Calling NHS 24: exploring caller decision making and help seeking behaviour within the context of out-of-hours health care provision

Abstract

Decisions about where and when to seek advice about illness are known to be complex and are often bound up with issues of risk, responsibility and legitimacy. They can be particularly difficult in situations where the meaning and severity of symptoms is unclear. In deciding whether or not to seek help, people must negotiate the tension between using health services in ways that are considered appropriate, while not taking risks with their health or that of the person they are caring for. This thesis explores how individuals account for a specific decision to call NHS 24 about symptoms in themselves or someone they were caring for and how that decision fits within their use of health services more generally. Building on what is already known about help-seeking behaviour, it seeks to understand how people interpret symptoms as needing or not needing attention and what is understood by appropriate help-seeking in the context of out-of-hours care. There have been significant changes to the way that out-of-hours health care is provided in Scotland. An increase in routes into care means that people must negotiate a complex health system when seeking help. At the same time, pressure on resources has created an imperative to ensure that health care is used in the most efficient way possible. NHS 24 is primarily an out-of hours triage service providing assessment and, where necessary, referral to other services. At its inception, NHS 24 was presented as being designed to simplify access to health care by acting as a ‘gateway’ to the NHS in Scotland. However, increasing demand has led to attempts to limit use of NHS 24, in the out-of-hours period, to situations where symptoms are considered to be too urgent to wait for a GP appointment. NHS 24 can now be understood as one of a number of different points of access to health care that people must choose between; this requires individuals to engage in a process of categorising their symptoms according to urgency as a way of ensuring that their call is considered appropriate. The thesis draws on data from 30 in-depth semi-structured interviews with people who had called NHS 24 in the out-of-hours period. The symptoms the participants had called about were generally, though not universally, what might be classed as minor symptoms. Most of the interviewees were given self-care advice rather than referral for a face-to-face consultation. The interviews focussed on a specific contact with NHS 24 but aimed to situate the call in the context of the interviewee’s understanding of NHS 24, as well as their illness behaviour and use of health services more generally. The analysis suggests that people’s understandings of NHS 24 are not straightforward and that this can cause some confusion and even anxiety for callers. Interviewees’ accounts emphasise uncertainty about the severity of symptoms, a sense of worry that symptoms may be indicative of a serious problem, and the inadequacy of their own knowledge in the face of potential risks. In talking about their reasons for calling NHS 24, they describe seeking, and obtaining, reassurance that they were ‘doing the right thing’. Although they generally construct themselves as healthy individuals, confident in their ability to self-care, and as responsible users of health services, people spoke frequently about their reliance on expert clinical knowledge in decision-making. The analysis suggests that when explored in the context of individual circumstances and the broader social context, calling NHS 24 about minor symptoms can be constructed as a rational and responsible act. While this thesis is primarily an exploration of the accounts of individuals who have called NHS 24, the accounts are situated within the broader social and structural context in which those individuals make their decisions about symptoms and help-seeking. A social constructionist perspective sees illness behaviour as shaped by the social structures and values of a society and by the health system operating in that society. Equally, the health system is shaped by individual actors, who define it by how they choose to use it and what they expect it to deliver. This thesis argues that understandings of risk and individual responsibility, as well as a policy emphasis on self-surveillance and self-care, shape the decisions made by individuals as well as the discourses available to them to account for those decisions. Drawing on theories of medicalisation and lay re-skilling, the thesis also aims to develop an understanding of the space that NHS 24 occupies in Kleinman’s (1980) model of the health system, and whether the service might best be conceptualised as ‘legitimation’ or ‘colonisation’ of the popular sector (Stevenson et al. 2003)