Urgent care provision has recently expanded in England, resulting in patients struggling to choose appropriate services. A study has identified the different types of work they do in making a decision
Abstract
Urgent care typically describes healthcare for non-life-threatening conditions requiring prompt attention. Urgent care services have proliferated in England, and this wider choice has led to a complex landscape of urgent and emergency care, with blurred boundaries between different services. A study has examined the amount and nature of effort that service users undertake to make sense of urgent care and seek help from health services; it has identified three distinct strands of work, categorised as illness, moral and navigational work.
Citation: Turnbull J, Saville C (2020) Making sense of urgent care: how and why do people use health services? Nursing Times [online]; 117: 1, 37-38.
Author: Joanne Turnbull is a lecturer, Christina Saville is a research fellow; both at the University of Southampton.
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Introduction
Urgent care services are often not clearly defined but are positioned somewhere between general practice and emergency care (NHS England, 2013). Urgent care typically describes care for non-life-threatening conditions requiring attention on the same day or within 24 hours. These services are mainly designed to assess and manage unforeseen conditions ‘out of hours’, during evenings and weekends. In England, urgent care services include the NHS 111 telephone service; GP out-of-hours services; urgent treatment centres; and minor injuries units.
Urgent care provision in England has been expanded in recent years. For example, access to alternative services such as NHS 111 was introduced; this telephone service was designed to signpost people to the services most appropriate for their needs. This urgent care expansion was partly to address policy concerns of patient choice and improved access to care, and partly to manage demand for crowded emergency departments (EDs) (NHS England, 2013). Offering urgent care alternatives may increase the timeliness of treatment or offer more convenient, less burdensome options for patients. However, the urgent care landscape is somewhat fragmented and the near-continual reconfiguration and extension of services creates confusion.
Choosing between urgent (and emergency) care service options is complex, particularly when someone is ill or injured. Service users need to distinguish between ‘routine’, ‘urgent’ and ‘emergency’, and an array of available services that may vary according to the time and day of the week (Pope et al, 2019). Complex interacting factors influence why people use healthcare. Theories exist about psychological (individual) and social factors that help explain how people seek help from health services. However, the study described in this article focuses more specifically on the amount and nature of effort (described in this article as “work”) service users undertake to make sense of urgent care and how this shapes its use (Pope et al, 2019; Turnbull et al, 2019).
Study design
The two-year mixed-methods study was undertaken by the University of Southampton and collaborators at University Hospital Southampton NHS Foundation Trust and South Central Ambulance Service NHS Foundation Trust. It used the following methods:
- A literature review of policy and research evidence to compare how policy, health providers and service users define and conceptualise urgent care;
- Four citizens’ panels, with 41 panel members in total, to deliberate and agree on definitions of urgent care; one panel was with the Polish community, one with a wider service user group, one with health professionals, and one with clinical commissioning group staff;
- Serial semi-structured qualitative interviews to examine sense-making and help-seeking, which were conducted with three groups of service users who are high users of urgent care or face particular challenges in navigating healthcare; one group was people aged 75 and over, one was 18-26-year-olds, and one was people from eastern Europe.
Patient work: choosing, accessing, and navigating services
The amount, type and nature of the work undertaken by service users to make sense of urgent care was a key theme in the study’s analysis. Three related, but distinct, types of work were identified: illness, moral and navigation work, discussed below.
The study also identified that work can either be individual, shared or delegated across social networks of friends, family, and colleagues. This work varies by social context, such as family circumstances, and by time available.
Illness work
Illness work means assessing symptoms, need and risk. People make sense of illness by interpreting the severity of symptoms and their psychological state (Corbin and Strauss, 1985), assessing risks and making decisions about accessing services. The study found that symptoms that were perceived as sudden, unusual or serious, or that interfered with daily life (such as impaired mobility), often prompted people to seek help.
Uncertainty about symptoms often provoked anxiety. People reporting lower levels of anxiety tended to seek reassurance from NHS 111, but those who were more worried used an ED. Managing uncertainty about symptoms entailed risk assessment and management work. Participants sought reassurance from health professionals or members of lay networks to ‘be on the safe side’. NHS 111 was often a first port of call, particularly for younger people and participants from eastern Europe.
Moral work
Moral work describes the work that service users undertake to present themselves as an appropriate or responsible user of healthcare (Hunter et al, 2013). Service users were often conflicted between their desire to represent themselves as a credible patient and a desire to delegate illness work to health professionals. Moral work involved being a good self-manager, who takes responsibility for their own health and uses knowledge to manage risks, to enable ‘appropriate’ judgements about symptoms. Service users weighed up the risk of harm against the benefit of taking action.
Participants were keen to demonstrate their responsibility, providing examples of when they had not sought help. Many described themselves as copers who tolerated symptoms and used self-care; they felt that not accessing services was a sign of stoicism. Many service users were acutely aware that ‘unnecessary’ service use might deprive care from those ‘who really need it’.
Navigation work
Navigation work involved identifying and making sense of the range of services on offer and finding out how to access them. Service users made choices based on what was:
- Available, for example due to staffing, resources and technology;
- Accessible, meaning how easily it could be physically reached;
- Acceptable, for example due to convenient opening hours.
There was considerable confusion about when to access urgent care services. In contrast, there was greater confidence about the services provided in an ED; for example, participants mentioned that EDs had specialist facilities such as X-ray. Choosing to attend an ED maximised the chances that the facilities needed would be available, therefore avoiding the risk of a wasted journey.
One of the key drivers of service use was perceived waiting time. Urgent care services were viewed as available and more convenient than general practice, primarily because an appointment was not required.
Conclusions
This study illustrated the work involved for the public to make sense of and access urgent and emergency care services. The researchers distinguished between three distinct types of work: illness work, moral work and navigation work. Understanding this work may help move the focus from blaming people for ‘incorrectly’ making sense of health services and making ‘inappropriate’ decisions. Instead, patients need to be supported in their efforts to understand and access health services. People’s ‘wrong’ choices are usually not deliberate; they are a consequence of the work they do.
Recognising that different or additional work may be required for other groups, for example different age groups or migrant populations, can inform service design and signposting. However, this must be directed at the work these groups have to do. For example, some migrant groups have no experience of non-hospital-based urgent care. They need support to navigate this different care landscape.
At a structural level, the impact of the frequent reconfiguration of urgent and emergency care services on patient work should be considered.
Key points
- Urgent care provision has recently expanded in England, resulting in a confusing array of services
- Patients often struggle to differentiate between the options and choose an appropriate service
- A study has interviewed service users and reviewed literature to investigate how choices are made
- It identified that patients do ‘illness work’ by assessing symptoms, ‘moral work’ by assessing appropriateness, and ‘navigation work’ by assessing availability and accessibility
- This article is based on Turnbull J, Saville C (2020) Making sense of urgent care: how and why do people use health services? Evidence Brief; University of Southampton, August 2020. Reproduced under the terms of the cc-by 4.0 licence (creativecommons.org/ licenses/by/4.0). The project was funded by NIHR HS&DR programme grant number 14/19/16. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the HS&DR programme, NIHR, NHS, or the Department of Health and Social Care. The research was conducted independently of the funding body.
Corbin J, Strauss A (1985) Managing chronic illness at home: three lines of work. Qualitative Sociology; 8: 3, 224-247.
Hunter C et al (2013) A qualitative study of patient choices in using emergency health care for long-term conditions: the importance of candidacy and recursivity. Patient Education and Counseling; 93: 2, 335-341.
NHS England (2013) Transforming Urgent and Emergency Care Services in England. NHSE.
Pope C et al (2019) Navigating and making sense of urgent and emergency care processes and provision. Health Expectations; 22: 3, 435-443.
Turnbull J et al (2019) A conceptual model of urgent care sense-making and help-seeking: a qualitative interview study of urgent care users in England. BMC Health Services Research; 19: 481.
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