Obstacles on the path to a primary-care led National Health Service: complexities of outpatient care

An interpretive qualitative study was carried out as part of a large cohort study of factors affecting outpatient re-attendance. Individuals from three groups involved in the provision of care across the primary-secondary interface were interviewed: patients, general practitioners and consultants. The aim was to explore understandings concerning referral to and re-attendance at outpatients, and to elicit detailed descriptions of the complexities of the outpatient experience for both providers and recipients of care at the primary/secondary interface, given the policy commitment to a 'primary-care led National Health Service'. Semi-structured interviews were carried out with nine individuals currently attending outpatients, ten general practitioners, and ten consultants. Transcripts were analysed individually and cross-checked between analysts for validity of interpretation, to identify key themes and sub-themes. Data were compared across the three groups. Negative case analysis was employed. Seven major issues were identified, some of which could be identified with interests and experience of the three obvious groupings, and some of which were common. The three groupings are not as homogeneous as is often supposed. From the cross-group analysis common themes included: interpersonal communication, knowledge, power relations and anxiety/reassurance. Issues of trust, social status, funding and consumerism/litigation were also highlighted. The analysis has implications for altering the balance of care across the interface, for example in the finding of what could be termed a dissonance in power perceptions, in that consultants perceived general practitioners as relatively powerful and 'able to influence things', whereas general practitioners often expressed themselves as relatively powerless and unable to be proactive in 'reclaiming' their patients. The analysis highlights the complexity of the outpatient experience, drawing attention to detailed areas of contradiction, irony and conflict in the total context of outpatient care. These areas should be addressed in policy development designed to shift the balance of care further towards the primary sector.