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CHAPTER SEVEN. CHOICE IN HEALTH SERVICE PROVISION

7.1 One of the key objectives of modernising health services in Scotland is to increase patient choice. In October 2002, Malcolm Chisholm, the Health Minister, announced the introduction of a new service allowing patients to choose where in Scotland they want to receive hospital treatment, by picking the hospital of their choice on the basis of new waiting list and waiting time statistics, resulting in a more flexible NHS. From October 2003, patients across Scotland have been able to access information from the national waiting times database on the world wide web, which provides information on over 3,000 clinics in the eight key specialities of general medicine; general surgery; ophthalmology; ear, nose and throat surgery; urology; gynaecology; dermatology; and orthopaedics. Through this, patients are able to see waiting times for outpatient services at various hospitals and can, in consultation with their GP, choose where they wish to go to see a consultant, although there are currently some constraints such as the distance of the possible alternatives.

7.2 Other strands in the drive to offer greater choice to outpatients in their treatment include the Outpatient Action Plan, and the work commenced by the Centre for Change and Innovation (CCI) on Patient Focussed Booking, both in 2003, to allow people to have more say in the date, time and place of appointments, allowing them to fit their consultation into their personal circumstances. Patients are also being given a wider choice in terms of the professional who they can visit in order to receive their treatment, illustrated in the Primary Care arena by patients seeing a Practice Nurse or having a telephone consultation rather than a personal appointment with their GP.

7.3 All of these initiatives are part of the drive to reduce waiting times, including from 1 ^st April 2004, a 48 hour target for access to a Primary Care health professional, subject to certain criteria including clinical need. The 48 hour access guarantee was introduced toward the end of the fieldwork for this survey and it is not possible, or the aim of this survey, to assess the extent to which the target was being met prior to and on its introduction. The fact that some people waited more than 48 hours to see a health professional may reflect personal choice or an assessment of clinical need.

7.4 In order to explore whether patients were aware of, and satisfied with, the degree of choice they are being offered, questions concerning choice, waiting times, availability of appointments, and experience of having a choice of a date or time for their consultation, were asked of those who in the last twelve months had

• a telephone consultation,
• visited a health professional at the local surgery,
• had an Outpatient appointment
• or been admitted as an inpatient in the last twelve months.

7.5 Patients making use of Primary Care services were asked which professionals in the PHCT they had seen in the past 12 months. Patients were then questioned about their last contact with either their own GP, another GP at the practice (excluding a locum) or the practice nurse in order to provide robust data on patient experience of each of these members of the PHCT. In assessing waiting times for Primary Care appointments/consultations, a check was made to ensure that patients had not been offered and turned down an earlier appointment/consultation through choice. Triage arrangements were not specifically explored.

telephone consultation

7.6 Those who had a telephone consultation with a health professional from their local surgery were asked if this was offered within 48 hours of making the request, even if the patient then elected to wait longer to talk to the person of their choice. Nearly nine out of ten people (87%) said that they were offered a consultation within 48 hours, but one in ten said that they had to wait longer for a consultation - see Figure 7.1.

Figure 7.1: Were you offered a telephone consultation with someone from the surgery within 48 hours of asking, even if you then chose to wait longer to talk to the person of your first choice? If yes, how long did you have to wait?

Base: All who have had a telephone consultation in the last 12 months = 369

7.7 Men (14%) were twice as likely as women (7%) to say that they were offered a consultation beyond the 48 hour time period. Having to wait longer than 48 hours for a consultation is linked with lower satisfaction levels, both in terms of the individual service and overall use of the NHS. Those who said they were offered an appointment within two days were more likely to be very satisfied with the NHS (93%), whereas those who had to wait longer were less satisfied with their overall contact with the health service (73%) - see Table 7.1.

Table 7.1: Were you offered a telephone consultation with someone from the surgery within 48 hours of asking, even if you chose to wait longer?

Base: all who have had a telephone consultation in the last twelve months = 369

7.8 Only a small number of people questioned about a telephone consultation had to wait longer than 48 hours to speak to a health professional and the resulting base size is not large enough to allow disaggregated analysis of the time that they had to wait. However, the average wait was six days while most people in this group waited no more than 4.5 days.

primary care (own GP)

7.9 Those who had visited their own GP at a local surgery were also asked about the circumstances of their appointment. Nearly two-thirds (65%) of these people reported that they were offered an appointment with someone at the surgery within 48 hours of asking, even if they then chose to wait to see the person of their first choice. Nearly three in ten said that they had to wait longer than 48 hours for an appointment and a small number of people (4%) said that they actually requested a later appointment. While comparisons are made slightly difficult by changes to the questionnaire since 2000, there appears to have a been a real increase in the percentage of patients who saw their GP inside 48 hours (65% in 2004 compared with some 55% in the previous survey.

7.10 As with telephone consultations, there is a correlation between receiving an appointment within 48 hours and overall satisfaction with the NHS. Those who received an appointment within this time period were more likely to be very satisfied with both this particular contact and with the NHS overall than those who had to wait longer - see Table 7.2.

Table 7.2: Were you offered an appointment with someone from the surgery within 48 hours of asking, even if you chose to wait longer?

Base: All who were asked about their own GP = 707

7.11 Younger women (16-34) were more likely to have received an appointment within 48 hours than any other female age group, and the likelihood of women being offered an appointment within this time lessened with age- see Figure 7.2

Figure 7.2: Were you offered an appointment with someone at the surgery inside 48 hours of asking, even if you then chose to wait longer to see the person of your first choice?

Base: All who were asked about their own GP = 707

7.12 Some of the geographical base sizes are too small to allow individual analysis, but it does appear that those living in rural areas were more likely to have been offered an appointment within 48 hours (80%) than those living in urban areas or towns (62%). This might reflect the use of 'open access' where the practice does not offer appointments but sees all of those patients who attend the surgery.

7.13 The respondents who reported that they had to wait longer than 48 hours for an appointment were asked how long they actually had to wait. The waiting times varied from three days to over a fortnight, with an average wait of about a week. Small base sizes within the demographic subgroups make further analysis impossible to conduct.

primary care (other GP)

7.14 Just under six in ten people (59%) who were asked about contact with another GP were offered an appointment within 48 hours of asking but over a third (37%) said that they had had to wait longer. Again, availability of an appointment within 48 hours impacted upon overall satisfaction with the NHS, with people who had early appointments being more satisfied both with this particular contact and with NHS services overall - see Table 7.3.

Table 7.3: Were you offered an appointment with someone from the surgery within 48 hours of asking, even if you chose to wait longer?

Base: all who were asked about an other GP = 181

7.15 Beyond the 48 hour period, the length of time that people had to wait for an appointment varied from three days to more than 2 weeks, with the average being about a week.

primary care (Practice Nurse)

7.16 Six in ten people (62%) who had been to see a Practice Nurse said that they had been offered an appointment within 48 hours, while 29% had been offered an appointment after this time. Satisfaction scores varied according to whether or not an appointment had been offered within 48 hours with those people who had to wait longer being less satisfied with their NHS contact overall.

7.17 Waiting times for an appointment beyond 48 hours again ranged from 3 days to over 2 weeks, but in concurrence with own GP and other GP, the average waiting time was approximately one week.

outpatients

7.18 Almost half (48%) of respondents who had attended an outpatient appointment in the last twelve months said these had been arranged by a GP. The remainder were repeat visits arranged by acute sector referral.

7.19 Younger respondents (16-24 years) were most likely to have attended an appointment that had been arranged by their GP (72%) rather than as a result of an outpatient/inpatient referral, or repeat visit (28%). This pattern was reversed amongst those respondents in the older age group (75+ years) who were most likely to have attended an appointment that was a repeat visit, or arranged as a result of an acute sector referral (72%), rather than organised via their GP (28%).

7.20 Of those whose most recent outpatient appointment was arranged by their GP, 27% had discussed a choice of location for their appointment. These are modest figures in the context of modernisation and some improvement might be expected by the time of the next survey in 2006. Men (33%) were significantly more likely than women (22%) to report that their GP had given them a choice but the sample is too small to detect urban/rural differences.

7.21 Where patients discussed alternative locations for an outpatient appointment with their GP, family doctors were more likely also to provide information on the likely waiting times for appointments at different locations (66% compared with 52% who were given information on waiting times without discussing alternative locations).

7.22 In just over a quarter (28%) of cases, the GPs who were involved in the referral process explained that the outpatient clinic might offer patients a choice of dates or times for the appointment. This was particularly the case amongst 16-24 year old patients - see Table 7.4.

Table 7.4: And did your GP tell you that the outpatient clinic might offer you a choice of dates or times for the appointment?

Base: all whose last appointment was referred by GP = 411

7.23 Of all the people questioned who had attended an outpatient appointment in the past twelve months, nearly half (45%) agreed their own appointment time with the clinic. This question was answered by all outpatients, including those on repeat visits arranged at the clinic. Patient Focussed Booking will offer this choice more widely in the future. Older men reported having been given a choice more frequently than either younger men or women of any age - see Table 7.5.

Table 7.5: Did you agree an appointment date and time with the outpatient clinic or weren't you offered a choice?

Base: All who have been to an appointment at an outpatient clinic in the past twelve months = 856

7.24 A minority (14%) of outpatients experienced either cancellation, or alteration of their appointment time after it had been agreed - see Figure 7.3. Patient Focussed Booking should decrease the instances where patient appointments are cancelled, through its associated policies on planned leave.

Figure 7.3: And once your appointment was agreed, did the clinic cancel or alter the time of your appointment?

Base: All who have been to an appointment at an outpatient clinic in the past twelve months = 856

7.25 All outpatients were asked whether they were offered a choice of time and place, for their last visit. Four in ten outpatients (42%) who took part in this survey said that they had at least some choice about the time of their appointment, whilst a quarter (25%) said they had at least some choice over the place. In both cases, being given a choice seems to have a positive link with overall satisfaction levels with the NHS.

inpatient admissions

7.26 Just under one in five (17%) of those people questioned in the survey had been admitted as an inpatient in the past twelve months. More than half (53%) of these admissions were planned in advance, around four in ten (43%) were the result of an emergency admission, and the remaining 5% were maternity cases - see Figure 7.4.

Figure 7.4: Thinking about your last stay as an inpatient, was it planned in advance or was it an emergency admission?

Base: All who have been admitted as an inpatient in the last 12 months = 411

7.27 Among the elective patients, one fifth (21%) reported that their GP had discussed different places that they could go for their treatment. This was particularly the case for men rather than women (27% compared with 14%), but small bases sizes make other sub-analysis, for example by geographical location, unreliable.

7.28 As with outpatient visits, patients whose GPs had discussed different places where they could go for their treatment were more likely to give people an idea of how long they might have to wait to be admitted - see Figure 7.5

Figure 7.5: Did your GP give you an idea about how long you might have to wait to be admitted?

Bases: All whose GP did not discuss different places to go for admission = 174

All whose GP discussed different places to go for the admission = 42

7.29 Overall, just over a third (37%) of GPs explained to elective inpatients that they might be offered a date or time for admission. Men (45%) were significantly more likely to report that they had had this explained to them than women (29%) but this was the only significant demographic difference.

7.30 When it came to making an appointment for admission, nearly a third (32%) of inpatients whose admission was planned in advance said that they had been given "some" choice over the date and time of their admission, but two thirds questioned said that they had "no choice at all" - see Figure 7.6.

Figure 7.6: And did the admissions department offer you some choice over the date and time of your admission?

Base: All whose admission was planned in advance = 216

7.31 Some 12% of inpatients whose admission was planned in advance reported that their agreed admission date or time was amended in some way, either through cancellation or alteration. Admission date alterations were significantly more likely to be reported by men (15%) than women (5%).

Summary

7.32 Most people were getting an appointment inside 48 hours of making a request however about a third of patients were waiting longer to see a health professional at the surgery although this may have been through personal choice or lack of clinical need. Access to telephone consultation was notably quicker than for personal appointments. The 2004 survey shows an increase in access to a Primary Care professional within 48 hours compared with 2000.

7.33 The modest proportions of people who discussed options for outpatient appointments and inpatient admissions with their doctors suggests that there is still some way to go in terms of routinely giving people choice in the NHS. It can be inferred that patients often have a choice of date and time for an appointment when arranged with an outpatient clinic (e.g. a follow up appointment) but this is less likely to be the case for initial referrals by GPs. The findings show a positive correlation between choice and satisfaction with both individual services and the NHS as a whole.

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