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Dr Simon Harbinson (GP),
Dr Ron Neville GP,
Dr Una MacFadyen (consultant paediatrician Forth Valley)


Since the change in the GP contract, general practitioners are no longer required to
provide 24 hour care for their patients, with the role now the responsibility of the
Primary Care Organisation.
Now, the process of phoning NHS direct (NHS 24 in Scotland) and speaking to a
receptionist, then a health professional who decides whether or where the patient
should be seen, starkly contrasts with the cultural tradition of being able to phone
ones own GP 24 hours a day in the expectation of an immediate home visit.
Changes in family structures and an ever-increasing consumer society with raised
expectations, has its own particular demands on the health service.

NHS 24 is arguably the envy of the world:- 24 hour a day, free, one stop, integrated
hospital and GP care, universally available with training standards and protocols.
There are however problems for patients and health professionals working in the
service. These include adjusting to the culture change, reception and nurse barrier to
GP access, lack of personal care and thus loss of clinical intuition, reliance on client
telephone skill and assertiveness to triage and screen calls effectively.
As the patients own health records are not currently available, this can provide an
extra challenge to the doctor or nurse treating a patient they do not know.
Health care professionals, patients and the media have voiced some strong opinions
on the service, but there is a lack of objective data
There is therefore a need for quantitative and qualitative survey. The under fives are a
high priority, as they are a vulnerable patient group with the potential for very serious
illness, associated with a high level of parental anxiety.

Pilot work included talking informally to parents during routine surgeries and baby
clinics and sending out 10 draft questionnaires to elicit parental experiences of using
Following this we identified children aged 5 or under, whose parents had contacted
NHS24 during the months of December 2005, January and February 2006.
We sent a questionnaire based on patient satisfaction surveys used by GP practices
and on a consumer questionnaire The questionnaire had 5 subsets: Access to Out to
Hours services, interpersonal skills, perceived quality of care, outcome and overall
Returned questionnaires were analysed/divided into deprivation subsets using
Carstairs social deprivation scores based on postcode. Patient groups were divided
into four subsets – most affluent, moderately affluent, moderately deprived and most
We then assessed overall satisfaction levels, social class variation in responses and the
percentage of patients who contacted friends or family before phoning NHS24. We
paid particular attention to low scores on the questionnaire, representing areas of
parental concern and dissatisfaction.

For in depth qualitative interviews, we constructed a sample matrix and interviewed
four parents. Two parents were from deprived areas and two were from affluent areas.
One parent had had a positive experience and one had had a negative experience from
each socioeconomic group. The interviews were semi structured and lasted for
approximately thirty minutes. Any emergent themes were recorded.


There were 101 recorded NHS24 encounters with children aged five and under in the
three month sample frame of Winter 2005/06, representing 86 children. 61 of these
were face-to-face contacts at the out of hours centre and 34 were recorded telephone
calls to NHS24 over the time period. Patient’s parents, phoning NHS24, described a
wide range of symptoms, the majority of which were viral type symptoms including
fever, headache, lethargy, off food and generally ‘not quite themselves’. (See table 1
and 2).
Only 3 parents were advised to take their child to accident and emergency and these
were all due to falls or accidental ingestion of potentially harmful substances. Those
patients examined, were medically diagnosed with a variety of conditions The
majority of these were ear, nose and throat or respiratory infections, presumed both
viral and bacterial. Four children were referred to hospital, three were due to severe
respiratory symptoms and one due to suspected appendicitis. The occurrence of
serious illness presenting was thus low.

A variation in response rates to questionnaires sent between different socioeconomic
groups was seen. Those families who lived in deprived areas, contacted NHS 24 most
and their response rate was lower, (See table 3 and graph 1)

Overall, parents were generally satisfied. 12 parents (30%)were completely satisfied,
17(43%) were very satisfied, 9(23%) were fairly satisfied, 1(2%) neutral and 1(2%)
were very dissatisfied.(graph 2) Despite this, there were many areas within access;
interpersonal skills and quality of care were patients were dissatisfied.
There were three main areas where parents were less than satisfied ;
     Time taken to be phoned back
     How thorough the doctor asked about the child’s symptoms and the parent’s
     The amount of time that the doctor spent with parent and child.

Many parents felt that doctors should be more ready to visit their child, whom they
perceive to be ill in the middle of the night.
Despite being satisfied overall, 50% of questionnaires returned had at least one
negative response or comment.
Several important recurring themes from the qualitative interviews were identified.
There were both positive and negative comments as well as some interesting quotes.
Parents were generally happy that there was a service available that they were able to
phone for advice at anytime –Some described NHS24 as ‘a good stop gap until child
could be seen by own practice’.
They were pleased that a health care professional would always offer to see the child
when appropriate. Parents also found all the staff generally pleasant and helpful.
Many parents reported that they were frustrated and unhappy about the length of time
they sometimes had to wait to be phoned back. One parent had to wait 5 hours
overnight only to be asked to attend the centre early in the morning.
Several parents didn’t like the uncertainty of telephone consulting and wondered if
they were explaining the child’s symptoms appropriately over the telephone.
Parents also didn’t like having to ‘repeat the same story’ as many as four times.
Other interesting quotes included – ‘It is a great service. If I can’t get an appointment
with my doctor during the day, I’ll phone up to get my child seen’; ‘There is little
hope of getting a doctor to visit a child during the night – They get paid enough so
why not!’; ‘I miss the old system when you could see your own Doctor, who you trust
and who knows you’.


The main finding from this study is that those families, who live in deprived areas,
contacted NHS 24 most but were least likely to respond to questionnaires seeking
their views. Chaotic and unscheduled patterns of accessing care by day manifest by
inability or willingness to use their own GP surgery effectively, and at night by
reliance of NHS. This could be due to lack of forcefulness when trying to get their
children seen for emergencies, general disorganisation within the family and single
parent families with lack of transport and other children to look after. These same
reasons could explain the lower response rate along with poor literacy skills. The
proportion of the practice patients without functional literacy skill is likely to be
around the Scottish average of 6%. In contrast, more affluent groups, whose rate of
contact with NHS24 was lower, had a higher response rate. Some of these patients
would attend OOH when parents return from work and children get out of nursery.
The more affluent are keener and better at making their voices heard and usually are
more able to access routine services.

In 1971, Tudor Hart first wrote about the inverse care law. This states "the availability
of good medical care tends to vary inversely with the need for it in the population
served." Although there were good medical services in this case, the inverse care law
appears to operate both in terms of access to services and willingness to comment on
and shape service delivery. In addition, articulate patients are more likely to possess
the necessary communication skill to ensure continuity of care with their own GP.
Although the overall parental satisfaction level of using NHS24 was good, there were
areas of concern, frustration and dissatisfaction in the care provided. Many parents
were unhappy with the time it took to be phoned back after contacting NHS24 and the
perceived lack of time the doctor spent listening to parents and explaining symptoms.
This may be due to a mismatch between what parents and doctors perceive as a sick
child and perhaps, on a busy on call shift, more time is spent with those children who
are more clinically unwell. From the clinical case mix, it can be seen that the majority
of diagnoses made after patients attended the out of hours centre, were of a low
clinical severity. It is tempting to speculate that parents might benefit from better
health education advice and support in the management of some minor childhood
illness, and some doctors may wish to improve their communication skills to anxious
parents. Staffing levels needs to be closely matched to demand, to avoid lengthy ‘ring

Some parents had unrealistic expectations of the service, including the wishing of more house
calls at night for social and transport reasons. The old image of the GP as the ever present,
always awake and caring Dr Findlay is no longer true, long gone in societies drive for
immediate consumer led 24 hour instant results culture.

Study limitations include modest numbers with limited scope for statistical
extrapolation. The out of hours centre is only one of many around Scotland and
therefore may not be representative of the service provided in other parts of the
country. The patients were all drawn from one health centre where the child care
service offered may be different to others.
The ethnic mix of the patients was homogeneous, with a low percentage of ethnic
minorities. This is different to other parts of the country where ethnic minorities are
more represented and obviously will not address many cultural differences and

In conclusion, parents are generally satisfied with the medical care of their children
‘out of hours’, but complained about the time taken to phone back patients, and a
perceived lack of time that the doctor spent listening and giving advice. Whether the
low clinical severity of most presentations justifies time delay and lack of medical
input is for society to debate, within the context of the ‘inverse care law’ skewing
consumer response.

Table 1 - Symptoms of patients phoning NHS24

Gastro - intestinal symptoms                   7
Urinary symptoms                               1
Accident/trauma                                3
Medication advice                              2
Rash                                           2
Respiratory symptoms                           4
Non specific viral symptoms                    16
Number advised to go to A/E – 3 (high clinical severity)

Table 2 - Diagnosis after seeing Dr at OOH.

ENT infection                                 11
UTI                                           1
Viral RTI                                     15
RTI (received antibiotics)                    10
Appendicitis                                  1
Asthma exacerbation                           2
Conjunctivitis                                3
Eczema/rash                                   3
Gastroenteritis                               3
Viral illness (not specified)                 8
Genital infection                             2
No diagnosis                                  2

Number referred to paediatrics – 4 (high clinical severity)

Table 3 – nos. of questionnaires sent and response rate between different
socioeconomic groups.

                   Most         Moderately         Moderately     Most
                   affluent     affluent (A2)      deprived(D2)   deprived
                   (A1)                                           (D1)
No. of             21(24%)      17(20%)            32(37%)        16(19%)
No. of             12(30%)      9(23%)             12(30%)        7(18%)
Graph 1
                                 Graph showing proportion of questionnaires sent and returned





            % 20                                                                                                                            %sent




                                     A1                        A2                          D2                          D1
                                                                    level of deprivation

Graph 2

                                                                    satisfaction score









                      completely              very          fairly           neutral       fairly satisfied   very satisfied   completely
                      dissatisfied        dissatisfied   dissatisfied                                                           satisfied

                                                                            satisfaction level


                 Consumer Questionnaire, BMJ paper (BMJ 1997;314:193 (18 January)
    (Reliability and validity of a new measure of patient satisfaction with out of hours primary
    medical care in the united kingdom: development of a patient questionnaire
   NHS 24 website
   The new GMS contract.
   Carstairs scores for Scottish postcode sectors from the 2001 Census – Philip McLoone, MRC
    social and Public Health Sciences Unit March 2004.
   Tutor Hart, J (1971) The inverse care law, Lancet :405-412..

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