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 thre e groups involved in the provision of cars across the primary-secondary int erface were interviewed: patients, general practitioners and consultants. T he aim was to explore understandings concerning referral to and re-attendan ce at outpatients, and to elicit detailed descriptions of the complexities of the outpatient experience for both providers and recipients of care at t he primary;secondary interface, given the policy commitment to a 'primary-c are led National Health Service'. Semi-structured interviews were carried o ut with nine individuals currently attending outpatients, ten general pract itioners, and ten consultants. Transcripts were analysed individually and c ross-checked between analysts for validity of interpretation, to identify k ey themes and sub-themes. Data were compared across the three groups. Negat ive case analysis was employed. Seven major issues were identified, some of which could be identified with interests and experience of the three obvio us groupings, and some of which were common. The three groupings are not as homogeneous as is often supposed. From the cross-group analysis common the mes included: interpersonal communication, knowledge, power relations and a nxiety/reassurance. Issues of trust, social status, funding and consumerism -litigation were also highlighted. The analysis has implications for alteri ng 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 influe nce things', whereas general practitioners often expressed themselves as re latively powerless and unable to be proactive in 'reclaiming' their patient s. The analysis highlights the complexity of the outpatient experience, dra wing attention to detailed areas of contradiction, irony and conflict in th e total context of outpatient care. These areas should be addressed in poli cy development designed to shift the balance of care further towards the pr imary sector. (C) 1998 Elsevier Science Ltd. All rights reserved.