Elsevier

Social Science & Medicine

Volume 56, Issue 4, February 2003, Pages 803-814
Social Science & Medicine

Eliciting preferences of the community for out of hours care provided by general practitioners: a stated preference discrete choice experiment

https://doi.org/10.1016/S0277-9536(02)00079-5Get rights and content

Abstract

Access to primary care services is a major issue as new models of delivering primary care continue develop in many countries. Major changes to out of hours care provided by general practitioners (GPs) were made in the UK in 1995. These were designed in response to low morale and job dissatisfaction of GPs, rather than in response to patients’ preferences. The aim of this study is to elicit the preferences of patients and the community for different models of GP out of hours care. A questionnaire was sent to parents of children in Aberdeen and Glasgow in Scotland who had received a home visit or attended a primary care emergency centre, or were registered with a GP. The questionnaire used a discrete choice experiment that asked parents to imagine their child had respiratory symptoms. Parents were then asked to choose between a series of pairs of scenarios, with each scenario describing a different model of out of hours care. Each model varied by waiting time, who was seen, location, and whether the doctor listened. The response rate was 68% (3893/5718). The most important attribute was whether the doctor seemed to listen, suggesting that policies aimed at improving doctor–patient communication will lead to the largest improvements in utility. The most preferred location of care was a hospital accident and emergency department. This suggests that new models of primary care emergency centres may not reduce the demand for accident and emergency visits from this group of patients in urban areas. Preferences also differed across sub-groups of patients. Those who had never used out of hours care before had stronger preferences for waiting time and the doctor listening, suggesting higher expectations of non-users. Further research is required into the demand for out of hours care as new models of care become established.

Introduction

There have been many changes to the delivery of primary care in many countries, as health care reforms introduce and experiment with new models of care. The provision of out of hours (or after hours) care by primary care physicians is a crucial element of primary health care in many countries. Concerns about access to primary care, increasing public expectations, and the effects on stress and family life for primary care physicians, have led to reform of out of hours primary care in several countries. A common theme in these reforms has been a degree of centralisation and integration of services through system-wide telephone triage (Vedsted & Olsen, 1999; Hansen & Munck, 1998) and growth in co-operative models of out of hours care, including the establishment of primary care out of hours emergency centres (Department of Health, 2000; Scottish Out of Hours Study Group, 2001). These changes have reduced the on-call commitment of primary care physicians, increased the proportion of telephone consultations, and changed the location and provider of health care. The effects of these major changes in service provision have therefore been supply-led, rather than demand-led. There is little evidence of the effects on patients.

In the UK, the provision of out of hours care by general practitioners (GPs) has changed radically since 1995. As a result of deepening concern felt by GPs about increasing workload out of hours and the ability to maintain their 24 hour contractual commitment, the arrangements for providing care out of hours were altered in 1995. Funding was made available to set up GP co-operatives, where many practices formally collaborate to provide out of hours care. This funding paved the way for the set up of new primary care emergency centres open during evenings, nights and weekends, and staffed by GPs from member practices. In many areas, this has led to reductions in the numbers of home visits as more patients are asked to travel to the emergency centre and more advice is given over the telephone. The structure and organisation of co-operatives vary, with some providing nurse triage, patient and doctor transport, and being supported by a formal management board and administrative structure. Others have a less formal structure, and are more similar to rotas. These changes have influenced mainly urban areas of the UK, with care in rural areas provided along more traditional lines with GPs providing their own cover for their own patients (Hallam and Henthorne, 1999; Department of Health, 1998).

These arrangements were devised and implemented to reduce stress and improve the morale of GPs, with little recourse to the preferences of patients and the community. The changes have had important effects on the process of care, including location of care, waiting times, and who is seen as well as potential effects on health status.

Several patient satisfaction studies have been conducted which have used a variety of instruments, and asked about a variety of different models of care (McKinley et al. (1997a), McKinley et al. (1997b); Salisbury, 1997; Bain, Gerrard, Russell, Locke, & Baird, 1997). However, satisfaction studies suffer from several known shortcomings. Although they ask about patients’ experience of the care they have had, which is relevant, they do not directly ask about preferences for alternative models of care. It is difficult to determine the relative importance of attributes from satisfaction studies, since dissatisfaction (or satisfaction) with an attribute does not necessarily indicate that it is the most important to patients (Scott & Smith, 1994; Carr-Hill, 1992).

Satisfaction studies also ignore the notions of sacrifice and opportunity cost: resources for out of hours care are finite and choices need to be made about where they are likely to have the best effect. To have more of one characteristic means less of another. It is impossible for patients to receive a home visit within 5 min of their call, from their own GP. It is therefore important to find out, from the patients’ perspective, which attribute they would most like to be improved, given that they cannot have the best level of every attribute. In short, priorities need to be set.

The aim of this study was to elicit the preferences of users and non-users (i.e. the community) for different models of out of hours care, and to examine the relative importance of attributes of out of hours care. The study uses a discrete choice experiment which has its origins in mathematical psychology, market research, and economics and has been developed as a method of examining preferences for attributes or characteristics of goods and services (Brunel University, 1993). Its application in health care is growing (Ryan, 1999).

Section snippets

Method

A postal questionnaire was developed which presented respondents with a number of pairs of scenarios, where each scenario described a particular model of out of hours care. For each pair, respondents were asked to choose which scenario they preferred (Fig. 1). The attributes for the scenarios were chosen from the existing literature and from face-to-face and postal piloting of the questionnaire (Table 1). Several studies have suggested that who the patient consults is important, as is the time

Results

Excluding those questionnaires that were not delivered (586), the final response rate was 3893/5718 (68.1%). Two questionnaires were completed by children and were excluded from analysis. Time to complete the questionnaire ranged from 2 to 60 minutes (mean 12 minutes), and 1760/3757 (46.8%) of respondents considered that the questionnaire was easy to answer. Characteristics of the respondents and their last out of hours consultation are presented in Table 2, Table 3.

For the regression analysis,

Discussion

The most important attribute was whether the doctor seemed to listen. This was independent of whether the patient knew the doctor, perhaps reflecting the real reason why other studies have reported low satisfaction with deputising services. This finding is consistent with other studies examining patient satisfaction with general practice and the doctor–patient relationship (Williams & Calnan, 1991; Savage & Armstrong, 1990; Wissow, Roter, & Wilson, 1994), with out of hours services (Scottish

Acknowledgements

Thanks go to Nicola Torrance for collecting data, and to the staff of G-DOCs and GEMS. Thanks also go to anonymous referees and Cristina Ubach for helpful comments. This project was funded by the NHS R&D Primary–Secondary Care Interface Programme. The Health Economics and Health Services Research Units are funded by the Chief Scientist Office of the Scottish Executive Health Department (SEHD). The views in this paper are those of the authors and not SEHD.

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