmes. We would propose several options:

• As 92% of the fee-paying population have attended a GP in the last two years, it could be argued that any patient having attended a GP in the last two years could be considered as 'registered'. However, it is not clear whether patients who visit a GP once will visit that same GP again.

• Respondents indicated that they would consider a GP their 'regular GP' after a mean of four visits. Patients who had attended four or more times with a GP could be considered as 'registered'. However, when considering invitations for screening, 'low-attendees' would be less likely to be screened.

• Practices could institute their own registration scheme. In exchange for 'registration', the practice could offer continuity of care and invitations to screening. Patients could continue to opt for 'non-registered' appointments.

• General practice could continue to pressure the government for a system of universal registration in order to enhance continuity of care and improve anticipatory care. This study suggests there is little opposition to this idea from patients, particularly when the benefits are explained to the patient. In addition, it appears that a more socially disadvantaged population are most supportive of universal registration. The reasons for this are not clear. However, the more socially disadvantaged group of private patients are particularly vulnerable in being just above the means tested limit for access to general practice. We would argue that this population might be most likely to benefit from universal registration as lack of registration has been linked to lower attendance in primary care by vulnerable populations[22].

There is a need in the Irish context to further establish the importance of continuity of care in relationship to other aspects of healthcare delivery such as speed of access. In addition, it is clear that not all patients need or desire the same aspects of care and developing models of health service delivery that are flexible enough to respond to these different needs and desires remains a priority.