Abstract

Background

In October 2009, NHS County Durham and Darlington introduced a single point of access telephone number for people requiring out-of-hours health care. We evaluated users' views and experiences of the service.

Methods

We used a validated questionnaire adapted for use in telephone interviews, with open-ended questions added to allow people to express their views. Interviews were carried out with 493 people who had used the urgent care line between April and July 2010 of 1626 telephone calls made, a response rate of 30.3%. SPSS 17.0 was used to analyse the quantitative data and Framework analysis the qualitative data.

Results

We found that (i) regardless of age or gender people who used the call line were satisfied with the service they received, (ii) the call line advised most cases to go to an urgent care centre, (iii) people who received advice other than that expected were still satisfied with the service. Criticisms of the service related to confusion about accessing the service and which number callers should use.

Conclusions

We found very high levels of satisfaction across all groups for a single point of access telephone number for urgent care. Clear information about the service, in particular that it will involve telephone triage and that access to a doctor or nurse is not immediate, may also resolve some instances of dissatisfaction. It appears that the service is effective in directing people to places where they can be dealt with appropriately.

Background

In recent years in the UK, there have been significant changes to the way in which health care is accessed out of working hours, including the introduction of walk-in centres and minor injuries units, changes to GP deputizing services and the introduction of telephone advice via NHS Direct. Previously, GPs provided round the clock care to patients on their list, although this system largely came to an end in 2004 with the new general medical services contract ‘investing in primary care’. After this time, responsibility for commissioning out-of-hours care passed to primary care trusts (PCTs).

The Department of Health strategy to reform emergency care published in 20011 included both improving public access to emergency care and minimizing workload for accident and emergency (A&E) departments by developing primary care alternatives for minor illness and injuries. In both cases, these new services were intended to be complementary to traditional GP and newer out-of-hours services. In order to access these services, it was recommended by the Department of Health in 20062 that people should be able to make a single call to a familiar number and be assessed and directed appropriately.

In response to these policy drivers, in October 2009, NHS County Durham and Darlington introduced a single point of access (SPA) telephone service, which allowed patients to ring a local number and, after going through a triage process, be given advice or passed to the service they needed. The SPA system was intended to improve and simplify access to non-emergency health care by providing clinical assessment at the first point of contact and routing customers to the correct service. It was a precursor to NHS 111, a system introduced by the Department of Health as a means of access to urgent care for those with health problems that were not severe enough to require an emergency 999 call, for which County Durham and Darlington were subsequently chosen as one of the three national pilot sites.

Urgent care is defined as ‘the range of responses that health and care services provide to people who require—or who perceive the need for—urgent advice, care, treatment or diagnosis’2 (p12). Those who require urgent care may utilize a choice of options, such as a telephone call followed by a visit to A&E or a walk-in centre, followed by admission as an in-patient or a subsequent visit to the GP.3

Key factors in patient satisfaction with out-of-hours or urgent care are ease of access, including ease of requesting care, telephonist's attitude, ease of getting a doctor to visit or of getting telephone advice and information about delays.4 Interpersonal aspects such as the doctor's attitude and the quality of care are also important. Mismatch between expectations and experience of care is strongly related to satisfaction with out-of-hours primary medical care5 (p336).

Telephone advice and triage may reduce immediate medical workload,6,7 but at a cost of patient satisfaction with telephone consultations8,9 and an increase in subsequent service use where patients are dissatisfied,10,11 patient satisfaction may be particularly low where patients expect a home visit but receive telephone advice instead12,13 or where response times are slow.14,15 Furthermore, some patient groups, such as the elderly, seem reluctant to make the initial call to access out-of-hours care because they do not want to make demands or because they are uncertain about the appropriateness of the call.16

In its first year, NHS Direct did not reduce pressure on NHS immediate care services, although it may have ‘restrained the increasing pressure’ (p153) on GP out-of-hours services.17 Although telephone consultations appear to be safe,18,19 other research suggests that telephone-based consultations for out-of-hours triage may not always be clinically adequate.20 Thus, there is a need for further research into patient satisfaction as well as use, cost and safety.

Aims

The aim of the study was to evaluate service users' experiences of the service provided out of hours by an SPA for health care, in particular the appropriateness, co-ordination (or fragmentation) and efficiency of care.

Research questions were as follows:

  • Efficiency—where were callers directed and what did they actually do?

  • Outcome and adherence—what was advised and did the caller adhere; if not, why not?

  • Acceptability—was the experience of the service acceptable and practicable? Were callers satisfied with the advice and the service as a whole?

  • System issues—were callers aware of how the system for urgent care worked and who to call?

Methods

Process

Contact details were provided by the North East Ambulance Service (NEAS) to the research team for callers who consented through the NEAS call handler to participate in the study. NEAS provides services for the whole of NHS County Durham and Darlington The research team then sent an information sheet to the caller describing the purpose of the research. Telephone interviews were conducted with callers soon after their encounter with the telephone advice service. Consent was reconfirmed at the start of the telephone interview, which was recorded. Interviews lasted on average 10 minutes.

All call handlers have a minimum of five GCSEs; they also complete the NHS Pathways Core Module One course which entails three pass/fail assessments.

Instrument

We adapted a validated postal questionnaire6 for use as a guide for our telephone interviews. Items related to the interviewee's experience of action taken as a result of their call to NEAS. We asked interviewees their gender, age and whether they owned a car; postcode data were provided by NEAS. Although the questionnaire largely collected quantitative data intended to answer the research questions set out above, the final question was an open question which asked whether the interviewee had any comments on or suggestions for improvements to the service.

Analysis

Socio-economic status was assessed using postcode data, by taking the quartiles of the index of multiple deprivation score.21 The quantitative data were entered in to a spreadsheet using SPSS 17.0 and where appropriate, responses were subjected to statistical analysis using chi-square test. The qualitative data from the final open question were fully transcribed and the Framework approach22 was used to carry out a thematic analysis of data from the open-response questions. Framework analysis is an approach to analysis developed for applied policy research, which allows the exploration of issues of interest as well as allowing for new issues to emerge. All transcripts were read by three members of the research team in order to identify themes and construct a framework; the framework was then applied to all transcripts systematically, and the team reviewed the transcripts and themes to ensure consistency and agreement of interpretation.

Results

Over the period of the study, 34 509 calls were made to NEAS. Of whom, 1626 (4.7%) agreed to be contacted for the purpose of research. We made 1626 telephone calls to potential study participants, resulting in 493 interviews (Fig. 1) (response rate of 30.3%). The number of potential respondents who declined was 318. A further 672 could not be contacted after three calls, and incorrect contact details were provided for 143 people.

FIGURE 1

Recruitment process

FIGURE 1

Recruitment process

Demographic data

The interviewee sample was representative of the NEAS caller sample in terms of age and gender (Table 1). The average age of callers interviewed was 44.3 ± 16.4 years [median 41.0, interquartile range (IQR) 31.0–59.0 years]. The age distribution of interviewees was bimodal, with a majority being in age groups 31–40 or 61–70 years. The average age of dependents (a person for whom the call was made) was 18.8 ± 26.9 years (median 5.0, IQR 2.0–15.8 years) (n = 212). The spread in age for dependents was also bimodal, with children aged 1–10 years and people aged 61–80 years having calls made for them.

Table 1

Comparison of the study sample to the NEAS caller sample by age and gender

 Study sample n (%) NEAS sample (N) % 
Calls made for an adult (≥20 years) 324 (65.8) 23 811 (69.0) 
Gendera   
    Male 104 (21.1) 13 597 (39.4) 
    Female 389 (78.9) 19 532 (56.6) 
 Study sample n (%) NEAS sample (N) % 
Calls made for an adult (≥20 years) 324 (65.8) 23 811 (69.0) 
Gendera   
    Male 104 (21.1) 13 597 (39.4) 
    Female 389 (78.9) 19 532 (56.6) 
a

For 1380 (4.0%) callers, gender was unknown.

The majority of interviewees were in the lowest (n = 173, 35.1%) and lower middle (n = 154, 31.2%) socio-economic quartile, with 13.6% (n = 67) in the upper middle quartile and 13.2% (n = 65) in the upper quartile. Of the interviewees, 98.8% were white British, which reflects the ethnic make-up of County Durham and Darlington PCT areas which is 94.0% white British.

Efficiency

Table 2 summarizes the distribution of what callers were advised to do. Nearly two-thirds were advised to go to an urgent care centre (UCC). UCCs treat injuries and illnesses that are not life threatening and do not require emergency treatment in A&E, but patients feel that they require prompt care. Only 14 of the 493 interviewees did other than advised by the SPA call handler: 5 went to a GP, 4 to A&E, 4 to an UCC and 1 went to a pharmacy. For seven of the eight who went to A&E or an UCC, the decision to do so related to the time they had to wait to be called back or to being told that a doctor would not be visiting them.

Table 2

Distribution of what callers were advised to do

 n (%) 
Go to a UCC 319 (64.7) 
Other (not advised to go somewhere) 56 (11.4) 
Wait for an ambulance 39 (7.9) 
Wait for a home visit 39 (7.9) 
Go to a GP 13 (2.6) 
Go to A&E 11 (2.2) 
Collect a prescription 10 (2.0) 
Go to a pharmacy 4 (0.8) 
Other (advised to go somewhere) 2 (0.4) 
Total 493 (100%) 
 n (%) 
Go to a UCC 319 (64.7) 
Other (not advised to go somewhere) 56 (11.4) 
Wait for an ambulance 39 (7.9) 
Wait for a home visit 39 (7.9) 
Go to a GP 13 (2.6) 
Go to A&E 11 (2.2) 
Collect a prescription 10 (2.0) 
Go to a pharmacy 4 (0.8) 
Other (advised to go somewhere) 2 (0.4) 
Total 493 (100%) 

Outcome and adherence

Satisfaction remained high regardless of whether the caller received the advice they had expected or not. For callers who expected a visit (a home visit or an ambulance), those who did not receive a visit (n = 14/18, 77.8%) were as satisfied as those who did (n = 21/22, 95.5%) (P = 0.093). Similarly, for callers who expected to be seen at a surgery or medical centre, those who were not advised to be seen (n = 16/19, 84.2%) were as satisfied as those who were (n = 150/159, 94.3%) (P = 0.096).

Acceptability

The majority of interviewees were satisfied with the call by all measures (Table 3). There were no statistically significant gender or age differences in satisfaction. People categorized in the lower (n = 36/158, 22.8%) and lower middle (n = 28/142, 19.7%) quartiles for deprivation scores were more likely to state that they would have preferred a visit from a doctor or nurse compared to people in the upper middle (n = 4/62, 6.5%) and upper quartiles (n = 6/59, 10.2%) (P = 0.012). Similarly, people without access to a car were more likely to express a preference for a doctor or nurse home visit (n = 30/101, 29.7%) than those with a car (n = 53/349, 15.2%) (P = 0.001).

Table 3

Satisfaction of callers

 n (%) 
Agree Disagree 
1. It was difficult to get through on the telephone 17 (3.4) 475 (96.3) 
2. There person who answered the phone gave all the necessary advice 459 (93.1) 31 (6.3) 
3. The person who took the message seemed to understand the problem 446 (90.5) 38 (7.7) 
4. I thought the call handler was right to give me guidance on the telephone 451 (91.5) 22 (4.5) 
5. I was unhappy with the telephone guidance I received 26 (5.3) 461 (93.5) 
6. I thought the call handler made me feel guilty about contacting him/her 11 (2.2) 481 (97.6) 
7. The call handler made me feel that I was wasting his/her time 12 (2.4) 479 (97.2) 
8. I think the call handler was a little rushed 10 (2.0) 482 (97.8) 
9. I would have preferred it if a doctor or nurse had spoken to me 82 (16.6) 317 (64.3) 
10. If possible, I would have preferred to have had a visit from a doctor or nurse 83 (16.8) 368 (74.6) 
11. The arrangements for contacting a doctor when the surgery is closed could be improved 167 (33.9) 302 (61.3) 
 n (%) 
Agree Disagree 
1. It was difficult to get through on the telephone 17 (3.4) 475 (96.3) 
2. There person who answered the phone gave all the necessary advice 459 (93.1) 31 (6.3) 
3. The person who took the message seemed to understand the problem 446 (90.5) 38 (7.7) 
4. I thought the call handler was right to give me guidance on the telephone 451 (91.5) 22 (4.5) 
5. I was unhappy with the telephone guidance I received 26 (5.3) 461 (93.5) 
6. I thought the call handler made me feel guilty about contacting him/her 11 (2.2) 481 (97.6) 
7. The call handler made me feel that I was wasting his/her time 12 (2.4) 479 (97.2) 
8. I think the call handler was a little rushed 10 (2.0) 482 (97.8) 
9. I would have preferred it if a doctor or nurse had spoken to me 82 (16.6) 317 (64.3) 
10. If possible, I would have preferred to have had a visit from a doctor or nurse 83 (16.8) 368 (74.6) 
11. The arrangements for contacting a doctor when the surgery is closed could be improved 167 (33.9) 302 (61.3) 

In total, 362 interviewees made a comment when asked for any comments or suggested improvements to the service. Of these, 97 (26.8%) commented positively about the service rather than making a suggestion for improvement, in particular, praising the attitudes and caring nature of the call handlers.

Everyone was really helpful and really nice and I was really distressed because I couldn’t breathe properly and everyone was just so nice and patient and kind. (98 female, 43, calling for self, car)

All I can say, I was treated with manners, respect, patience, nice telephone manners, everything about the service was fine. (173 male, 44, calling for self, car)

The most frequent comments, apart from those complimenting the call handlers, concerned the number of questions that the call handlers asked and the repetitive nature of the questions if the caller had been passed on. Interviewees tended to be aware that this was a necessary part of the process of ascertaining what kind of help was needed but found it frustrating:

I know it’s protocol what they’ve got to ask you but you go through 10 minutes of questions, you know when you’re in pain and you just want an appointment with your doctor, you have to go through all these questions. (199, female, 42, calling for self, car)

It also led to some people feeling that the call handler was not listening to them properly, which led to them getting annoyed:

It was just like the person on the end of the phone could not veer from that script that they had in front of them … I got very exasperated. (421, female, 33, calling for self, car)

System issues

The second most frequent group of comments concerned the length of time that it took to get through to speak to a call handler, and how long it took to be called back, usually by a doctor or nurse. Some people had been told that this may take up to 6 hours, which had alarmed them, only to then be called after 10 minutes.

Just trying to get through seemed to take a while and for us to get to speak to somebody and then having to have people phone you back. It just seems to take forever so a lot of the time now I would just go to urgent care because I can be there in the time it takes me to get through. (429, female, 30, calling for child, 9)

Waiting was a particular concern where people had called about a child, as they were worried about how quickly a child's condition might deteriorate:

Sometimes with the children we’ve waited a long time for the doctor to call. You’re not sure really whether you should be waiting or how long you can wait especially with children. (115, female, 38, calling for self, car)

Several interviewees wished to talk directly to a doctor rather than call handlers; this was linked to interviewees disliking having to give answers to the same questions more than once and having to explain their problem to more than one person:

You go through and speak to three people, the same thing, which it should just be them then straight through to a doctor or something. (464, male, 75, calling for self, car)

Interviewees were also concerned that they were not speaking to a ‘qualified’ person, qualified in this case meaning a doctor or nurse. They also wanted to have contact with their own GP, or, if not one particular GP, at least one from their practice. People who had chronic illnesses felt that it would be better for them if they could speak to someone who was aware of the issues related to their illness:

I think you should have been able to get a hold of your own doctor or someone who knew about it. (298, female, 52, calling for son, 20, no car)

As well as wishing to speak to a doctor, either immediately or earlier on in the process, a number of interviewees said that they would have liked a visit from a doctor and felt that doctors were reluctant to carry out home visits:

There is a reticence of the doctors to actually come and see you. (49, Male, 61, calling for self, car)

Sometimes the wish for a doctor to visit was linked to the circumstances of the patient, particularly where they did not have transport of their own or had small children:

It was at night and I had a baby in bed and they said there was nobody to come out and see us. (413, female, 25, calling for self, no car)

Other issues

Distance to travel, and lack of transport, was another issue, with several people commenting on the distance by saying they themselves had a car, but that it would be difficult for people who did not have access to a car. Travelling to the UCC at night was also perceived as a problem for many people, again particularly those who had small children or an elderly person who needed to be seen.

Discussion

The introduction of an SPA for urgent care achieved high levels of satisfaction among interviewees regardless of age or gender. We found that the urgency with which cases were handled and the time to wait for a call back were the major concerns expressed.

Most interviewees followed the advice they were given, which in most cases was to go to an UCC. Where people received advice other than that which they had expected, they were still satisfied with the service they received, contrasting with earlier findings that this was associated with lower levels of satisfaction.4 However, service purchasers and providers need to consider how patient expectations must be managed, as one of the more frequent comments about this service related to patients not knowing what to expect when they rang or feeling unsure about how the out-of-hours service worked.

Our study suggests that an urgent care point of access performs a similar function to NHS Direct, i.e. there is still significant medical workload in terms of visits to urgent care centres, but this is for the most part instead of attendance at a GP surgery.

General practices in the area of the study diverted their phone lines to the SPA number out of hours. This may account for the fact that most people interviewed were advised to go to an UCC. Nevertheless, most went as advised and it may have helped people avoid accessing multiple services. The recent introduction of ‘NHS 111’ may result in a more diverse range of end dispositions being offered than callers had considered. Our findings suggest that this may result in higher levels of out-of-hours referrals to UCCs as compared to referrals to A&E or to the GP. An evaluation of NHS 111 is currently being undertaken. Further study is required to evaluate the number of people who subsequently attend their GP or an A&E department after first attending an UCC. Where people attend minor injuries units subsequent use of health care services, particularly general practice, is common.23 A further study including follow-up could also assess whether an SPA access for urgent care results in changes in utilization of the range of urgent care services.

This paper adds to existing knowledge about the extent to which callers to an SPA follow the advice given. The study is limited by its low response rate (30.3%), and caution should be used to interpret levels of satisfaction. Although the random selection of callers to NEAS for inclusion in this study is a strength, the non-response rate indicates a possibility of bias due to self-selection by those who agreed to take part in an interview and who may have different experiences to non-responders. Follow-up study of non-responders was not possible with this study design.

Purchasers and providers should address patient expectations, in this case specifically by educating users on how the service works and what to expect. Clear information about the service, in particular that it will involve telephone triage and that access to a doctor or nurse is not immediate, may also resolve some instances of dissatisfaction. It should be borne in mind, though, when discussing reasons for dissatisfaction that the vast majority of those interviewed in this study were satisfied with the service they received and complimentary about the call handlers delivering the service.

Conclusions

Our study found high levels of user satisfaction that were consistent across gender and age groups. One key source of confusion, the number to call, has been resolved by the introduction of NHS 111. The other main issue for users who commented on the service was the number of questions that the call handlers asked. Clear information about the service, in particular that it will involve telephone triage and that access to a doctor or nurse is not immediate, may also resolve some instances of dissatisfaction.

Declaration

Funding: The Evaluation, Research and Development Unit is funded by NHS County Durham and Darlington PCT.

Ethical approval: Research Ethics Committee, School of Medicine and Health, Durham University.

Conflict of interest: none.

References

1
Department of Health
Reforming Emergency Care: First Steps to a New Approach
 , 
2001
London, UK
DOH
 
2
Department of Health
Direction of Travel for Urgent Care: a Discussion Document
 , 
2006
London, UK
HMSO
3
O'Cathain
A
Knowles
E
Munro
J
Nicholl
J
Exploring the effect of changes to service provision on the use of unscheduled care in England: population surveys
BMC Health Serv Res
 , 
2007
, vol. 
7
 pg. 
61
 
4
McKinley
RK
MankuScott
T
Hastings
AM
French
DP
Baker
R
Reliability and validity of a new measure of patient satisfaction with out of hours primary medical care in the United Kingdom: development of a patient questionnaire
BMJ
 , 
1997
, vol. 
314
 (pg. 
193
-
8
)
5
McKinley
RK
Stevenson
K
Adams
S
Manku-Scott
TK
Meeting patient expectations of care: the major determinant of satisfaction with out-of-hours primary medical care?
Fam Pract
 , 
2002
, vol. 
19
 (pg. 
333
-
8
)
6
Balas
EA
Jaffrey
F
Kuperman
GJ
, et al.  . 
Electronic communication with patients—evaluation of distance medicine technology
JAMA
 , 
1997
, vol. 
278
 (pg. 
152
-
9
)
7
Lattimer
V
George
S
Thompson
F
, et al.  . 
Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial. The South Wiltshire Out of Hours Project (SWOOP) Group
BMJ
 , 
1998
, vol. 
317
 (pg. 
1054
-
9
)
8
Salisbury
C
Postal survey of patients' satisfaction with a general practice out of hours cooperative
BMJ
 , 
1997
, vol. 
314
 (pg. 
1594
-
8
)
9
Leibowitz
R
Day
S
Dunt
D
A systematic review of the effect of different models of after-hours primary medical care services on clinical outcome, medical workload, and patient and GP satisfaction
Fam Pract
 , 
2003
, vol. 
20
 (pg. 
311
-
7
[Review]
10
Christensen
MB
Olesen
F
Out of hours service in Denmark: evaluation five years after reform
BMJ
 , 
1998
, vol. 
316
 (pg. 
1502
-
5
)
11
Hansen
BL
Munck
A
Out-of-hours service in Denmark: the effect of a structural change
Br J Gen Pract
 , 
1998
, vol. 
48
 (pg. 
1497
-
9
)
12
Salisbury
C
The demand for out-of-hours care from GPs: a review
Fam Pract
 , 
2000
, vol. 
17
 (pg. 
340
-
7
)
13
Egbunike
JN
Shaw
C
Bale
S
Elwyn
G
Edwards
A
Understanding patient experience of out-of-hours general practitioner services in South Wales: a qualitative study
Emerg Med J
 , 
2008
, vol. 
25
 (pg. 
649
-
54
)
14
Kelly
M
Egbunike
JN
Kinnersley
P
, et al.  . 
Delays in response and triage times reduce patient satisfaction and enablement after using out-of-hours services
Fam Pract
 , 
2010
, vol. 
27
 (pg. 
652
-
63
)
15
Gerard
K
Lattimer
V
Turnbull
J
, et al.  . 
Reviewing emergency care systems 2: measuring patient preferences using a discrete choice experiment
Emerg Med J
 , 
2004
, vol. 
21
 (pg. 
692
-
7
)
16
Richards
SH
Pound
P
Dickens
A
Greco
M
Campbell
JL
Exploring users' experiences of accessing out-of-hours primary medical care services
Qual Saf Health Care
 , 
2007
, vol. 
16
 (pg. 
469
-
77
)
17
Munro
J
Nicholl
J
O'Cathain
A
Knowles
E
Impact of NHS direct on demand for immediate care: observational study
BMJ
 , 
2000
, vol. 
321
 (pg. 
150
-
3
)
18
Gallagher
M
Huddart
T
Henderson
B
Telephone triage of acute illness by a practice nurse in general practice: outcomes of care
Br J Gen Pract
 , 
1998
, vol. 
48
 (pg. 
1141
-
5
)
19
Bunn
F
Byrne
G
Kendall
S
Telephone consultation and triage: effects on health care use and patient satisfaction
Cochrane Database of Systematic Reviews
 , 
2004
 
issue 4. Art. No.: CD004180
20
Derkx
HP
Rethans
J-JE
Muijtjens
AM
, et al.  . 
Quality of clinical aspects of call handling at Dutch out of hours centres: cross sectional national study
BMJ
 , 
2008
, vol. 
337
 pg. 
a1264
 
21
Noble
M
Wilkinson
K
Whitworth
A
Barnes
H
Dibben
C
The English Indices of Deprivation 2007:
 , 
2008
London, UK Communities and Local Governments:
22
Ritchie
J
Spencer
L
Bryman
A
Burgess
R
Qualitative data analysis for applied policy research
Analysing Qualitative Data
 , 
1994
London, UK
Routledge
(pg. 
173
-
94
)
23
Rubin
G
Unscheduled care following attendance at Minor Illness and Injury Units (MIU): cross-sectional survey
J Eval Clin Pract
 , 
2010
, vol. 
18
 (pg. 
100
-
3
)