Feature

Should I bother the doctor?

Demand for out-of-hours care has now become a major policy problem. Cathy Shipman and Jeremy Dale sought public reaction to one high profile ‘solution’

Rising out of hours demand and ‘inappropriate’ contacts continue to be major concerns for GPs, despite the agreement reached with the Department of Health on changes to their terms and conditions of service earlier last year.

It is also over a year since the launch of the Patient Partnership Campaign by the DoH and British Medical Association.¹ The intention was to make people think before contacting their GP, to take more responsibility for their own healthcare and to provide information on ‘appropriate’ use of services. It was funded by £750,000 from the DoH and £20,000 was made available by each health authority from their general allocation of resources. A range of different approaches was planned, from local radio, TV and newspaper advertisements, to self-help booklets and information leaflets.

Criticisms about the limited funding were voiced from the outset. Evidence is now coming to light about the difficulties of putting plans into practice, together with perceptions of little overall effect on demand,² although market research has shown that 30 per cent of patients in Northern and Yorkshire region were more aware of the issue following a TV advertising campaign, with 23 per cent more willing to accept telephone advice.³ The camapgin was relaunched last Easter, though attempts to assess its impact remain inconclusive.

The posters developed by the BMA and DoH were critically received by consumer groups. A survey by Which? found that about 20 per cent of respondents thought the posters might stop them contacting a GP and a further 20 per cent considered them harmful because of this.⁴ Their impact was felt to be alarmist and confusing, particularly as conflicting health messages from other sources were relayed through the media, for example about identifying meningitis.

At the time of the national campaign in late February and March 1996, an audit and research study was being carried out on use and provision of out of hours GP and A&E services within Lambeth, Southwark and Lewisham in London.⁵ Part of this work involved interviewing 120 patients about their out of hours contact. We asked for the main reasons patients needed help. Responses generally concerned the need for advice, reassurance and explanation: for example, on the significance of symptoms, what could be done, and about medication usage. Anxiety about the cause of the illness was a major concern, particularly in relation to children.

We asked interviewees whether they had seen the DoH’s patient education campaign and 23 per cent had done so. Half of these had then contacted their GP and half had attended A&E departments. Comments on the impact of the information varied. About two-thirds of all respondents who had seen the campaign considered it necessary, while thinking that their own circumstances did require out of hours care, for example a family who visited an A&E department when they suspected their father had broken his arm following a mugging:

‘I think its fair, there’s a lot of people who call the doctor out at the drop of a pin, it’s not really fair to them (doctors), its a wasted journey, there could be somebody who really needs them.’

For others the message made sense and was what they would do normally:

‘Oh, it’s commonsense I think. I mean nobody really wants to go to the doctors or ring them if they don’t have to.’

But for some, knowing when to call was problematic, for example the mother of a 2-year-old child with diarrhoea who needed advice from her GP on what was happening to her daughter and what she should do:

‘As far as I am concerned, everybody’s case is an emergency to them. You might not be an emergency to a doctor but it might be an emergency to me…because he’s a qualified doctor whereas I am not.’

A man with severe chest pain who called an ambulance said:

‘Well I mean they’re eye openers really (adverts). We’re not very knowledgeable of medicine, we do tend to think the worse when anything happens…the doctor might be able to offer sound advice.’

Such comments highlight the need for many decisions on what is ‘urgent’ to be medically based, and these are judgements the public cannot be expected to make. Where children were involved it would seem that less risk was taken with symptom interpretation as in the case of a mother of a 9-month-old baby who considered that a temperature of 39° C was too high:

‘If I’m worried about my baby I’m not going to look at an advert and not phone a doctor — no, I don’t think they’re effective — maybe for someone who does call in…for a repeat prescription…maybe they’d think twice.’

Some respondents thought the adverts were effective and necessary, and this may have contributed to their attendance at A&E departments. One interviewee commented that the adverts had made her stop and think and she had decided to consult a pharmacist instead of her GP, although she had later visited an A&E department when her daughter had coughed up blood. But others were concerned that the messages might not reach the right people:

‘I think it would put people off, people who wouldn’t normally ring…and people who would ring will just continue…I can’t see the sense in that advert really.’

These responses indicate that people’s needs are varied and unpredictable and likely to be dictated by the context surrounding their illness. Uncertainty is a major issue for patients who have little medical knowledge on which to assess the significance of their symptoms, and this is often accompanied by anxiety which shapes the experience and perception of illness. While for some minor illness may appear identifiable, it would seem unreasonable to expect all patients to be able to assess what might require urgent help and what might wait until the following morning. As yet there is little evaluation of the effectiveness of self-help and minor injury leaflets. There may be circumstances in which such materials are useful, but they are unlikely to address the unique context of illness and variability of symptoms that all individuals experience.

Our sample of interviewees do not represent people who may have been influenced by the campaign and so did not call for help. There is a need for research to take account of the needs of potential as well as actual users. It is possible that campaigns make an impact on people who are in need of help, for example, older people who traditionally under-use out of hours services. Some users over 65 appear to be reluctant to ‘bother’ their GP, and this can lead to delays in seeking help and the need for intervention by the emergency services.⁶

A new series of patient education campaigns focusing at the local level started last Easter. In addition, the Royal College of General Practitioners has recently launched a series of five leaflets intended to help patients use GP services — including out of hours services — ‘appropriately’. Although demand for out of hours care did seem to be reduced in some areas of the country over the holiday weekend, the fine weather may have been more important than the BMA campaign. It will be important for systematic evaluation to accompany these developments.

But without more rigorous understanding of the needs of people from different groupings, communities and cultures for out of hours services, it is difficult to see how such campaigns will succeed. ‘Appropriate’ contact is only ascertainable with hindsight, a point made recently by the Chief Medical Officer in his report, Developing emergency services in the community. Effective responses are needed and may include encouraging people to seek telephone advice. To identify which measures will be most successful is likely to require investment in a substantial body of research and evaluation concerning use of services and needs for advice, information and reassurance. An approach that works in partnership with patients and potential patients may yield the most profitable results.

This work is part of an ongoing research and development project, facilitating the development and evaluation of new out of hours arrangements within Lambeth, Southwark and Lewisham.