Who Uses Nhs Direct? Factors That Impact on the Uptake of Telephone Based Healthcare
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WHO USES NHS DIRECT? FACTORS THAT IMPACT ON THE UPTAKE OF TELEPHONE BASED HEALTHCARE. E. J. COOK Ph.D 2013 UNIVERSITY OF BEDFORDSHIRE ii WHO USES NHS DIRECT? FACTORS THAT IMPACT ON THE UPTAKE OF TELEPHONE BASED HEALTHCARE by Erica Jane Cook A thesis submitted for the degree of Doctor of Philosophy to the University of Bedfordshire JANUARY 2013 iii WHO USES NHS DIRECT? INVESTIGATING THE FACTORS THAT IMPACT ON THE UPTAKE OF TELEPHONE BASED HEALTHCARE E.J. COOK ABSTRACT This research aimed to investigate the socio-demographic characteristics alongside the psycho-social factors that impact on the uptake of telephone based healthcare using a socio-cognitive approach. The first study analysed four ‘one month’ periods of national NHS Direct call data (July 2010, October 2010, January 2011 and April 2011) for all 0845 4647 calls in England. Expected and actual usage of NHS Direct was determined for each ethnic group of the population and compared using Chi-square analysis. Results confirmed that White British used NHS Direct more than expected, alongside Mixed (Caribbean/African) and Asian Pakistani groups, with lower representation found for Asian Indian\Bangladeshi, Black African\Caribbean, alongside Chinese ethnic groups. No gender differences were noted. Calls were then analysed for age, gender and deprivation (IMD health, income, employment & education) using negative binominal regression. Results suggest that deprivation increases call rates for adult calls but reduced in calls about children (<15 years). This study also highlights that NHS Direct call rates (all ages combined) are highest in areas with deprivation levels at, or just above, the national average, which remains consistent when accounting for employment, income and education deprivation. The second study, adopted a qualitative approach to explore the psycho-social factors that impact on the uptake of telephone based healthcare. Focus groups were conducted with low user groups (Manchester (N=3) and Mendip (N=4)), alongside high service users (N=2) and service providers (N=2). Five themes emerged: attitudes, structural and perceived barriers, knowledge and awareness of NHS Direct alongside improving access. Findings highlight a preference for instant face-to-face reassurance in low user groups, whereby low users appear to have lower perceived confidence in self-management of symptoms and engaging with telephone based health services. In conclusion the findings suggest there is variation in usage of NHS Direct, influenced by ethnicity, gender, age and deprivation. This research has explored some of the barriers, and has provided a theoretical framework that can be applied to understand uptake of telephone based healthcare. This research can help enable the development of future promotional campaigns that can target particular sections of the population to encourage use of telephone based healthcare services. iv In memory of B.E.Warren 1910-1997 v Contents Page Abstract ............................................................................. Error! Bookmark not defined. List of Tables ....................................................................................................................... xi List of Figures .................................................................................................................... xiii Acknowledgements ............................................................................................................ xv List of abbreviations .......................................................................................................... xvi Chapter 1 Aims and Overview .......................................................................................... 17 1.2 Overview of chapters .............................................................................................. 18 Chapter 2 NHS Direct: The evolution of telephone based healthcare .............................. 21 2.1 Telemedicine and Tele-health: Competing definitions ........................................... 21 2.1.1 Telemedicine ................................................................................................... 21 2.1.2 Tele-health ....................................................................................................... 23 2.2 The development of tele-health .............................................................................. 26 2.2.1 The evolution of remote healthcare ................................................................. 26 2.2.2 Historical overview of tele-health..................................................................... 27 2.2.3 Tele-health and Tele-nursing .......................................................................... 30 2.2.3 The current development of telephone based healthcare: An international perspective ............................................................................................................... 31 2.3 Policy implications for telephone based healthcare: The NHS............................... 32 2.3.1 Evolvement of the National Health Service ..................................................... 32 2.3.2 NHS Direct and New Labour ‘A New NHS’ ..................................................... 33 2.4 NHS Direct and the self-care model ....................................................................... 34 2.4.1 Self-care in recent history ................................................................................ 35 2.4.2 What is self-care? ............................................................................................ 35 2.4.3 Why adopt the self-care model? ..................................................................... 36 2.4.3 Who uses self-care? ........................................................................................ 37 2.3.3 The evolvement of NHS Direct ........................................................................ 38 2.5 The NHS structure of primary and secondary care ................................................ 43 2.5.1 NHS Direct integration within primary care .......................................................... 43 2.5.2 NHS Direct today ............................................................................................. 47 2.5.3 The future of NHS Direct ................................................................................. 48 Chapter 3 Geographical and socio-demographic predictors of healthcare utilisation ...... 49 3.1 Introduction ............................................................................................................. 49 3.2 The health inequality divide .................................................................................... 49 3.3 Socio-demographic characterisations and use of primary healthcare services ..... 53 3.3.1 Inequity in healthcare access .......................................................................... 53 3.3.1.1 Ethnicity .................................................................................................... 54 3.3.1.2 Age ........................................................................................................... 55 vi 3.3.1.3 Socio-economic status ............................................................................. 55 3.3.1.4 Gender ..................................................................................................... 56 3.4 Urban and rurality: The impact of geography on health ......................................... 57 3.4.1 Defining urban and rurality .............................................................................. 57 3.4.2 The impact on health ....................................................................................... 58 3.4.3 Impact of geographic location on health service utilisation ............................. 60 3.4.4 Future research ............................................................................................... 61 3.5 Who uses NHS Direct? A systematic review .......................................................... 61 3.5.1 Introduction ...................................................................................................... 61 3.5.2 Methods ........................................................................................................... 62 3.5.2 Results ............................................................................................................. 65 3.5.2.1 Gender ..................................................................................................... 65 3.5.2.2 Age ........................................................................................................... 65 3.5.2.3 Ethnicity .................................................................................................... 66 3.5.2.3 Socio-economic groups ........................................................................... 67 3.5.2.3 Geographical factors ................................................................................ 68 3.5.2.4 Conclusion ............................................................................................... 68 Chapter 4 Study 1: Profile characteristics of NHS Direct users ........................................ 70 4.1 Introduction ............................................................................................................. 70 4.2 Research Design .................................................................................................... 70 4.3 Aims and Objectives ..............................................................................................