A patient led NHS: managing demand at the interface between lay and primary care
BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7147.1816 (Published 13 June 1998) Cite this as: BMJ 1998;316:1816
- Anne Rogers, reader in sociologya,
- Vikki Entwistle, research fellowb,
- David Pencheon, consultant in public health medicinec
- aNational Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL,
- bNHS Centre for Reviews and Dissemination, University of York, York YO1 5DD,
- cInstitute of Public Health, University Forvie Site, Cambridge CB2 2SR
This is the second of five articles on ways of managing demand for health care
People currently deal with many, if not most, health problems without consulting the health service. Relatively small decreases in these self care behaviours or increases in the accessibility of services could produce large changes in demand for formal care. We believe that scope exists for the health service actively to promote self care and improve the way it responds to people's illnesses so that needs are met efficiently in appropriate and acceptable ways. This may mean both encouraging demand for some forms of care — for example, for problems where early intervention is desirable and promoting self care for other problems. We examine particularly how the NHS should support self care as a way of managing the demand for formal health care.
Summary points
Knowledge, culture, attitudes, experience, and healthcare organisation are the key determinants of when, why, and how people access formal health care.
To ensure the most appropriate demand on the health service, the NHS needs to encourage some demand and promote alternative ways of managing other demand.
This can be done by building on the ways in which people already take responsibility for managing their health and illness
Information that is relevant, accessible, meaningful, and integrated with other formal care is important
So is a culture in which risk, responsibility, control, and uncertainties can be discussed and shared between providers, funders and users
More graduated access to the system should be offered, through a single point of entry-triage
Patterns of self and informal care
Informal and self care constitute an important but often hidden aspect of the supply of health care. Ordinary people are providers of care. They have experience of caring for themselves and others and regularly provide advice about, and take responsibility for, matters of health and illness.1 The extent and nature of available social networks affects levels of both advice and informal support.2Self care can act as both an alternative and a supplement to formally provided care.3 Once people have recognised their symptoms they have the following range of options before and beyond seeking a professional consultation.
Doing nothing about symptoms may be unwise neglect, but it may also be a positive, appropriate, and logical first response to an illness,4 both acute-temporary and long term.5 A subsequent decision to act tends to be precipitated by the actions or advice of others or a change in the assessment of risk or the situation, or where the containment of illness is no longer possible.6
Self care without medication includes a wide range of practices including changing diet, using home appliances like massage pads, taking homemade remedies, starting an exercise regimen, rest, having a holiday, staying at home, and reducing (or increasing) regular activities. The type and degree of self care is influenced by social, economic, and psychological resources and attitudes and knowledge about health and illness.5 Older people use traditional home remedies more than younger people, 7 8 while homeopathic and herbal medicines have grown in populararity among 30-45 year olds.8Different and a wider range of practices are evident among some ethnic groups. For example, Jesson et al found that Afro-Caribbean respondents were more likely than Asian respondents to use traditional remedies and older respondents were more likely to use them than younger ones.9
Self care with medication is an important part of self care. Sales of non-prescribed, over the counter, medications in 1994 were the equivalent of one third of the NHS drug bill and were used to treat one in four symptoms.10 Homeopathic and herbal preparations are an increasing source of self medication for both acute and chronic conditions, and international trends towards deregulation of prescription only to over the counter medicines have increased the potential for lay choice in symptom treatment. Over the counter medications can reduce the need for primary care consultation, as, for example, with vaginal antifungal treatments.11 The increasing availability over the counter of other medicines, such as antihistamines and H2 antagonists, and of home testing kits will probably reinforce self care actions by some groups.
Some health professionals are worried that self and informal care may be inappropriate. Many working in the NHS fail to recognise and respond to the growing popularity of alternative therapies and may be unfamiliar with the rationales underpinning care that is not based on biomedical principles. A better understanding of the contribution of these types of care may help us develop better ways of managing demand.
Access and organisation of services
Primary care services (including accident and emergency departments) are most influenced by patients' decision making about when and how to access services. The organisation of primary care and the way patients make decisions strongly influence each other. Access to services is affected by many things: proximity to services with respect to social resources such as transport and child care12and financial resources (for those who cannot afford an over the counter drug a consultation is a means of getting it free13).
Accessibility is also related to how health care services are organised. For example, patients attending singlehanded practices are more likely to consult than those attending group practices.14 The availability and type of appointment system also influences service use. The perception of difficulties in obtaining appointments influences people's use of primary care services, and for these reasons, some people may choose to use an accident and emergency department.15 Different ways of offering same day access to general practitioners may prevent the need to access care out of hours,16 and some British general practitioners are even starting to offer an email query service or a dedicated period each day when they are available for telephone consultations.
Previous experience of illness and service use
Previous experience of services also influences subsequent demand and help seeking behaviour. The familiarity of symptoms, familial and personal history of illness, and experience of identifying and managing illness all form a backdrop to lay action and may affect the timing and type of self care and help seeking. Additionally, assessments of what can and cannot be done about a problem are based on people's prior service contacts and those of their friends and relatives. Patients and informal care givers learn over time how to fit into what health professionals require of them. They get a sense of what doctors consider to be legitimate illnesses and the way in which illness is responded to by health professionals feeds back into how illnesses are subsequently perceived and managed.17
The combination of personal knowledge and the way primary care is made available may limit the control people feel they have over their ability to delay seeking formal care or to self treat common ailments. Good evidence exists that prescribing antibiotics for sore throats does little to alleviate symptoms but it does enhance belief in the efficacy of antibiotics and make patients more likely to consult again.18
Conversely, unsatisfactory contacts with services, such as unsympathetic or fatalistic professional attitudes, may exacerbate patients' needs. While some patients who have been told that their problem cannot be treated may become reluctant to use services again for that problem, others may consult more in an attempt to resolve their problem.17
What can be done?
The role of information
People's views about self care and consulting behaviours are significantly influenced by their understanding of:
the causes, symptoms and outcomes of illness;
the roles and capabilities of different healthcare providers (including themselves);
the general processes and outcomes of different ways of prevention, diagnosis, and treatment;
the local availability of, and access to, services.
Information has an important role in making people aware of the healthcare options available and helping people appraise how best to help themselves. Many health care funders and providers now produce leaflets and advertisements to persuade people to adopt particular patterns of health care use (see box).
Examples of information intended to influence self care in the U
When should I call the doctor? Getting the most from your local GP services
This leaflet was produced by North Yorkshire Health Authority and distributed to all households. It covers various common health problems, giving suggestions for self care and indicating which symptoms warrant contacting a doctor or the emergency services. It tries to discourage use of out of hours services for non-urgent problems without dissuading people from contacting their doctors in real emergencies.
How to work with your doctor
The Royal College of General Practitioners led the production of this series of leaflets: How the family doctor service works; You and your GP during the day; You and your GP at night and weekends; Coping with minor ailments; and Getting the most from your pharmacist. The leaflets aim “to help people understand how the family doctor service works and enable them to get the best health care from their general practitioner.”
Heavy periods? You can get help
A leaflet produced by Buckinghamshire Health Authority and other local agencies. It emphasises that heavy menstrual periods are common and that there are treatments that can help (hormonal and non-hormonal drugs, and surgical options). It encourages women with heavy periods to discuss the problem and the treatment options with their doctor.
The motivations of information producers vary, as do their views of what constitutes appropriate self care and consulting behaviour. An increasing number of information campaigns aim to influence demand on primary care services. In the context of limited resources and a drive towards clinical effectiveness, many promote self care for minor conditions and encourage people to seek professional advice if they have symptoms of serious conditions or those for which effective treatments are underused. However, few of these campaigns have been rigorously evaluated. People are exposed to many competing and often inconsistent messages from diverse sources (see box). Also people vary in the way they interpret information about health care because they attach different meanings to language and symbols and understand illness within different belief systems. The credibility of information may be affected by the extent to which it fits with prior experiences of illness and health care and by opinions about the information producers.19 Moreover, getting good quality information to people as they face decisions about self care and consultation remains a challenge. Some of the organisations that produce consumer health information materials have narrow viewpoints or vested interests and do not always provide balanced information about the full range of relevant health care options.20 For example, leaflets produced by the pharmaceutical industry about prevention of heart disease may tend to emphasise the role of cholesterol; those produced by medical professionals about back pain may ignore the potential of osteopathy; those produced by mental health consumer groups with an antidrug bias may downplay the value of antidepressants.
Sources of health information that may influence help seeking behaviour
Family, friends, work colleagues, acquaintances
Community leaders, local people recognised as sources of health related advice
Self help groups and voluntary organisations
Consumer health information and advice services
Telephone help lines and high street and hospital information points
Health food retailers
High street pharmacists
Healthcare providers outside the official healthcare system (acupuncturists, chiropractors, herbalists, homeopaths, osteopaths, spiritual healers)
Healthcare providers within the official healthcare system (dentists, doctors, healthcare assistants, homeopaths, nurses, occupational therapists, physiotherapists)
Individuals associated with healthcare providers (relatives and friends of health professionals, medical receptionists)
Pharmaceutical companies
The media (news items, specialist health features, advice columns or programmes, health related episodes in dramas and soap operas)
However well produced, information is not the sole means of influence on help seeking behaviour. Providing people who consult about a common condition with information about the condition and the time it usually takes to recover from it may reduce the rate of consultation,21 but the detailed self care manuals produced by health maintenance organisations in America have had only a modest impact on the use of services. As well as information, changes in the pattern and delivery of services are needed as a means of better managing demand. Both information and services need to be more specifically orientated to the way in which people actually assess the need for care and the resources they have available to manage illness.
Changing professional-patient relationships
The model of health care in which knowledgeable and skilful doctors make decisions on behalf of their patients is being increasingly criticised,20 and more patient centred models of care in which patients play an important role in decisions about their treatment are becoming the norm.22 Doctors are now expected to share their knowledge (and ignorance and uncertainty) with patients, some of whom are already well informed about symptoms, diagnoses, and treatments. People vary in their response to attempts to share information, uncertainty, and decision making responsibility. Moves to encourage shared decision making between health professionals and patients may reinforce self care efforts and promote better use of both informal and formal healthcare services among some people. In others, however, such moves may increase anxiety and reduce confidence in both the individual and health professionals. Judging the extent of sharing information, uncertainty, and decision making responsibility which will best suit each individual is a major challenge in consultations.
Managing expectations
Satisfaction with a service depends on the degree of match between expectation and reality. Demand for publicly funded health care is never likely to be managed satisfactorily until we are explicit about how we decide what is funded, and for whom. Unless the issues are debated openly and communicated explicitly, people will understandably be unaware of what the NHS can and should provide. Being explicit about what is cost effective and available is clearly an important part of managing expectations (and thus demand).
Offering graduated access
Internationally the low cost of primary care in Britain and its open access are envied. However, the present configuration of services is not necessarily the most effective or appropriate way of meeting need. Out of hours visits by general practitioners are a particular point of tension where people are increasingly being told they must not call out the doctor “inappropriately” and are being made to feel guilty about the use of such services. At the same time doctors are seeking ways of reducing their commitment to providing out of hours care as a way of reducing their overall workload.
The most notable feature about the current system is the lack of a graduated service. A worried parent of a child with fever could be served by many other services before a doctor visiting the home is needed. There is a role for explicit self care manuals which are closely integrated with easily accessible advice and support over the phone. The next level of access might be a visit to the out of hours centre to see a nurse practitioner. Other ways of developing graduated access might be to build on the community pharmacy.13 Opening other direct access points and encouraging the development of mutual support and self help groups (perhaps based in primary care buildings) could also provide alternative sources of advice that form part of a system of graduated access from the informal to the formal healthcare sectors. This might form part of the commissioning and providing strategy of primary care groups and local health improvement programmes outlined in the recent white paper for England.23
If they are to be effective, graduated levels of access need to be based on models of service that are sensitive to people's needs and acknowledge that people's use of services is shaped over time. Meeting unmet health need as part of a positive demand management strategy also requires ensuring that resources and services are targeted at disadvantaged groups. Thus the introduction of a graduated approach to services must recognise the dangers of exacerbating or failing to address existing inequalities. For example, differences have been found in the nature and quality of advice giving provided by community pharmacies operating in different localities.24 The needs of black and other ethnic minority groups will also need to be taken into consideration in the development of telephone advice lines such as “NHS Direct.”25
Conclusion
Managing demand better at the interface between the public and the NHS will require three things:
Integrated informationabout self care closely integrated with health care;
Graduated access
Shared control — a willingness from both professionals and patients to share control, risk, responsibility, information, and decision making.
The last point requires a recognition of the responsibilities that people already have for their own health care and of the unequal resources that people have available to be able to respond to and manage illness.
Acknowledgments
With special thanks to Philip Hadridge.