Patient choice research amongst ethnic minorities: Qualitative research
Summary of findings
Awareness of Patient Choice amongst the Target Ethnic Minority Communities
Overall awareness of patient choice amongst the six ethnic minority communities researched was relatively good. However, there were some inconsistencies across the sample in terms of how knowledgeable people were of the scope of patient choice. General engagement with the NHS varied amongst the sample, with some groups less engaged than others. This appeared to impact on current awareness and take up of patient choice.
Younger Caribbean and African men and older Black African women in this sample were generally least engaged with the NHS and a number did not feel they were well served by their GPs or by the health service in general and they were less likely to seek out information about healthcare or to be aware of their right to choices unless GPs provided information about patient choice.
Older Bangladeshi and Pakistani patients in the sample and younger recent immigrants from these communities often lacked English skills and some had low literacy levels. This affected the nature of their interaction with the health service. These patients were highly dependent on family members for information and for assistance in making healthcare decisions. Although usage of the health service amongst these patients was often high, their awareness of patient choice depended on communication via their GP or family members.
Other patients in the sample were typically more engaged with the NHS and knowledgeable about new healthcare initiatives in general. They were also more likely to have some awareness of patient choice through community and social networks, from friends and family or via mainstream messages. However, these patients reported that they were not fully aware of the scope of the choices available to them.
There appears to be some regional differences in awareness. Feedback suggested that there was higher awareness in London across most ethnic groups. There was also some awareness in Birmingham and but this was lowest in Leicester, Oldham and Bradford.
Current Attitudes to Patient Choice
Most people researched were positive about the concept of choice and a patient having more control over their healthcare was seen as a ‘good thing’ for both the patient (and also the NHS in general). However, in reality, not everyone wanted choice.
Younger and more educated people in the sample were motivated by having greater choice and control over their healthcare and wanted to be able to choose both the hospital to which they would be referred to and the date and time of their first appointment.
Others were interested in some aspects of patient choice. Being able to choose the date and time of their hospital appointment was seen to be particularly appealing but many did not really want to make decisions about hospitals except in a limited way i.e. choosing between one or two local hospitals. These patients generally lacked the confidence to make informed decisions and were likely to rely on their GP’s recommendations. Older patients, especially those with English language difficulties, and some younger patients who lacked general confidence, were more likely to defer to the GP’s knowledge and expertise and were less able to challenge GP decisions.
Factors Impacting on Choice
For a minority of the sample, mainly younger and more educated patients, choice of hospitals was likely to be determined by hospital reputation and specialism, infection rates and waiting times. These patients were willing to travel outside their PCT in order to use a hospital that met these priorities and were comfortable in seeking information to help them make their decisions.
For a majority of the sample, convenience, access to public transport and waiting times were more important considerations. As a result, these patients were happy to be referred to hospitals within their PCT, choice being based on either their prior knowledge of specific hospitals or their GPs’ suggestions.
For both of the groups, the patient’s condition at the time of referral could alter the factors considered important.
Cultural factors (e.g. prayer facilities) were generally not considered to be major considerations in the choice of hospital.
Experiences of Patient Choice Delivery
Actual experiences varied across the sample of people who had been offered choice. Some people reported positive experiences and outcomes while others did not feel that the system of making choices was straightforward or reliable. This highlighted inconsistencies in patient choice delivery.
For those who had been offered choices regarding their healthcare, there were variations in terms of what specific choices they had been given and how these choices were offered. Delivery of patient choice appeared to depend on the attitudes of GPs and how well surgery and PCT systems were geared to enable people to exercise their choices.
Those who reported positive experiences said they had been supported by their GPs. They had been offered a selection of hospitals to choose from (although these were typically within the local PCT), had been presented with information by the GP at the referral appointment and decisions were taken at this time of the most appropriate hospital and appointment.
A few patients claimed that they had been offered a choice of local hospitals and appointment times by their GP which was registered by their GP on their system. However, a few people had not received an appointment at the hospital of their choice. In these instances, patients were not clear about why this was the case and this led to disappointment.
Other patients had also been offered a choice of local hospitals and were able to book their appointments directly with the hospital of their choice via the Choose and Book system. This group of patients reported mixed experiences of this booking system. Some had little difficulty arranging a suitable appointment and these patients were largely satisfied about how they had been offered choice as they felt their choices had been delivered. However, other people reported problems accessing the Choose and Book system, claiming they could not get through easily by telephone or Internet to arrange their appointments, causing frustration and delay.
Responses to Communications Materials
Overall responses across the sample were relatively positive although some materials worked better with particular groups than others.
‘It’s your choice’ Advert
There was some limited recall of the advert. Most people across the sample were generally positive about the advert and it was perceived to communicate a patient’s right to choice which hospital they are referred to and that choices can be based on the patient’s specific priorities. Overall, the style, tone and language worked well with this audience and most people liked the cartoon approach. The visuals were also felt to convey inclusivity through the range of types of patients shown. However, it was felt that making the communication ‘It’s your right to choose’ more prominent and the copy larger would have made the advert more effective.
Patient Choice Leaflet
A few people had seen this leaflet in GP surgeries. It was generally liked and many reported that it was informative, easy to read and well laid out. The leaflet was perceived to contain useful and relevant information about what choices patients have, how they can choose a suitable hospital and where they can receive further information and support. However, unsurprisingly the Age Concern branding on the leaflet shown was off putting for some and it was not considered to be particularly inclusive of ethnic minority patients. Providing more information about the process of making hospital appointments, including more visuals of ethnic minority patients and changing the branding could have made the leaflet more motivating.
Life Channel (GP surgery) Adverts
None in the sample had seen these in their GP surgeries. The two 60 second adverts were generally thought to be informative. There was clear information of what patient choice is, what the GP can do to support patients and where patients can access information to help them make their decisions. The use of patient case studies was liked. However, there was a general preference for case studies that focussed on key patient needs such as waiting times.
‘Ask a librarian’ Poster
One or two people in the sample claimed to have seen the poster. Generally the poster was seen to work relatively well, at least visually. It was deemed to be bright and colourful by some. However, most people did not view the library as an effective source of information about healthcare as they (in particular, older Asian women) did not use them. This limited the relevance of this communication tool in its present form.
The main research objective was to provide deeper insight into awareness and understanding of patient choice amongst different ethnic minority groups.
More specifically, the research aimed to:
- Map the patient decision making process from the point of referral to their actual hospital appointment
- Explore views of the existing campaign message and information materials in terms of style, tone, language, channels, imagery etc.
The principle of choice is central to the Government’s public reform agenda to empower patients, reduce inequalities in access to healthcare and improve outcomes for all patients. A national consultation in 2003 amongst a range of audiences highlighted a common theme: a desire for more choice about healthcare for all, not just the affluent. People also wanted the right information to help them make informed choices.
Since April 2008 all patients registered with a GP in England have the right to choose any NHS provider when they are referred by their GP to a hospital or a consultant (except when speed of access is required or for some services/conditions). A launch campaign in the spring of 2008 was designed to raise awareness amongst all adults that patients can choose which NHS provider to go to for healthcare. The main message was “You have the right to choose”. The first stage of activity included local press, local radio adverts and interviews, a downloadable toolkit, the NHS Choices website, P.O.S. video footage on Life Channel via GP surgeries, and local PR.
DH are now gearing for a second phase of the campaign, focusing on the stage in the patient journey when patients need to make choices and to widen the audiences to those that are harder to reach and their key influencers.
More specifically, this second phase aims to:
- continue to raise awareness and understanding of patient choice and educate target audiences and stakeholders on the delivery of this choice;
- ensure patients feel empowered to make those choices;
- develop targeted activity for hard to reach groups and their influencers;
- improve the toolkit and collateral provided to regional stakeholders to help them implement the national strategy at a local level;
- advise on how to communicate via the toolkit with the hard to reach and their influencers.
Qualitative research to build on existing knowledge about the attitudes of ethnic minorities to Patient Choice in order to inform targeted messaging for these communities.
Six ethnic minority communities researched: Black African (Nigerian/Ghanaian), Black Caribbean, Pakistani, Bangladeshi, Gujerati Hindu & Punjabi Sikh
It was important to understand to what extent, if at all, age impacted on awareness and attitudes to patient choice. As a result it was felt to be important to provide both a younger and an older perspective. It was likely that older people from ethnic minority communities may face a range of cultural and language issues that could impact on awareness and attitudes to patient choice. Equally, it was important to understand whether these issues were more or less applicable to younger generations.
Thus, two age groups were researched: ‘younger’ i.e. those aged between 25 and 45 and ‘older’ i.e. those aged between 46 and 65. Amongst the younger sample, we included patients and some parents of children who had been referred to hospital.
- Patients – mix of triads and paired depths
- GP & Influencers – Individual depth interviews
Data collection methodology
Other data collection methodology
Paired depths, triad depths
TOTAL = 73 respondents:
- Triads = 12 (36 respondents)
- Paired depths = 12 (24 respondents)
- Influencers = 8
- GPs = 5
August - September 2009