Table 2.
Evidence for each programme theory
| Programme theory | Qualitative research | Existing theory | Quantitative research |
|---|---|---|---|
| 1. Uncertainty about symptoms causing anxiety: I am worried because I do not know what is wrong |
A decision to seek emergency or urgent care seemed likely when there was uncertainty surrounding the symptoms. This uncertainty manifested itself in various ways: where the cause of the symptoms were unknown,32, 33, 36 the symptoms were ‘different’ or more severe than previously experienced,37, 38 or symptoms lasted longer than expected.36, 39, 40, 41, 42, 43, 44 This uncertainty surrounding symptoms could increase the perception of risk that there might be something seriously wrong.36, 37, 39, 40, 45 This created a need for fears to be allayed by seeking reassurance that the problem was not serious and that the illness was being treated appropriately.33, 39, 42, 46, 47, 48
Uncertainty surrounding the cause of symptoms, and the need for reassurance, was particularly prevalent amongst parents of young children42, 46, 47, 48 who often have to rely on signs and behaviours of their children to ascertain what was wrong.39, 41, 42, 44, 45, 47
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There was considerable support for this programme theory from existing theories, as well as further understanding of how anxiety affects decision making. Leventhal's Common Sense Model49, 50 suggests that when experiencing symptoms, people form a ‘cognitive representation’ of their illness based on knowledge and experience. This representation is comprised of the identity, duration, cause, controllability and consequences of the symptoms and is used to determine the amount of threat it imposes and therefore what coping strategies or other help‐seeking action should be taken. Leventhal highlights that help‐seeking is more likely to be triggered when people are unable to fit their symptoms to a label, or when their initial identification is disrupted due to the symptoms unexpectedly changing or continuing. The role of uncertainty in decision making has been explored, defined as the inability to determine the meaning of illness‐related events or to accurately predict their outcome.51, 52 This can be due to a range of factors including lack of clarity in the symptom pattern, unfamiliarity of symptoms, or inconsistency with expectations. In addition, illness and pain have been found to impact on people's information processing, undermining their ability to make sense of their illness, further increasing uncertainty.51 In situations of uncertainty, coping ability decreases, whilst anxiety and a sense of threat are increased, all of which are likely to increase help‐seeking behaviour. Cameron highlights how anxiety is associated with more impulsive, habitual patterns of behaviour, less ability to identify alternative strategies of action and reduced capacity to take in advice and information.53 |
There was evidence from cross‐sectional surveys of service users at emergency departments and GP out of hours services that attendees were worried or anxious29, 31, 54 or perceived their problem to be serious.26, 55, 56 There was evidence that a feeling of helplessness was also an important mechanism for parents of young children.54 Surveys also highlighted that not all users expressed anxiety or thought their problem was serious.54, 56 |
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2. Heightened awareness of risk as a result of experience or knowledge of traumatic health events leading to anxiety: After what happened before I don't dare risk it, I don't trust myself |
The importance of past experiences and how these affected decision making was evident in the literature. There were indications that individuals were more likely to be anxious and more risk averse when they had experienced a traumatic event in the past,38, 42, 43, 48, 57, 58, 59 had experienced an occasion when the illness had been more serious than they first thought,44, 58 were aware of the adverse experiences of others,46, 59 or media campaigns/news stories had heightened awareness of potentially life‐threatening conditions.45
This experience or knowledge resulted in heightened awareness leading to a concern or belief that the illness could be a threat to life,38, 44, 48, 58, 59 a tendency to be over‐cautious, and fear and anxiety arising at the slightest of symptoms.43, 48, 58 Past incidents could have a subconscious effect.48
A traumatic incident in the past could lead to a loss of confidence and feelings of helplessness in their ability to diagnose and manage the illness, particularly for parents of young children42, 43, 44 who were considered to be more vulnerable.42 Fear or psychological distress created and increased the need to get help as quickly as possible60, 61 and a need to hand over the decision making to somebody with more expertise.43, 58 The psychological effect of a past health scare could also be seen in those with chronic conditions38, 44, 58 who were more likely to have experienced significant health events.44, 57, 59 |
There was considerable support for this programme theory from existing theories. As described in the previous section, Leventhal's Common Sense Model can be used to understand how people use their present moment experience and accumulated knowledge and beliefs to interpret their symptoms and decide on a course of action.49, 50 One key influence on these decisions is personal experience of a prior traumatic or life‐threatening event, or knowledge or awareness of such experiences in others in their social network. Once a situation is perceived as threatening, anxiety increases and Cameron identifies how an increased perception of danger prompts selection of risk‐averse options as well as a desire for diagnostic tests and a belief in their benefits.53 Even when no direct experience is present, Leventhal notes how the media can inform representations of illness,49 whilst Pescosolido emphasizes the influence of social norms in perceptions of illness and response to it.62 In this context, Beck's work on the ‘Risk Society’ suggests that people are operating within a risk‐based culture, which places emphasis on the responsibility to prevent problems before they arise.63, 64 Such a future‐orientated perspective and concern to avoid blame is likely to trigger early help‐seeking behaviour. |
None of the included quantitative research considered the effect of past traumatic events. As noted in the qualitative evidence, this issue may be something that is not necessarily apparent to the individual so may not be amenable to quantitative testing. |
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3. Fear of consequences when responsible for others: In my position, it's better to be safe than sorry |
The concept of ‘caretaker responsibility’ was specifically reported by Guttman41 who noted that the notion of responsibility was used as an explanation by parents in situations which they clearly did not equate with a medical emergency even though they were visiting a paediatric emergency department. Those with responsibility for making a decision on behalf of others seemed to be less tolerant of risk and more likely to err on the side of caution. This lower tolerance of risk and a ‘better safe than sorry’ attitude was implicit in much of the paediatric literature41, 42, 43, 45, 46, 47 and was related to feelings by parents of having a ‘duty of care’ to provide the best possible care to relieve any suffering. It was for this reason that expert opinion was often sought either at the paediatric emergency department42 or the GP out of hours.43
This low tolerance of risk was enacted under a societal expectation that risks should not be taken with a child's health36 and was endorsed by practitioners who stated that they preferred to trust parents' instincts and refer to the emergency department rather than risk a child's health.47 It was not only the consequences relating to the illness of the cared‐for person that were feared but also the feelings of distress and guilt that would result from not pursuing the best possible care.41, 65 This created an additional dilemma of balancing the guilt of not doing enough against that of being an unnecessary burden on emergency services.43
Although caretaker responsibility and having a duty of care were predominantly witnessed in the paediatric literature, this were also seen in relation to those responsible for elderly people and people with complex medical problems65, 66 and people in positions of responsibility such as teachers, employers, the police. Calnan et al36 found that there was a greater likelihood of a decision being made to seek help from the emergency department rather than general practice when that decision was made outside the home by people other than the individual or their relatives. In these instances, it was argued that the driver for the decision was the potential moral and legal consequences of not acting in the way commonly regarded as being appropriate.36 |
There was considerable support for this programme theory from existing theories. Leventhal identified that one of the important considerations of a person's self‐regulation of their health and coping behaviour was an assessment of the likely long‐term consequences.53 For parents and carers of vulnerable people the consequences of ‘doing the wrong thing’, that is not seeking help, could be both devastating and profound, both for the sick individual and the person responsible for their care. This sense of responsibility is increased within the ‘risk society’,64 with the increasing risk of legal action when mistakes are made and public scrutiny of the morality of individuals' decisions. In this context, social norms of caution predominate. Dixon‐Woods72 found that carrying ‘responsibility for others’ over‐rode a person's consideration of being ‘undeserving’, such that those who were responsible for the welfare of others (partners, elderly parents and children) felt an explicit sense of entitlement which justified ‘being demanding’. Dingwall noted that in contrast to adults attending with trivial problems, emergency department staff did not apply the same categorization of ‘bad patients’ to children brought for treatment, and that social norms meant they were automatically upgraded to ‘mandatory preciousness’.73 |
There was little evidence exploring this in the included quantitative research. There were tenuous links in that autistic children had higher rates of non‐urgent use of emergency departments.74 |
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4. Inability to get on with daily life: I need to get back to normal |
Evidence from qualitative research: The need to be able to function and get on with everyday life was found to influence whether a person sought urgent care,37, 67 most often in relation to work and/or child care responsibilities. The need to take care of social responsibilities meant that individuals used an emergency service at a point when they no longer felt physically able to discharge their responsibilities; this particularly related to looking after children. Stafford37 identified how the inability to perform these activities of daily living resulted in distress which motivated individuals to seek urgent care.
Support from existing theories: There was considerable support for this programme theory from existing theories. Both the Illness Action Model and Common Sense Model of behaviour50, 53, 68 propose that when faced with illness, individuals take action to regulate or manage threats to normality in physical and social functioning. Leventhal identifies the consequences of illness, including impact on function, as one of the key domains of illness representation,50 and Cameron's work using this model found the degree of disruption experienced due to symptoms to be an important trigger for help‐seeking.53 Interference with sleep has been found to be a significant influence in this context.69 Zola70 identifies five triggers for help‐seeking, including perceived interference with vocational or physical activity and perceived interference with social or personal relations and suggests that these factors are potentially more important than the stress of the illness itself in prompting help‐seeking. Underlying social and cultural norms will also significantly influence norms of behaviour. Zola highlights cultural differences in the significance of particular triggers to help‐seeking,70, 71 whilst Beck suggests that a social emphasis on individual responsibility encourages people to take action to maintain their health and working ability in order to avoid blame.63, 64 Support from quantitative research: This issue was not addressed in the included quantitative research. It is possible that it is labelled as convenience use of emergency and urgent care in this literature.28 |
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5. Need for immediate pain relief: It's urgent because it hurts |
The need for relief from pain as quickly as possible was prominent within the qualitative literature.33, 37, 41 Pain was not necessarily considered an emergency in terms of being ‘life‐threatening’0.41, 75 Rather there was a perceived need for urgent or fast care, sometimes defined as an emergency, to ease the pain and the distress it was causing.32, 33, 37, 41, 47, 58, 60, 67, 75, 76, 77
Caretakers found children in pain intolerable41, 76, 78 and Guttman41 found this to be one of the primary reasons for using a paediatric emergency department. This behaviour was associated with uncertainty about symptoms (programme theory 1), parental responsibility (programme theory 3) and ability to function, such as eating, sleeping and working (programme theory 4). It was sometimes reported that the person had first attempted to gain an appointment with their GP when experiencing pain33, 37, 67 and it was only when a timely appointment was unavailable that an emergency service, primarily the emergency department, was used. |
Leventhal's Common Sense Model50 suggests that pain or other symptoms trigger the development of a ‘cognitive representation’ or interpretation of the situation which then guides the individual's action. The model identifies one key dimension of this representation as the controllability of the symptoms and in a situation where pain is experienced as unmanageable, this is likely to trigger help‐seeking action. Leventhal also recognizes the significance of the emotional response to symptoms. In this context, Cameron notes that anxiety has been found to increase the painfulness of symptoms,53 which in turn is likely to further impact on anxiety, and thus on the mechanisms of decision making identified in programme theories 1 to 3. In relation to Andersen's model of health‐care utilization, Hodgins and Wuest28 found that severity of symptoms was a key reason given for emergency department use, with less willingness to wait being particularly associated with pain and injury. The social dimension of this is illustrated by Beck, who proposes that the development of a culture which promotes medicine as the solution to problems has led to reduction in the tolerance of pain or illness.64 | The need for pain relief was not addressed within the included quantitative research. |
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6. Waited long enough for things to improve: I can't delay this any longer, I need to deal with it now |
People described delaying seeking care, and would ‘wait and see’, often using self‐care methods, before accessing emergency services.32, 33, 40, 57, 67, 75 Reasons given for such a delay were varied and included a belief or hope that the problem would resolve itself over time, or deliberation and indecision about using primary care services appropriately or mistrust of the medical authorities.79 Complex and difficult living situations, particularly experienced by those with low economic status, could mean that dealing with day to day challenges (financial, employment, child care) took priority over health care.57, 76, 79 Additionally, due to work commitments during the day, decisions to seek care would often not be made until the evening when symptoms had deteriorated and/or anxieties increased, particularly for parents of children with fever.39, 78
One consequence of these delays was that help was only sought when the problem became physically or psychologically intolerable and there was then a need to get help quickly. Once people had waited and deliberated for some time, they made a decision that they had waited long enough and any further delay could not be endured.39, 44, 60 However, a timely primary care appointment might not be available,57, 66 leaving only the choice to attend an emergency department or contact an out of hours service. This was primarily reported in the parent/child literature.39, 44
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There was considerable support for this programme theory from existing theories. The duration of symptoms is identified as a key predictor of help‐seeking in both Andersen80, 81 and Leventhal's50 work, whilst Mishel recognizes how unexpected duration contributes to uncertainty and therefore influences decision making.51, 52 Leventhal's Common Sense Model suggests that there is a period of delay between the onset of symptoms and seeking help, during which the person appraises the symptoms and addresses the situation using ‘active problem‐solving behaviours’0.49, 50 It is only when their appraisal is challenged by symptoms continuing or worsening despite their actions that people interpret it as serious and seek help. This understanding is supported by Rogers et al who identify that, in most illness episodes, no external help is sought at all and the situation is managed through self‐care or waiting for it to resolve.82 Symptom duration is noted as one of the key triggers for finally seeking professional care (also identified in Programme Theory 1 as increasing uncertainty and anxiety), along with impact on function identified in Programme Theory 4 and coping capacity identified in Programme Theory 7. There is also a strong social dimension to delays in help‐seeking, with Zola identifying how people from different ethnic groups were eventually prompted into help‐seeking behaviour by a range of triggers.70, 71 One such trigger, ‘temporalizing’, where people decided to wait for a specified amount of time, was particularly associated with Anglo‐Saxon Protestant patients but did not significantly influence other groups. |
There was considerable support from cross‐sectional quantitative studies for people delaying attending services and trying to self‐manage problems: there was an increase over time in emergency department users who had waited a week or more before attending23; duration of symptoms was an issue for emergency department users55, 83; a survey of people with minor injuries in an emergency department identified a delay in help‐seeking31; 68% of people in an emergency department waiting room28 and 21% of febrile children attending a GP out of hours service54 had used over the counter remedies beforehand; people with illness waited longer than people with injury before attending an emergency department84;and 41% of non‐injuries in a paediatric emergency department arrived 2‐7 days after onset.56 In a comparative study, medically unnecessary users of GP out of hours had longer lasting problems than medically necessary users.29 |
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7. Stressful lives: I just can't cope with the illness or making an appointment |
The theme of distress and its impact on the use of emergency services was most evident in research conducted in populations of low socio‐economic status.57, 59, 67 Stressors experienced were of both a social and psychological nature included social isolation and limited social networks,43, 59, 67 single parentage,43, 57 problems with family and social relationships,67 grieving,67 housing and financial difficulties,57, 59, 75 being unable to afford to take time off work,46, 48, 61, 76 discrimination57, 75 and the traumatizing impact and disruption to life and work of long‐term medical problems.59 Implicit within this literature was that those dealing with distress in their daily lives had fewer material, social and health resources available to them, the absence of which were stressors in themselves. People thus had multiple responsibilities to manage with too few resources.48 Current levels of stress were often associated with past trauma of either a medical or non‐medical nature (see programme theory 2). Olsson et al59 noted how most participants had ‘struggled hard throughout their lives’ and highlighted the amount of ‘threat’ and ‘danger’ that featured in the narratives. Although they may make concerted efforts to cope, feelings of loss of control and helplessness lead them to seek emergency care. The emergency department was often accessed due to ease of use which was important in the context of stressful lives48 and could be regarded as a place of refuge and safety in times of distress.67
The perceived lack of social and health service support, particularly during the night, combined to increase people's feelings of vulnerability and stress.43, 78 Increased levels of anxiety and tiredness further hampered the ability to think rationally. Parents of young children were found to make frequent use of GP out of hours services at night,43 whilst people with complex stressful lives and with little social support were reported as frequent users of emergency services.43, 57, 59
People in distress could view the process of seeking a GP appointment as burdensome (see Programme Theory 10), or difficult to access due to financial difficulties or lack of transport.32, 57, 65, 75 Support from existing theories: |
There was considerable support for this programme theory from existing theories. Andersen identifies lack of coping capacity as a predisposing factor to health‐care utilization,80, 81 and Antonovsky highlights how coping is linked not just to the problem being faced, but to the resources available to a person to manage it.85, 86 The latter identifies a range of ‘Generalized Resistance Resources’ or characteristics which help people manage stressful situations including physical (eg health), material, cognitive and emotional, social support, and attitudes and coping styles. Antonovsky suggests that the availability of these resources impact on a person's tendency to see their life as more or less ordered, predictable and manageable, labelled as a ‘sense of coherence’. Those with a weak sense of coherence are less resilient and more likely to see stressful situations as threatening and anxiety provoking.85 Feelings of lack of control create helplessness, resulting in an inability to use the resources available and thus a reduction in coping capacity. The ‘candidacy theory suggests that in these circumstances people are likely to use services which present the least barriers to access.72 Gaining access to health care can be complex, and those who lack resources and competencies are likely to opt for more ‘permeable’ services, for example those which do not require appointments or a need to clearly articulate a problem in order to access help. In addition to the impact of anxiety discussed in programme theories 1 and 2, other work highlights how stresses including illness or time and resource constraints impact on the decision‐making process in a variety of ways. These include reduced sense‐making and problem‐solving ability,51, 52 increased likelihood of more spontaneous and less considered decisions,62, 87 and a greater sense of urgency and narrowing of focus to meet immediate short‐term needs.88, 89 |
There was some support for this in the included quantitative articles: people arriving at an emergency department by ambulance and classed as non‐urgent were more likely to be homeless and have mental health problems33; people who were more likely to use an ambulance in a hypothetical situation that did not require an ambulance had no car or they lived alone6; and 49% of parents of a febrile child who used a GP out of hours services felt helpless.54 However, not all the studies supported this programme theory. One review concluded there was little evidence for the association between personality, including coping mechanisms, and use of emergency departments4 and another that there was some evidence that affluent groups were more likely to go to an emergency department for minor problems.83 |
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8. Following advice of trusted others: That's what they said to do, and they know better than me |
The involvement of others in decision making to contact an emergency service was a strong theme that ran through much of the literature, particularly relating to emergency departments. This could be advice received either from family and friends32, 36, 39, 40, 44, 46, 65, 67, 77, 90 or from primary care services.32, 47, 48, 61, 67, 77, 90, 91 McGuigan et al40 stated that being advised by others, particularly family, was a common reason for deciding to attend the emergency department, with a tendency for advice to be sought by women; they referred to this as ‘sanctioning’. Research conducted in the Caribbean found that use of the emergency department was a socially shared custom in which family and friends encouraged the habitual use of the service,77 indicating cultural as well as individual mechanisms at play. Contacting trusted friends and family was conceived as a natural coping mechanism when in distress and indecisive about what to do.37, 67 Additionally, when feeling in distress, people were more likely to be receptive to the advice of another.37
Whilst there was evidence that family and friends had the most impact on decisions regarding the use of emergency services,36, 40, 58, 90 health‐care practitioners were also influential in this decision‐making process. Primary care practitioners and staff were often described as having recommended attendance at an emergency department for both adults32, 67, 77, 90, 91 and children.47, 48, 61 Individuals were essentially given permission to attend an emergency department,41, 58 with the decision being sanctioned by another ‘trusted decision maker’0.41, 58 This in turn could influence and encourage future use of emergency services in similar circumstances to save time and ‘cut out the middle man’.58
There was evidence to suggest that, once advised to take this course of action, there were feelings of obligation to do so, even if it was not considered appropriate, particularly where children were concerned (see Programme Theory 3). It was also noted that individuals may have felt pressurized by others into contacting an emergency service when they would not have ordinarily done so.36 In turn, the advice given by others may be influenced by their perceived moral and legal obligations and thus they advise the least risky course of action (see Programme Theory 3). |
There was considerable support for this programme theory from existing theories. Social and cultural influences on health behaviour have received greater acknowledgement in later formulations of both Leventhal's Common Sense Model49, 50 and Andersen's Model of Health‐care Utilization.80, 81 Pescosolido62 places the most emphasis on the social context in which people operate, highlighting how illness beliefs and behaviours are influenced both by individual social networks and the social structure. These influences can be both direct and indirect. Direct influence takes the form of being advised on a particular course of action by peers or by health‐care professionals, with some groups having more ready access to the latter due to their social and economic characteristics.72 Pescosolido also notes how people are most likely to adopt a behaviour if they know others are doing the same, particularly when those people are similar to themselves and that those in dense social networks appear more likely to delay help‐seeking, but people are more likely to have an ‘avoidable visit’ if they have consulted family members.62, 87 |
Cross‐sectional quantitative studies offered evidence to support people following the advice of family and friends, and of health professionals—especially general practice—when attending an emergency department. The most frequent reason reported for attending an emergency department was following the advice of others.30 Family and friends offered advice to 31% of emergency department attenders,24 and 52% had discussed their febrile child with others before calling a GP out of hours.54 It was also common to follow instructions from primary care staff: 27%,25 26% 24 and 66%56 were referred to an emergency department by a GP, with the proportion unclear in other studies.4, 31, 55 There was also some evidence that people went straight to the emergency department because they felt the GP would send them there anyway.31 |
| 9. Perceptions or prior experiences of services: I'll get a better and faster service from the hospital/ambulance |
Emergency services were often accessed because people believed that primary care lacked the necessary care, expertise or resources to provide good quality care. This could be due to a generally held belief, sometimes acquired from family and friends,32, 65, 77 or based on past personal experience.36, 41, 42, 46, 47, 57, 61, 65, 66, 76, 77, 91, 92 Patients reported being dissatisfied with general practice for a range of reasons: perceived inadequate care or misdiagnosis36, 41, 47, 66, 77, 78, 92; the short amount of time spent with the doctor and/or lack of thorough examination, particularly where children were concerned42, 46, 61, 77, 78, 91; not feeling listened to41, 57; failure to answer questions47, 78; or not being taken seriously.41, 57 Such experiences could lead to a lack of confidence and trust in general practice41, 47, 66, 76, 78, 79 and the use of an emergency service, particularly emergency departments, to obtain a second opinion.36, 41, 46, 57
Conversely, emergency departments were accessed because of a belief that they were the best or most appropriate place to be due to the availability of expertise or resources such as laboratory tests, X‐rays, etc33, 40, 41, 42, 46, 47, 61, 66, 75, 76, 77 Again, this perception could be due to past personal experience or a culturally held belief perpetuated by friends and family. Having both access to resources and the expertise of emergency department practitioners meant that patients had trust and confidence in the service and hence felt safe.41, 58, 76 This seemed to be especially true for parents42, 46, 47, 61, 76, 78 and for those with chronic conditions58, 90 where familiarity and previous experience played a part in the decision making when feeling anxious.41, 58, 66
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There was considerable support for this programme theory from existing theories. ‘Recursivity’, or the influence of past experiences of services on patterns of future use, can result in poor experiences of care either reducing use of a service or increasing it in the desire to obtain resolution of a problem.82 Andersen identifies satisfaction with services as predisposing factor to health‐care utilization, and recursivity is introduced as a key element of later iterations of the behavioural model.80 Other authors93, 94 also emphasize the role of habit within decision making, whereby once a pattern of behaviour is established, this is likely to continue, particularly where elements of the situation are familiar due to past experience. Experience may also come from sources other than direct contact with a service95 through ‘mediated experience’, where information is obtained and internalized from people's social network and media portrayals, and ‘imagined services’, where perceptions are based on wider cultural assumptions of the nature and quality of service provision. This is in line with Pescosolido's work, which argues that all actions are taken within a social context and cannot be understood without recognition of this.62 They identify how three systems interact to influence an individual's response to their symptoms: their individual social context (including social characteristics and prior experience of illness and services); their personal social network (including beliefs and attitudes, interactions with others for advice); and the treatment network (including the organization of health care and ease of access to treatment). In relation to the organization of services, their ‘permeability’ or ease of use impacts on people's decisions.72 In particular, those who are disadvantaged are likely to select services which are perceived to present least barriers to those with challenges such as low literacy, difficult time management or an inability to clearly articulate their needs. |
There was considerable support from cross‐sectional quantitative articles for the attraction of the tests available and the quality of care at emergency departments. Some studies were vague by describing a belief that an emergency department was required 84 but others identified specific attractions of this service including providing a ‘one stop shop’ for people with chronic conditions,96 the ease of getting tests and treatments,83 the preference for a specialist within paediatric emergency departments55 and the availability of X‐ray facilities. X‐rays were a key issue in that around half of people attending an emergency department thought they might need one24, 30 or they were a reason why people perceived a GP would not be able to help.25 Further support for this was the belief that emergency departments were better than GPs for injuries.31, 55 Concerns about poor quality general practice were largely related to lack of tests such as X‐rays and accessibility (see Programme theory 10). |
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10. Access to a GP—I can't get an appointment quickly enough |
The inability to obtain a timely appointment with a GP was a commonly reported reason for contacting an emergency service.33, 37, 42, 61, 66, 67, 76, 91 Whilst this could be a perception that they were unlikely to be able to get an appointment based on prior experience,46 it was commonly reported that people had first attempted to gain an appointment with their GP and it was only when a timely appointment could not be obtained that an emergency service, primarily an emergency department, was used.33, 37, 42, 61, 66, 67, 76, 91
There were indications that the inability to get an appointment when feeling ill and distressed could exacerbate existing feelings of anxiety and stress, leading to panic, and further increase the perceived need to get help quickly.65, 66, 67 High levels of anxiety could in turn exacerbate pain.37, 60
The inability to obtain an appointment and the complexity of appointment systems could lead to feelings of frustration and anger and an increased propensity to use an emergency service.33, 37, 42, 47, 61, 65, 76 This was particularly reported in the literature relating to parents with an ill child.42, 47, 61, 76 Frustration was also a factor amongst those with English as their second language who had difficulties communicating their requirements over the telephone when trying to get an appointment. In this situation people felt they had little choice but to make use of an emergency service, that it was ‘unavoidable’ and used as a ‘last resort’ because there was ‘nowhere else to go’58, 65, 67, 76 When feeling ill and in distress, with no timely GP appointment available, the emergency department was considered the most accessible service.41, 58
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There was considerable support for this programme theory from existing theories. Anderson highlights how availability of services is a key enabling factor in people's utilization of health care, and in later work places increased emphasis on the role of differential access to services as a determinant of behaviour rather than the characteristics of the individual.80 This Programme Theory is a factor in many of the other Programme Theories and therefore many of the exiting theories discussed in the previous nine Programme Theories have relevance here. | There was evidence from cross‐sectional studies that perceived or actual difficulty accessing a GP in the time frame required by patients affected their use of emergency departments and GP out of hours services. This included unavailability of a GP,24, 28, 31 19% being dissatisfied with GP appointments,23 negative perceptions of GP access,4 worse in‐hours access associated with GP out of hours use,97 difficulty accessing a GP in terms of getting an appointment,83 or not wanting to wait for a GP appointment for 12 hours or two days.96 Lack of access was sometimes due to the time of day, that is the primary care facility was closed,98 and unwillingness to wait for an appointment (see Programme Theory 6), as well as inability to get an appointment. In some studies, a sizeable minority of patients had attempted to contact the GP before going to an emergency department or GP out of hours service: 20% of those presenting in‐hours to an emergency department had been unable to get a GP appointment,25 and 25% had sought care from a GP.84 However, this percentage was lower in some studies: 8% reported poor access to a GP.29 Patients from deprived communities identified having more problems with access to a GP in working hours.99 |