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Student: Monica Johnson
Topic: Patient expectations for accessing after-hours health care in rural areas.
Supervisors: Les Toop & Kelly Maw
Sponsor: Partnership Health Canterbury/Pegasus Health

Awarded Best Speaker in the "Community" Category

Official figures estimate that one quarter of New Zealanders live in rural areas or small towns. General Practitioners (GPs) in these areas spend more of their time providing after hours care than doctors who work in larger towns and cities. There are many issues surrounding the provision of afterhours care in rural areas, especially as many rural areas are understaffed, and as the GP population ages there are less and less younger GPs to replace those who are leaving. Previous research has described the type of medical care available in rural areas and examined some of the issues surrounding medical care, especially afterhours. After hours care and weekend cover is often reported as one of the most onerous part of being a rural GP. Having to be 'on-call' is one of the major reasons that many doctors choose not to work in rural areas. However, less is understood about what people living in rural areas expect in terms of afterhours health care.

The purpose of this study was to explore the current use of afterhours care by those who live in rural areas around Canterbury. The study also aimed to explore and compare the views, experiences and expectations of afterhours care of people in rural Canterbury compared with those living in urban Christchurch.

An initial literature review showed that a large number of studies have been conducted on afterhours medical care in rural areas, and acknowledgement made to the significant burden on those who provide this care. It also produced one study focusing on patient satisfaction surveys with the provision of afterhours care by their primary health care provider. However there was little research relating to patient expectations of an acceptable level of afterhours care within the rural setting, use of current services and the barriers patients face when trying to access this care. A questionnaire was then designed and sent out to 500 people randomly selected from Canterbury rural and urban electoral rolls. The responses from these questionnaires were analysed to compare the thoughts of those who live in rural areas with those who live in urban areas. Volunteers were then contacted to participate in a focus group where issues that were raised in the questionnaire were explored in more depth. The discussion from the focus group was transcribed and themes drawn from it.

We had a 25% response rate from the questionnaires sent out, with an even mix of urban (58) and rural (53) participants. Unexpectedly many of the respondents with rural addresses in Canterbury reported accessing afterhours health care in Christchurch, either at the 24 Hour Surgery or at the Emergency Department (ED) at the hospital. Many people face barriers when trying to access health care, especially afterhours, but rural people reported more difficulty accessing a General Practitioner (GP) both during the working week and afterhours. Specific barriers identified by those from rural areas were the long travel distance / time and the high cost of afterhours care. High cost was also a significant barrier reported by those from urban areas. Participants who live in urban areas appear to be more satisfied with the health care available afterhours in their area, with more than 80% of them rating themselves as being Very Happy or Happy with the current afterhours care available in their area, compared with only 50% of rural respondents. Quality GP consults, pharmacy and ambulance services were rated as the most important afterhours resources by both sectors, with telephone advice being next for rural respondents and x-ray being rated next by urban respondents. When asked about expectations for accessing afterhours care rural respondents were prepared to travel further and pay more to access their afterhours care.

There were many important issues raised in the focus group. It seemed from the focus group that rural people tended to be less likely to want to seek care for medical issues afterhours, unless it was a medical 'emergency'. (This may not be representative and therefore generalisable of all rural adults as the participants of the focus group were all from a similar generation (over 50, most over 60).) They all expressed the attitude that they don't want to 'waste anyone's time'. A second opinion was seen as very useful before deciding on making the long trip into town to the 24 Hour Surgery. Telephone services such as Healthline or HML provide this service however it seems many people do not know that these services exist or how they work. Another suggestion that could potentially save a trip into town would be if weekend surgeries were held in certain rural centres, allowing people to see a GP for a more minor issue without having to travel into town. The efficiency of the 24 Hour Surgery in Christchurch was praised and it was suggested that there were many people presenting to ED who could be dealt with just as easily at the 24 Hour Surgery. The fact that rural areas in Canterbury aren't as isolated as in many other parts of the country was raised, and the fact that there is a shift towards more semi-rural areas such as Rolleston or Rangiora, a small township in itself where people do not classify themselves as living rurally. This raised the issue of a decreasing community mindset in rural areas and the important role that communities play when it comes to contributing towards and participating in rural health. It is important in future years to be aware of the growing number of people living in semi-rural areas with greater expectations for accessing health care and to make a concerted effort to try and meet their needs or change their expectations. Although this survey did not ask rural participants to contribute to how their afterhours health services could be improved, this could be a topic for future research.

People have many different views and expectations about accessing afterhours health care. It is hard to separate people's ideal expectations from what they think they can reasonably expect as logically everyone would like to be able to have ready access to affordable high quality care. This makes it difficult to interpret peoples' realistic expectations. However in Canterbury the majority of people surveyed seemed to be happy with the afterhours care that has been provided for them, so presumably most of their expectations are being met. In general rural people find it harder to access a GP however they are also prepared to travel further and pay more than their urban counterparts for afterhours care. As many of the rural areas in Canterbury are not as isolated as in other parts of the country, numerous people still come into Christchurch centre for their afterhours care. To make these results applicable to the whole of New Zealand it would be necessary to carry out the survey throughout other regions in the country.

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