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CHAPTER FOUR. AWARENESS AND USE OF SERVICES

Awareness of services

4.1 Modernisation of the NHS in Scotland has a focus on the development of services to improve access, and also to improve communications and the level of public involvement in service design. In the context of these developments, it was important to measure levels of awareness as low levels of knowledge about these services will not lead to more positive views of the NHS. The sample was asked about awareness of a range of eleven NHS services and initiatives in Scotland. Many of these reflected the modernisation of the health service through improvements to access (e.g. NHS 24, extended prescribing and having outpatient treatment rather than inpatient admission) and the extension of choice (e.g. for dates and times of appointments). Awareness would in turn reflect possible service usage.

4.2 The awareness levels were relatively high for six services or initiatives, with over half of the people questioned saying that they had heard of them. Awareness was rather lower for the remaining five services, notably for those connected to 'choice', with under a third of respondents claiming to have heard of them - see Figure 4.1.

Figure 4.1: Awareness of new or modernised NHS services

Base: all = 2600

4.3 The highest level of awareness was recorded for " being admitted for a day rather than staying overnight in hospital for minor treatment or surgery" (i.e. day case admission), with almost seven out of ten people questioned saying that they had heard of this service. Awareness was significantly higher amongst women than men (71% compared with 66%) but lower amongst the older respondents (65+ years) than all other age groups. Awareness was also relatively low among respondents in C2DE households. See Table 4.1 for more details.

Table 4.1: Have you heard of being admitted for a day rather than staying overnight in hospital for treatment or minor surgery?

Base: all = 2600

4.4 Almost two-thirds of people questioned (63%) said that they had heard of " nurses and other health professionals at your surgery who are trained to deal with a wider range of health issues so that you don't have to wait to see a doctor". Awareness was highest amongst women (66% compared with 59% for men), and amongst those living in ABC1 households, but it was the younger, rather than the older respondents who were the least likely to have heard of this service. Those whose overall satisfaction with the NHS was high (i.e. "very satisfied") were also more likely to have heard of this initiative than those with lower overall satisfaction levels. Awareness was higher in the least deprived areas than in the more deprived communities.

4.5 Nearly six in ten of the people interviewed were aware of " consultation with local pharmacist/chemist about minor health conditions and ailments". Again, women were more likely to be aware of this service than men (62% compared with 51%), and those in the ABC1 social classes were more likely to have heard of this than those in C2DE households (71% v 59%). Awareness was higher amongst middle-aged people (68% of 45-64 year olds) than either younger or older respondents.

4.6 Of all respondents interviewed, 56% had heard of the " Out-of-hours service offered by, or on behalf of, your surgery in order to see or speak to a doctor or nurse outside usual surgery opening hours". Women were once again more likely to have heard of this service (62% compared with 50% of men), as were those in the ABC1 social classes. As with pharmacist consultations, the middle-aged respondents were significantly more likely to be aware of this service than both the youngest and oldest people interviewed.

4.7 Just over half of those interviewed (53%) were aware of " NHS 24 - the 24-hour telephone health and advice service being introduced across Scotland". NHS 24 is being rolled out gradually across Scotland and, at the time of the survey, only about half of the population actually had access to this facility. The question was, however, asked of people in all parts of Scotland as media coverage, word-of-mouth, etc. could mean that respondents in non-NHS 24 areas had heard of the service (and perhaps even used it). This was indeed the case, though the awareness figures in the 'live' areas were higher than elsewhere (57% compared with 48%. More generally, women and those in ABC1 households were most likely to say that they had heard of this service, as were people aged 25-54 - see Table 4.2.

Table 4.2: Have you heard of NHS 24 - the 24-hour telephone health and advice service being introduced across Scotland?

Base: all = 2600

4.8 Some 53% of people interviewed were aware of the NHS having " more treatment available as an outpatient rather than having to be an inpatient" - this included 56% of women compared with 49% of men. Awareness varies by social class, from 68% of those in AB homes to 46% in DE households - see Table 4.3.

Table 4.3: Have you heard of more treatment available as an outpatient rather than having to be an inpatient?

Base: all = 2600

4.9 Over a third of people questioned (37%) had heard of " a telephone consultation about your health with a doctor, nurse or other health professional", and once again, awareness was higher amongst women (41% compared with 32% for men), and those in the professional and managerial (AB) social classes. A third of people (34%) were aware of " getting prescriptions from someone other than a doctor, such as a practice nurse", with those in AB households again being most likely to have heard of this facility.

4.10 Three in ten respondents were aware of " having a choice of appointment time in the NHS". In contrast to the services discussed so far, those in AB and DE households were most likely to be aware of this service - see Table 4.4. When looking at these particular results in relation to overall satisfaction scores with the health service, it is clear that those who said that they were "very satisfied" with their overall use of the NHS were significantly more likely to have heard of the availability of choice than those users who were "not satisfied" (39% compared with 17%).

Table 4.4: Have you heard of having a choice of appointment time in the NHS?

Base: all = 2600

4.11 Almost three in ten (28%) of those questioned had heard of " seeing a specialist at a local surgery or clinic rather than at a hospital", with the 16-24 year age group being more likely than any other age group to be aware of this service.

4.12 Just over a quarter (27%) of respondents were aware of " having a choice of where you can go to see a health professional or receive your treatment", and, as with seeing a specialist at somewhere other than a hospital, the younger age group (16-24 years) were significantly more likely to have heard of this service than any of the other age groups. Those in the ABC1 social classes were also more likely to be aware of this choice, as were those who were "very satisfied" with the NHS.

4.13 Awareness of these services/initiatives was analysed in the context of overall satisfaction with NHS services (i.e. with all of those used in the last 12 months). For a number of services, there was no difference when looking at awareness in the context of satisfaction with the NHS but in more than half of cases, those who had heard of a particular service were more likely to be very satisfied with their overall use of NHS services. This does suggest that some of the modernisation is impacting on satisfaction with the health service in Scotland. This was notably the case for:

• Consultation with a pharmacist
• Telephone consultation
• A choice of appointment time
• Choice of where to go to see a health professional
• More treatment as an outpatient than as inpatient
• Nurses and other health professionals being trained to deal with a range of issues

Use of services

Multiple use of NHS Services

4.14 As was the case in 2000, many people had used more than one NHS service in the past twelve months. For example, most people who had attended an outpatient clinic had been referred by their GP - hence 80% of all people attending an outpatient appointment had also seen a member of their PHCT in the past twelve months - see Table 4.5.

4.15 Other relationships between the use of different services can also be seen; for example, amongst those who reported receiving care at home, 84% had also seen a member of their local PHCT at the surgery, 64% had been to an outpatient clinic, and 54% had been admitted to hospital as an inpatient. In the case of those who been an inpatient in the last twelve months, 79% had seen a member of their local PHCT at the surgery and 69% had been to an outpatient appointment. This may reflect the need for elective admissions and post-operative checks or treatment. Table 4.5 below also suggests that those receiving home visits were most likely to have used other NHS services.

Table 4.5: Respondents who have used different combinations of NHS services

Base: all = 2600. OOS is the Out-of-hours service

4.16 Whilst the data does not tell us how many times people have used each service, it does examine the depth of usage in terms of the number of individual services that people had used in the last twelve months. It is most common for people to have used one service (32%), with just over a fifth (22%) using two services, and one in ten using three. In total, 9% of respondents had used four or more services. By contrast, a quarter of respondents had not used any NHS services at all in the last 12 months.

4.17 As with the usage of individual services (though to a lesser extent than in 2000), multiple usage of the NHS is linked to both sex and age - women, for example, were more likely to be multiple users than were men. However, usage by women was strikingly consistent by age, whereas male usage increased markedly with age - see Figure 4.2.

Figure 4.2: Multiple use of NHS services:

Base: all = 2600

4.18 The youngest age group (16-24 years) were predictably the most likely not to have used any NHS services in the past twelve months, whereas those aged over 75 were most likely to have been multiple users. Younger men (aged under 35) were notably less likely to have used any NHS service in the last year. Those who rated their health as bad were most likely to have used more of the main services - Table 4.6 shows that there is a steady increase in service usage with self-reported poor health.

Table 4.6: Usage of multiple services by own health status

Base: all = 2600

NHS 24

4.19 Of those who claimed to be aware of NHS 24, one in five had actually called the service at least once in the last twelve months. Usage was notably high amongst those who had also used an NHS Out-of-hours service - there may be some further potential here for reducing the demand on such resource-intensive services once the telephone advice facility is extended throughout Scotland (and promoted more widely). About a quarter of those in the 'live' areas who had heard of NHS 24 said that they had called it in the last year - see Table 4.7. Based on the areas in which the service was operational at the time of the survey, this means that 14% of the adult population of Scotland claimed to have called NHS 24 in the previous 12 months.

Table 4.7: Have you called NHS 24 in the last 12 months?

Base: all who have heard of NHS 24 = 1443

Pharmacists

4.20 Just over four in ten (42%) of those who were aware of pharmacist consultations had actually consulted with a local pharmacist about a minor health condition or ailment in the past 12 months. Women were more likely to have used this service than men (46% compared with 36%), as were those aged 25-44 compared with people of other ages - see Table 4.8.

Table 4.8: Have you consulted with your local pharmacist or chemist about a minor health condition or ailment in the last 12 months?

Base: all who have heard of consultation with a pharmacist = 1579

Prescriptions from someone other than a doctor

4.21 About one in six people (17%) who had heard of getting a prescription from someone other than a doctor, such as a nurse, had actually used this service in the last year. Younger women (21%) were more likely than any other sex/age combination to have used this service than were men of any age (average 12%) - see Table 4.9.

Table 4.9: Have you had a prescription from someone other than a doctor such as a nurse?

Base: all who have heard of getting prescriptions from someone other than a doctor = 938

Overall usage of the main NHS service areas

4.22 Exactly three-quarters of people interviewed had used one or more NHS services in the last 12 months. Across the whole sample, two-thirds had visited their local surgery to see someone from their Primary Health Care Team. More modest numbers were recorded for use of the other NHS services that were examined in detail in this survey, although a third of the sample had been to an outpatient appointment in the last year - see Figure 4.3.

Figure 4.3: In the last 12 months, have you…

Base: all = 2600

4.23 Where these figures are comparable with those collected in 2000, the results are similar, with the exception of Primary Care where there has been a drop in the number of people who reported visiting the surgery. Alterations to the question wording may account for some of this change, although the extension of telephone consultation and the introduction of NHS 24 may have led to a drop in the number of people visiting surgeries.

4.24 As was the case in 2000, those who reported that they had a disability or long-standing illness, and those who rated their health as Fair or Bad, were more likely to have used one or more of each of these services in the past year.

Out-of-hours service

4.25 Two NHS initiatives that were not investigated in 2000, but which were included as part of this survey, were the Out-of-hours service, and telephone consultations. Women aged 16-54 and men aged 65+ were the most likely sex/age groups to have used an Out-of-hours facility, along with those with a limiting disability/illness and renters of social homes. A breakdown by sex and age is shown in figure 4.4.

Figure 4.4: In the last 12 months, have you used an Out-of-hours service…?

Base: all = 2600

4.26 The majority of the Out-of-hours users saw a GP (79%), though rarely their own family doctor (17%). In the context of the policy of modernisation, it is notable that 14% of these patients saw a nurse, with the remainder seeing another health professional, such as a locum.

4.27 In most cases (59%), patients attended a formal Out-of-hours clinic, although a quarter of people interviewed said that they were visited at home and a further 17% only spoke to someone over the telephone.

Telephone consultations

4.28 Women were significantly more likely than men to have had a telephone consultation about their health with a professional from their surgery (17% compared with 11%). More specifically, telephone consultations were most heavily used by women aged up to 64 - a fuller breakdown by sex and age is shown in figure 4.5.

Figure 4.5: In the last 12 months, have you had a telephone consultation in normal surgery hours?

Base: all = 2600

4.29 Most telephone contact (55%) was with the respondent's own GP or another GP from the surgery (14%) but, reflecting the changing professional boundaries, one in five calls involved a Practice Nurse and 7% spoke to another health professional (7%).

Primary Health Care Team at the surgery

4.30 As was reported in 2000, women (71%) were more likely than men (58%) to have been to the surgery to see a member of their local PHCT. However, this gender difference was not consistent amongst all age groups - men aged 55+ were almost as likely as women in this age group to have visited their surgery. The highest user figure was recorded for 16-54 year old women (74%, half as high again as for men in the same age group). The percentage of people using this service was lower in the four main cities than anywhere else in Scotland - see Table 4.10. The higher levels of contact for women and increasing contact for older men reflect the findings of the 1998 Scottish Health Survey on GP contact.

Table 4.10: In the last 12 months, have you seen a member of your local Primary Health Care Team such as a GP, practice nurse, health visitor or other health care professional at a local surgery?

Base: all = 2600

4.31 Reflecting the focus on improving local access, the surgery visitors had seen a wide range of health professionals though GPs and Practice Nurses in particular are mentioned most frequently - see Figure 4.6. The question is not properly comparable with the one used in 2000 but (in line with the modernisation agenda) it is very likely that there has been a significant increase in contact with the Practice Nurse. The previous survey asked respondents about their most recent surgery visit and only 4% of the 2000 sample said that the last person seen had been the Practice Nurse.

Figure 4.6: Which of the following people have you seen at a local surgery in the last 12 months?

Base: All who have personally seen someone at PHCT in the past 12 months = 1700

4.32 Women (64%) were significantly more likely than men (52%) to report that they had seen a Practice Nurse, or a Health Visitor. As the latter contact was highest amongst women aged 16-34 years, it is possible that some of these people saw Health Visitors for maternity reasons, in connection with contraception or through checks on women and children's health. Contact with the Practice Nurse increased with age (perhaps because of factors such as targeted flu jabs or routine blood-pressure monitoring) - see Table 4.11

Table 4.11: Which of the following people have you seen at a local surgery in the last 12 months?

Base: all who have personally seen someone at PHCT in the past 12 months = 1700

Home visits

4.33 When examining home visits, it can be seen that the usage is also following much the same pattern as in 2000, with women being twice as likely as men to have received a home visit (12% compared with 6%). Age, however, was the most significant explanatory factor; nearly a quarter (23%) of those in the oldest age group had received a home visit compared with just 6% of those in the youngest age group. Those living in the four main cities were less likely to have used this service than those living in other areas of Scotland, both urban and rural. Home visits were also more common amongst DE respondents than any of the other groups, though this may be partly a function of age because many people in these households are of pensionable age - see Table 4.12.

Table 4.12: In the last 12 months, have you received care at home such as from a health visitor, a GP, a District Nurse, a Community Midwife or other health professionals within surgery hours?

Base: all = 2600

4.34 Many (38%) of these home visits were made by the respondent's own GP, followed by another GP or locum (15%), a Practice Nurse (12%), a Health Visitor (11%) and a District Nurse (10%). The spread of health professionals involved in the home visits reinforces the diversity of involvement in primary/community settings.

4.35 The clear majority of these home visits (63%) were routine appointments, with approximately one-third being emergency visits. There were no differences among the various demographic groups.

Outpatients

4.36 The 2000 survey showed that women were more likely to have attended an outpatient appointment than men but the 2004 research shows that this is no longer the case, with 34% of men, and 33% of women questioned saying that they had had an outpatient appointment. These 2004 figures were similar to those recorded in the 1998 Scottish Health Survey. In terms of age, the 2004 findings mirrored those of 2000, and showed that people were increasingly likely to attend an outpatient clinic as they get older; four in ten of those aged 75+ had attended in the last twelve months compared with only one in four 16-24 year olds (Figure 4.7). The apparent differences by tenure shown in Figure 4.7 may well be a reflection of the age variation between the profile of owner-occupiers and renters - see discussion in Chapter 3.6.

Figure 4.7: Have you been to an appointment at an outpatient clinic in the past 12 months?

Base: all = 2600

Inpatients

4.37 In addition to being more likely to have attended an outpatient appointment, those living in social housing were also more likely to have been admitted to hospital as an inpatient (25%) than either owner-occupiers (15%) or those renting privately (13%). Those in DE households were the most likely to have been admitted to hospital, while those living in the least deprived areas had low levels of admission. There were also some fairly consistent trends by age, with the over 65s being more likely to have been admitted as an inpatient - see Table 4.13 for more details.

Table 4.13: In the last 12 months, have you been admitted to an NHS hospital as an inpatient, even if you went home on the same day?

Base: all = 2600

4.38 Just over a third (37%) of those people who had been admitted to hospital as an inpatient in the past twelve months were admitted as day cases. However, many admissions (41%) involved stays of more than two days but less than one week. In 15% of cases, the respondent was in hospital for over one week, but less than two, and in the remaining cases (8%), the stay was for two weeks or more.

4.39 Day admissions were more common among the under 65s than those aged 65 or over - they were also more frequently used by those from AB households than the other social classes. Those who rated themselves as being in very good, or good health were also more likely to have had day admissions rather than an overnight stay.

Summary

4.40 Awareness levels for the services varied widely and it is important to note that the figures are quite low in respect of initiatives to extend choice. However, a majority of people were aware of some of the modernisation themes, including NHS 24, nurses and other health professionals being trained to deal with a range of issues and being treated as an outpatient rather than an inpatient. In general, the highest levels of awareness were found among women and patients from ABC1 households. Echoing this point, many of the services examined here also showed higher levels of use by women than men, including Out-of-hours services, telephone consultation and surgery consultations.

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