Rheumatology patient preferences for timing and location of out-patient clinics
K. M. J. Douglas1,
T. Potter1,
G. J. Treharne1,3,
K. Obrenovic2,
E. D. Hale1,
A. Pace1,
D. Mitton1,
N. Erb1,
A. Whallett1,
J. P. Delamere1 and
G. D. Kitas1,3
1 Department of Rheumatology and 2 Department of Audit, Dudley Group Hospitals NHS Trust, Dudley and 3 School of Psychology, University of Birmingham, Birmingham, UK
Correspondence to: K. M. J. Douglas, Department of Rheumatology, The Guest Hospital, Tipton Road, Dudley, West Midlands DY1 4SE, UK. E-mail: Karen.Douglas{at}dgoh.nhs.uk
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Abstract
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Objectives. To determine the preferences of rheumatology patients for the time and location of their out-patient appointments.
Methods. All patients attending the rheumatology out-patient services at Dudley Group of Hospitals NHS Trust over a 2-week period were asked to complete a purpose-designed, scannable, previously piloted, self-administered questionnaire.
Results. Four hundred and nineteen patients completed questionnaires (response rate 87%). Age ranged from 16 to 92 yr; 38% of responders were over 65 yr, 72% were female, 57% had an inflammatory arthritis, 20% had a connective tissue disease, 8% had degenerative joint disease and 15% had another diagnosis; 29% were employed, 51% retired and 20% unemployed. Fewer than 1% of patients would like to be seen at community general practice centres (99.3% would prefer a hospital site). Proximity to their home was the main determinant of hospital choice. Monday was the most popular day for appointments, and days from Tuesday to Friday received equal rankings. Only 0.5% of patients would choose a weekend clinic. Fifty-eight per cent of patients would prefer morning appointments, 24% afternoon appointments and 2% evening appointments; 16% did not mind. Only being employed predicted out-of-hours preference.
Conclusions. In this predominantly suburban, industrialized area, rheumatology out-patients prefer to be seen in the hospital rather than primary care environment, ideally close to their home, with appointments in the morning and on a weekday. These results may be generalizable to other districts and other chronic disease states, but we suggest that similar surveys become part of routine service provision and inform current and future planning.
KEY WORDS: Out-patient clinics, Proximity, Timing, Blood tests, Patient preferences
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Introduction
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Giving patients more choice about how, when and where they receive treatment is part of the Government's health strategy [1]. The Prime Minister has stated: ... the needs of the system have come before those of the patient. The result has been that it has been the hospital that decides when they can fit you in rather than the other way around. That is no longer good enough. People have busy lives juggling work and family. In today's world we book things to suit ourselves. I want the same principle to be at the heart of our new NHS. [2]. It is assumed that improvement of patient choice and access requires changes to current configurations of service provision. The out-patient department is being targeted for some of these changes. The new consultant contract offers the option of running clinics in the early evening and/or Saturday mornings [3]. This is promoted as potentially beneficial to individual patients (by increasing their choice), consultants (by increasing flexible working patterns) and the efficiency of the whole system of out-patient care delivery, particularly in view of space constraints in some new hospitals. Specialist clinics held in primary care settings may also relieve constraints while theoretically improving patient access. Planning and tailoring specialist services, as part of the modernization of the NHS, depend on an intimate understanding of patient needs in a local context. This study aimed to determine our patients preferences for the timing and location of their out-patient clinic appointments and identify predictors of these preferences.
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Methods
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Questionnaire and procedure
A self-administered questionnaire was designed specifically for this study, and after piloting a final version was formatted digitally. Nursing staff or an allied health professional (AHP) presented a questionnaire to all patients attending the rheumatology out-patient services over 2 weeks in the autumn of 2003 at the three sites of the Dudley Group of Hospitals NHS Trust: Corbett Hospital (CH), Guest Hospital (GH) and Russell's Hall Hospital (RHH). Completed questionnaires were anonymous and were returned to nursing staff or AHP in the clinic.
Participants
The response rate to the questionnaire was 87% (419/482 approached). Table 1 shows patient demographics and employment status. Of the total number of respondents, 44% attended CH, 46.5% GH and 8% RHH; 1.5% were unknown; 14% were new patients and 85% were follow-up appointments (five patients did not specify). Inflammatory arthritis was the most common diagnosis (55%), followed by connective tissue disease (19%) and degenerative arthritis (8%), 18% being unknown. Most respondents (75%) were attending an appointment with a rheumatology consultant, 6% a podiatrist or orthotist, 10% a physiotherapist and 7% a clinical nurse specialist, and in 2% it was unknown. Most people (72%) came to clinics in their own car; 16 and 5% came by public transport and taxi respectively and 2% came by ambulance. Fewer patients were joined by a companion (40%) than patients attending alone (60%).
Data management and statistics
Completed questionnaires were scanned by an independent audit officer using a FORMIC optical data capture unit (Formic, London, UK) onto an Access (Microsoft, Redmond, WA, USA) database with 98% accuracy. These data were transferred to an Excel (Microsoft) spreadsheet and a Statistical Packages for the Social Sciences database (version 11.0.5; SPSS, Chicago, IL, USA) for analysis. Bivariate analyses were carried out using odds ratios and
2 tests or Fisher's exact test when n
5 occurred in one or more cells; multivariate analyses involved logistic regression. In some analyses, age was split about an approximate median into the most comparable groups (age <55 vs age >55, with n = 167 and 252 respectively). Other binomial collapsed categories consisted of inflammatory arthritis vs other diagnoses, seeing a rheumatologist vs AHP, being employed vs being retired or unemployed, and coming by private car vs other forms of transport.
This was an audit collecting patients views on service provision and no sensitive areas were included in the questionnaire. Therefore ethical approval was not necessary. By voluntarily completing the questionnaires patients gave consent to their involvement in the audit.
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Results
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Patients prefer to attend the hospital site closest to their home rather than their local primary care centre
We asked patients which hospital they lived closest to and where they would ideally like to have their appointment: 75% would like to be seen in the hospital closest to their own home, 12.5% preferred another hospital site, and 11.5% had no preference. Only three patients (<1%) would prefer to be seen in their community general practice centre. Comparing patients who preferred to be seen in the closest hospital to their own home with other patients, more people seeing doctors preferred the closest hospital (78%) than people seeing other professionals (64%), giving an odds ratio of 2.04 [95% confidence interval (CI) 1.253.34, P<0.01;
2 test]. In the logistic regression, this difference by health professional was confirmed (Wald = 8.80, P<0.01). A significant difference in mode of transport was also apparent (Wald=4.46, P<0.05), such that more patients without a car preferred the closest hospital (82%) than those who travelled by their own car (72%), giving an odds ratio of 1.76 (95% CI 1.003.11). Identical results occurred with the uncollapsed variables. Of patients requiring blood tests, 48.5% would rather they were carried out while attending clinic.
Day of the week preference
Forty-seven per cent of patients did not mind which weekday they came to clinic. Those that chose a specific weekday more commonly chose Monday, though this did not reach statistical significance. Days from Tuesday to Friday received similar responses for preference (Fig. 1). Only two patients (0.5%) would prefer to come on Saturday; both were young males in employment. There were no significant differences identified when comparing these two patients with the others. No variable was associated with day of the week preference in the logistic regressions.
Time of day preference
Morning appointments were preferred by 58% of patients and afternoon appointments by 24%; 16% did not mind what time of day they were invited to attend. Only seven patients (1.7%) would prefer an evening clinic, all of whom did not mind on which day this was. Comparing these seven patients with the others, the only significant difference was in employment status. More people in employment preferred evening appointments (5%) than people who were retired or unemployed (<1%), giving an odds ratio of 14.71 (95% CI 1.75123.55, P<0.01; Fisher's exact test). This difference was confirmed as the sole effect in the logistic regressions (Wald = 6.36, P<0.05).
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Discussion
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The introduction of routine weekend and evening out-patient clinics within the British NHS is likely to occur in the near future. There is little data published in this area; however, the Department of Health in May 2000 carried out a national survey on how the NHS needs to evolve. Approximately 200 000 responses were received and included about 50 000 NHS workers. Appointment waiting time was the third commonest item that was brought up (26% of all responses), within which the third most common suggestion was to provide more flexible appointment times [4]. We set out to assess where and when rheumatology out-patients prefer to attend clinic appointments. Most patients preferred the nearest hospital to their home, few would prefer weekend or evening appointments, and Monday morning was the most popular time. This is likely to be the true preference, although order effects may have occurred. Randomized order of presentation of the days of the week in future studies would discount this possibility.
We identified only one comparable survey: Churchill et al. [5] reported results from an ophthalmology out-patients department similar to those obtained in our study: 89% of ophthalmology out-patients were content with the current system of service provision, and only 4% found appointments between 8 a.m. and 5 p.m. Monday to Friday inconvenient; in contrast, 48 and 66% would find Saturday and Sunday mornings inconvenient respectively. Weekday mornings were the most popular time for attending clinics irrespective of employment status. Sixty-three per cent of the retired population surveyed would not attend an early evening appointment and 81% would not after 8 p.m. It was suggested that lack of confidence about travelling in the dark and poor public transport were the major reasons. These factors might also be applicable to a rheumatology out-patient population that is characterized by varying degrees of physical disability. As in our study, more individuals in employment preferred the option of an early evening clinic (up to 8 p.m.) rather than any time at the weekend. Another issue raised by the paper by Churchill et al. was that patients with young children might find evening appointments inconvenient. Though we did not investigate this point, it certainly warrants consideration.
There are a number of reasons why our findings and those of Churchill et al. may not be generalizable to all populations or specialities. The hospitals surveyed in both studies were in urban/suburban areas with individual local characteristics, social status, attitudes and employment patterns that differed from other areas of the country. In our study, those in employment had surprisingly similar views to retired and unemployed patients. The Dudley area has a history of heavy industry, though now light industry and retail are commonest and people tend to work close to home. Their preferences may differ from, for example, patients working within an agricultural area, where distances are greater and working patterns different; or those within the commuter belt, who frequently do not work close to their local hospital. In these situations alternative clinic times may be preferred. The chronicity of illness may also be important. Patients attending a single appointment may have priorities different from those with a chronic disease, needing frequent visits. Our study found no significant difference between new and follow-up patients; however, the number of new patients was small and these findings may not be a true representation of this group's preferences.
There is a renewed trend for movement into the community and additional clinics outside the traditional hospital setting. In the past, the majority of outreach clinics in Britain were fuelled by general practice fundholding, and were driven primarily by health system rather than patient care interests. As fundholding declined in the late 1990s, so did the amount of outreach activity. From previous studies, outreach clinics may have benefits in terms of patient experience; however, specialists found outreach clinics inconvenient and inefficient, whereas general practitioners did not feel that they had the interaction with specialists that had been anticipated [6]. Rural areas are more likely to benefit from outreach clinics, and in many cases satellite clinics in old cottage hospitals continue to run successfully (closure of these is a separate but relevant issue). This setting may be different from that of primary care practices in urban/suburban areas, as it may provide access to associated services, such as phlebotomy, radiology and physiotherapy. Such facilities are uncommon in the primary care setting, so what patients may gain by attending a local clinic may be lost by the need to travel to the hospital for investigations and treatments. In our study, very few patients would prefer to attend a community-based clinic, though it is possible that this may be because they are content with the current situation and hence any change would be undesirable. Another reason for this may be that the area served is relatively small and densely populated, serviced from three hospital sites spread across the district; thus, patients rarely travel long distances for appointments.
An area not covered in our survey was the effect of the availability of adequate parking facilities. This would have been particularly relevant, considering that most of the patients travel to hospital using their own car. Inadequate parking has been identified as an important patient issue in a number of surveys [7]. In future studies it would be worth exploring whether the ease of parking out of routine hours would affect patient preferences about clinic timing.
Current government plans to extend the working week and move services into the community as a way of improving patients access and choice appear to be conceptually sound and, if appropriately resourced, may lead to improvements in service provision. Our study, however, together with that of Churchill et al., suggests that local results may be counterintuitive, so there is a clear need for local surveys before the large-scale implementation of political imperatives. We would suggest that such surveys become part of routine service provision and inform current and future planning.
The authors have declared no conflicts of interest.
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References
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- Department of Health, UK. Standards for better health. Health care standards for services under the NHS: A consultation: Fifth domain, D8. February 2004. www.doh.gov.uk
- Speech by the Prime Minister Tony Blair at the opening of the central Middlesex Ambulatory Care Centre. 2 December 1999. www.number-10.gov.uk/output/Page1464.asp (accessed 21/06/04)
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- Department of Health, UK. Analysis of responses to the NHS Plan public consultation. www.publications.doh.gov.uk/nhsplan/shiftinggearsanalysis.htm (accessed 21/06/04).
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- Gruen RL, Weeramanthri Ts, Knight SE, Bailie RS. Specialist outreach clinics in primary care and rural hospital settings (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, 2004.
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Submitted 21 June 2004;
revised version accepted 6 August 2004.