Title: A study of sense-making strategies and help-seeking behaviours associated with the use and provision of urgent care services
Funder: Department of Health and Social Care

Abstract: BACKGROUND Urgent care reform has led to the development of multiple services (e.g. out-of-hours, walk-in centres, NHS 111) designed to improve access and manage rising service demand [1,2]. Policy has sought to influence patient behaviour and choice of service [1,3] in this complex urgent care landscape. Guiding patients to ‘get the right advice in the right place, first time' [3], reducing unnecessary emergency department attendances by providing more responsive urgent care services, and providing better support for people to self-care has increasingly been the focus of national and local health policy [1,2,3]. However, effective service provision requires a much deeper understanding of the factors that influence patients’ help-seeking and choices. This project seeks to address the gaps in this evidence base to inform commissioners, providers and policy decision makers. Research that has examined the use of emergency services for ‘non-urgent’ or primary care reasons suggests that there may be a mismatch between service provision and patterns of service use [4-5], and in turn, a potential disconnect between how patients/users define urgent care and how policy makers and service providers define it. Much of what we know about how patients and health professionals make sense of urgent and emergency care is derived from a sizable literature about the ‘inappropriate’ use of health services [e.g. 6] but there are inherent difficulties in defining what is inappropriate or unnecessary since service commissioners, policy makers, providers, clinicians and patients may hold different viewpoints. Findings from the literature have suggested that health professionals and patients judge the severity and urgency of a condition differently [7]. Furthermore healthcare professionals themselves do not always agree on what constitutes ‘inappropriate’ use [8]. However, whilst healthcare professionals may deem some service use as ‘inappropriate’, patients often have clear rationales for help seeking, even for symptoms that may be perceived as ‘trivial’ [4,9]. However, there are few studies that have directly compared patient and health service / professional conceptualizations of urgent or emergency [7]. More recently, policy has focused on emphasizing minimising disruption and inconvenience for people using urgent care [1]. It is therefore timely to examine in detail the ‘work’ that patients are required to do to access and navigate the urgent care system. Studies suggest that patients may be unaware or confused about which service to use, and are often unsure about the appropriateness of their call to urgent and emergency services [5], indicating that there may be burden for patients when deciding to seek help. Evidence suggests that some patients may choose emergency services over urgent care services because they perceive that the ED or emergency ambulance services are more responsive to their needs or are more convenient [5,10]. Patients have reported ‘battling’ or ‘struggling’ to access urgent care services with additional difficulties in finding transport [5]. Studies such as these indicate that there could be considerable work required by patients with urgent care needs to access, negotiate and participate in advice and treatment. Concepts of ‘minimally disruptive medicine’ [11] and the ‘burden of treatment’ (i.e. the workload delegated to the patient by health professionals and services), can include accessing and organizing contacts and appointments, self-care and managing therapeutic regimens [12]. Until now, these concepts have mostly been applied to patients with long-term conditions. However, we believe that these concepts provide a useful and novel framework for thinking about notions of patient ‘workload’ for those using urgent care when considering convenience and ‘minimal disruption’. It is not clear what role burden of treatment plays in patient (and health professional) decision making in urgent care, or whether the way in which urgent care is organised and delivered increases or reduces treatment burden for patients. AIMS AND OBJECTIVES To identify sense-making strategies and help-seeking behaviours which explain the utilization of urgent care services in a complex urgent care landscape. 1. To describe how patients, the public, providers (professionals and managers), and shapers (commissioners and policy makers) define and make sense of the urgent care landscape. 2. To explain how sense-making influences help-seeking strategies and patients’ choices in accessing and navigating available urgent (and emergency) care services 3. To analyse the ‘work’ (‘burden of treatment’) for patients involved in understanding, navigating and choosing to utilize urgent care 4. To explain urgent care utilization and identify modifiable factors in urgent care patient decision making. METHODS Mixed methods sequential design consisting of 3 work packages (WP): literature review and two citizens' panels (WP1), serial qualitative interviews (WP2); and an integrative analysis and conceptual model (WP3) (see flowchart for study integration). WP1: This comprises a literature review, followed by two citizens’ panels. The literature review will generate meanings and definitions of urgent care from the multiple perspectives of policy makers, service providers and patients/the public. These meanings and definitions will then be debated in two citizens’ panels - one group of citizens (the public) and one group of health providers (professionals and commissioners). Sense making perspectives [13] will be used to gain insight into contested definitions and meanings of urgent care, which are likely to have implications for peoples’ attitudes and behaviours associated with the use of urgent care services (Objective 1). WP2: Qualitative interviews (Objectives 1-3) to identify and explain patient help-seeking strategies, choices and workload in accessing and navigating available urgent care services. The setting for WP2 is a geographical area served by one NHS 111 provider (South Central) covering 4 counties. To obtain the rich description and understanding required, we propose to conduct qualitative semi structured interviews at two time points, with three carefully selected groups of service users that reflect a diversity and range of experiences of urgent care need. WP3: Integrative analysis of data collected in WP1 and WP2 to build a conceptual model that explains the urgent care utilization from which we can identify modifiable factors that affect urgent care patient decision making (Objective 4). ANALYSIS Our data clinic approach will be used to share and interpret data, build emergent themes and develop narrative and interpretive summaries. Analyses will be informed by conceptual ideas drawn from previous research and theorising (i.e. sense-making, burden of treatment). We will also use techniques such as decision trees and models of interaction choices and behaviours. BENEFITS TO NHS The research will allow researchers, healthcare professionals and policy makers to reach a shared definition/conceptualization of urgent care. A comprehensive model of patient sense-making strategies that influence help-seeking choices and behaviours will identify what policy makers, commissioners and providers should take into account when making changes or introducing new interventions.

Lay abstract: Urgent care includes a range of services (e.g. out-of-hours, walk-in centres, NHS 111) that have been designed to improve access and manage rising service demand. These services are also closely linked with emergency care (e.g. 999 ambulance services and emergency departments). Patients with a perceived urgent care need are required to navigate and access a complex system of urgent and emergency care. Recent national and local health policy has attempted to reduce unnecessary emergency department attendances by providing more responsive urgent care service, help guide patients to ‘get the right advice in the right place, first time', and provide better support for people to self-care. However, effective service provision requires a much deeper understanding of the factors that influence patients’ help-seeking and choices. This project seeks to address the gaps in this evidence base to inform commissioners, providers and policy decision makers. Insight into patients' knowledge and understanding is essential as it will influence their attitudes towards, and use of, these services. Rigorous evidence is needed to optimise urgent care provision and improve care so that patients experience ‘the right service, at the right time’. We will investigate what patients think and feel about urgent care services, and how and why they use them. This will allow us to develop a conceptual model to explain patient choices, decisions and behaviour in relation to urgent care. This will be done using a mixed methods sequential design consisting of 3 work packages (WP): literature review and two citizens' panels (WP1); serial qualitative interviews (WP2); and an integrative analysis and conceptual model of urgent care use (WP3). WP1: Literature review (Objective 1) of policy documents and research to identify meanings and definitions of urgent care from multiple perspectives (policy, service providers, patient) and citizens' panels convened to debate and offer direction about how to define and conceptualise urgent health care. WP2: Qualitative interviews (Objectives 1 to 3) to identify and explain patient help-seeking strategies, choices and workload in accessing and navigating available urgent care services. The setting for WP2 is a geographical area served by one NHS 111 provider (South Central) covering 4 counties. WP3: Integrative analysis of data collected in WP1 and WP2 to build a conceptual model of urgent care utilization and patient decision making (Objective 4). ANALYSIS: Our established data clinic approach will be used to share and interpret data collectively, build emergent themes and develop narrative and interpretive summaries. Analyses will be informed by conceptual ideas drawn from previous research and theorising (i.e. sense-making, burden of treatment). The demand for urgent and emergency care is high with over 100 million calls or visits to services each year, accounting for over half of NHS costs. This proposal offers value for money as it will provide evidence about how patients understand and define urgent care (‘sense-making’) and their behaviour and use of urgent care. Producing rigorous evidence underpinned by robust theoretical concepts will inform the development of future models of urgent care provision.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE