Department of Applied Health Research
Factors that influence patient and public
views about proposals for major service
change: evidence from the English NHS
Helen Barratt, Naomi Fulop, Rosalind Raine
Department of Applied Health Research
Background
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1Imison
Health care systems face the challenge of meeting rising
demand with diminishing resources
For policy commentators, decisions about organising
care involve ‘trade-offs’ between interlinked factors1
C. Reconfiguring hospital services. London: King's Fund, 2011
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Background
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In England, proposed service changes such as A&E
closures often face public opposition
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Government policy emphasises the role of clinical
evidence to convince the public of the need for change
Aim
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To examine whether patients + the public are willing to
accept the trade-offs involved in such decisions
Department of Applied Health Research
Study design
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In-depth interviews in two urban areas:
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Area 1: ‘Greenville’ – service changes proposed
– Parents of young children (n=5)
– Older people (n=6)
– Activists and patient reps (n=9)
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Area 2: ‘Hilltown’ – no changes proposed
– NHS patients with chronic condition (n=8)
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Analysis combined inductive and deductive approaches with
sociocultural perspectives of risk as an analytic focus
Interview flash cards
• Participants invited to select their priorities for A&E from a range of
flash cards
– Aspects they might be prepared to have ‘less’ of (e.g. quick access)…
– …if it meant having ‘more’ of another (e.g. consultant-delivered care)
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A local hospital to serve the local community
Good bus or tube links
Easy to park
Patients can choose which A&E to go to
Sick patients taken to A&E as fast as possible
Consultants on duty in A&E 24 hours a day
Patients’ care meets nationally agreed standards of quality
A&E convenient to get to for patients and their families
Findings
Four groups in terms of response
Group 1 (n=2/28):
• Willing to consider longer journey in an emergency
• Only Greenville interviewees in favour of change
• Both had close contact with medical profession
Group 2 (n=5/28):
• Rejected trade-off approach as overly simplistic
• Response would depend on variables including:
– Severity of the situation
– Additional distance
Findings
Group 3 (n=2/28):
• Challenged concept of making trade-offs in context of
health care
I don't think trading off... We should never ever have to trade-off
with national health services. It's okay to discuss it, but it's not
something that should be considered. Why don't they just upgrade
services all round? (Greenville Parent 4)
Findings
Group 4 (n=11/28):
•Perspective of majority of participants
•Unwilling to accept trading-off any aspects of care with
access
In extreme circumstances it could be the matter of between life and
death, couldn’t it? In an extreme situation, you know, taking your
child to hospital, minutes could be critical. So having a facility
further away is... No, it’s not ideal at all.... [Getting there] is
critical... I think having a facility nearby is essential, absolutely
essential. (Greenville Parent 2)
Risk
• Interviewees would be ‘frightened’ or ‘worrying’
• Unclear how to help a sick relative
• ‘Burden’ of caring passed on on arrival at hospital
• Implicit assumption: timely access = better outcomes
– ‘Every minute counts’ - time ‘is of the essence’
• Get to the ‘experts’ and ‘get seen quickly’
Health care is quite simple, I don’t feel very well, my wife doesn’t feel very
well, I want to get myself, my wife or my child to somewhere quickly
where someone competent can do a triage and say you’re dying, its
indigestion or we’re putting you in for surgery. (Greenville Activist 7)
Risk
• Douglas: risk = probability + probable magnitude of outcome
• Participants clear that probability small
–‘The really big stuff happens thankfully less often and might not even
happen at all’ (Greenville Parent 3)
• Public select a risk because they value what is under threat
–Risk = possibility of negative outcomes
• Travelling further for care constituted ‘unacceptable danger’
It's my life! I mean it could be my life... I may not die, but maybe they
could help prevent something worse happening. Prevent catastrophe,
maybe. (Greenville Parent 4)
Quality of care
• Quality of care = interpersonal quality of care
– Timeliness – ‘not having to sit around for hours’
– Attentiveness of staff - ‘having plenty of staff around’
• If an ED closes:
– ‘Double’ the number of patients will attend the alternative
– Staff would be ‘swamped’
• Technical aspects of care not ‘gains’ worth having
– Perception of little difference between hospitals (and doctors)
– Lack of clarity about role of consultants
Conclusions
• Clinical leadership + detailed explanation of case for change
were insufficient to overcome opposition in Greenville
• Most participants not prepared to travel further because of a
belief that timely access = better outcomes
• Participants perceived service consolidation would decrease the
safety and quality of care
• Participants held similar views in both areas, suggesting that
these perceptions are widely held
Conclusions
• Previous research has largely concentrated on policy issues
• No studies have formally examined the views of patients and
members of the public at large
• Little information to date on whether views vary within and
across populations
• Findings based on a single reconfiguration in an urban area
• Qualitative approach permitted in-depth exploration of public
response when discussions about change were ongoing
Implications for policy and practice
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We cannot assume that evidence will persuade communities to
accept service change
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Commissioners should:
• Make explicit plans to accommodate changes in patient flows
• Clarify the roles of key staff groups for the public
• Acknowledge local experience e.g. about public transport
Acknowledgements
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Prof Rosalind Raine
Prof Naomi Fulop
Dr David Harrison - ICNARC
Interview participants
Individuals who helped pilot topic guide + flash cards
Individuals who assisted with recruitment
Work funded by a Wellcome Trust Research
Training Fellowship (WT091024MA)