What Personal Care Means
Definitions of personal care were elicited through direct questioning and detailed accounts of examples of times both when they had and had not received or provided what was thought to be personal care (see both types of example in data extracts below). It was talked about in three different ways by both patients and GPs: As resulting from the practitioner having a particular consultation style (personal consultation style); through the whole practice providing accessible, friendly and well co-ordinated care (whole practice care); and as the result of care which occurs within a relationship with one or a small number of practitioners built over time, one crucial characteristic of which is that the patient knows and is known by the doctor (relational continuity).
Whilst personal care was described in these three ways, providing or receiving care experienced as personal was rarely conceptualised exclusively one way or the other. Usually participants talked about them, not as distinctive but, as related concepts. Care given by the known doctor with whom an interpersonal connection had been established was overwhelmingly the main way that participants discussed how personal care was provided. However, consulting the known GP by itself was not thought necessarily to result in care they deemed personal. Seeing the same practitioner who did not have a particular consultation style and with whom there was no interpersonal connection usually was not regarded as personal care. Only a few participants regarded personal care as being possible within the context of a single encounter even when such a consultation style was used. Whole practice care was considered by some participants to be a way through which personal care could be provided. However, on the whole, this was not regarded as essential to or a substitute for the main way that personal care is provided; by the known practitioner who has a particular consultation in the context of a trusting relationship in which patient and doctor know one another.
Patients from large (and, of course, single-handed) practices were more likely to refer to having an exclusive relationship with one doctor, whilst those from small practices tended to refer to having a relationship with more than one practitioner. This difference may be due to the fact that in smaller practices patients have a greater chance of seeing all the doctors for the logistical reason that surgeries must be shared by two or three practice partners. It seems reasonable to suggest this enables patients to get to know and be known by all of the doctors in the smaller setting and to build a trusting relationship with them in a way not so possible within the larger. However, within smaller practices, the emphasis on an exclusive relationship as an essential facet of personal care was notably greater when the patient or a member of her family suffered a complex, serious and worrying problem. In these situations of high emotional salience, patients in small practices usually expressed personal care as occurring through the context of a relationship over time with one specific doctor. No differences were found in how patients defined the meaning of personal care with respect to relative practice deprivation.
Specific features were regularly mentioned as being important in providing care that was experienced as personal. Both patients and GPs talked about all practice staff having a particularly pleasant and approachable manner and attitude towards the patient, but especially that of the consulting practitioner. They also mentioned the patient being dealt with as an individual whose treatment is tailored to her particular circumstances and needs. Most patients and all GPs thought treating the patient as an individual required the doctor to hold knowledge about the patient as an individual (previous medical history, response to medications, personality and preferences), as well as wider family and social/economic circumstances. Both participant groups thought that having an interpersonal connection with the practitioner who knows the patient and who has a commitment to her general wellbeing were also important to care being personal. Generally, it was couched by patients in terms of the patient seeing my own doctor, the usual doctor, my family doctor, and it frequently included a sense of the patient identifying and sharing an interpersonal connection with the doctor who knows them. As noted, seeing the same doctor over time without this connection and the feeling of knowing and being known was not considered to result in care being personal care.
The following extracts from patients' data illustrate some of these points regarding the meaning of personal care:
'Personal care... would be one doctor, who personally looks after me, and he would be the only one person that I would see. That's what I would take it to be. So, they would really know me' (MP01-04).
'... I think the main thing is that [the known GP] has been there for me in the past... it's nice to know... that your GP's there... that he's really interested in what's happening with you... and caring about your health... and concerned about your well-being, you know, it's nice to know that somebody's there... [Personal care is not when] ...my son took ill with epilepsy... he had that first one... through the day and went on to have another two that evening, and I was really distraught, you know, really frantic, and he [the unknown doctor] came out and said, "Well, it's only a fit", and I was saying, "Well, you know, there's something wrong, this isn't the normal pattern for Douglas, there's got to be something wrong here...". But, in the end, it was a case that my son is going into hospital because there is something wrong, but he was like, "Well, it's just a fit"...' (PP 02-01).
'It [personal care] is not something that would necessarily follow [from always seeing the same doctor] ... if the doctor doesn't make someone, it has got to come from the doctor, too, of relating to the person they're dealing with... if you've got the kind of doctor who is very aloof and not really listening, he could see you twenty times and it wouldn't make any difference because they're not interactive...' (PP01-01).
These extracts from doctors' data similarly illustrate these points regarding the meaning of personal care:
'Well, [personal care is] I think the essence to me of what general practice is, is that you have a relationship with a patient over time and, if you've been their GP for a number of years' (PD01-02).
'I suppose by definition..., I was thinking about personal care, and I was thinking very much in terms of continuity of care and length of relationship and things' (MD03-03).
'...it's an ongoing commitment really, it's not a one-off consultation with an individual patient, but it's kind of something over a prolonged period of time or for which the doctor feels responsible for that patient, outwith a particular consultation. It also means being available, the patient knowing that the person they go to who will take that responsibility for it... It's a kind of ongoing commitment really' (PD01-01).
' [Personal care is not] ignoring their agenda, dealing with only the technical side, not the personal, the emotional side, making presuppositions about them, I mean, labelling them, for instance, failing to negotiate. I think, like I said before, failing to develop any mutual respect or empathy, whatever that might be. It doesn't have to be affection. I mean, ideally, there should be an element of affection, but some sort of respect of the situation they're in and how they're dealing with it' (PD 03-01).
The Benefits of Personal Care
Numerous benefits were ascribed to personal care usually when defined as seeing the known doctor. This is implicit in the way participants talked about what providing and receiving such care means to them (see above data extracts). Most regarded it as an important aspect of high quality care. Patients and GPs reported experience of similar benefits relating to quality of care in terms of, first, improved health outcomes and, second, the experience of seeking, receiving and providing health care.
Patients and GPs reported health outcome benefits including that the doctor's greater knowledge of the context of people's lives led to quicker, more accurate diagnosis and more individualized and efficacious treatment. It was also thought to improve the ability of both patient and doctor to monitor and manage a treatment plan. Both sets of participants reported more patient participation in the consultation, as well as greater patient trust in the doctor, and that this led to the patient being more involved in, and committed to, the treatment plan. In addition, doctors reported that personal care supported them to arrange fewer medical investigations and hospital admissions and to prescribe less, whilst taking fewer risks than with unknown patients. This was regularly compared favourably by GPs to work within the out-of-hours service.
Experience of Seeking, Receiving and Providing Care
The benefits of personal care reported by patients and GPs relating to the experience of seeking and receiving care included that patients could more easily consult about some (though not all) personal concerns. They stated that both time and effort were saved due to the doctor having assumed, shared knowledge of the patient that does not have to be repeated. They agreed that it led to patients generally feeling more comfortable during, and being enabled to participate more in, consultations. Patients were thought to be taken more seriously and to be believed by the known doctor.
Generally, personal care was considered to attend well to the emotional or affective aspects of the experience of seeking and receiving healthcare. In particular, it was described mainly, but not exclusively, by patients as allowing the patient to be known as a competent person with a legitimate claim to service, as someone who would not 'waste' the doctor's time. Patients further emphasised how it enabled doctors to know them as competent parents with expert knowledge of their children. This was clearly of importance to patients as it reassured them during stressful times when they were concerned about their children's health or that of other adults that appropriate medical care would be provided. This was described as resulting in them having their healthcare expectations for themselves and their families better met and generally in being provided with a higher quality service for the whole family. Some patients reported that it sometimes led to ease of access for more urgent care.
In addition, doctors contended that personal care helped them to encourage the patient to 'open up', for them to 'get behind the presenting problem', and to better negotiate an agreed plan of action with the patient which the patient would then be more likely to carry out. GPs noted that providing personal care is what gives them a sense of vocational satisfaction (although it is also reported to place a strain on their own internal resources). Further, they reported that it enabled them to better manage those patients deemed 'problematic'.
In respect of both areas of benefits ascribed to personal care, no differences were noted according to either practice size or deprivation score.
The following extracts from patients' data illustrate some of these points regarding the benefits of personal care:
'Eh, the doctor knows the two of them [her daughters] inside out... she knows it's going to be either 'A' or 'B' between asthma and periods... you're only in about five minutes because you don't have to go through the whole history of them... I think that is a major advantage because when I work full-time, I don't have time to sit for half-an-hour in a doctor's surgery. If you just go in, get seen, get what you want and out the door... Yes, I think it is just the family unit and you want the family unit to be stable... he's got problems [her husband], the two kids have got problems... I just like the family unit to be stable and whoever goes down to the doctor is going to come out with the right answer' (PP 03-01).
'That's if we get the same doctors ... if you get a different doctor, you go, "He's (young son with asthma) wheezy", that's it... or you are so uptight because you are so panicky. Where, if you get your normal doctor, you can relax and go, "Right, this is what has happened..."' (MP02-04).
'I feel comfortable when I do go to those two doctors [her known doctors]. But, if I go to another doctor, eh, you know, I feel uncomfortable. Like, quite a few times I've had a different doctor, eh, I felt uncomfortable, "What can I say to them, like?" But, with they doctors, I just sit there, go in, just sit comfortable and get really comfy. I feel comfortable with they doctors, but with the other doctors I just dinnae feel comfortable' (MP 01-03).
'... somebody who knows you and believes you,..., if you go to a GP that you don't know, they don't know if you are making it up, or exaggerating, and I have a sister who has never got anything wrong with her, and she's a chronic, "Oh, I've got a terrible headache, oh, I feel awful". You feel like saying to her, "There's really nothing wrong with you". It's not that there's nothing wrong with her, but she moans a lot about it, so I suppose the GP knows who's like that or who is quietly saying, "I've got a bit of a headache", and has actually got meningitis...' (PP01-01).
The following extracts from doctors' data similarly illustrate some of these points regarding the benefits of personal care:
'Well, the example again would be the mums. ..."Wee Jamie's not well", you know, "He has a temperature", or whatever. If I knew it was [name of patient], I know she's a caring mum who's got two kids, lives down the street and she's got a nanny and, you know, she hasn't phoned up for a year... I would take this pretty seriously because she never phones up, she's a sensible mum, she wouldn't phone unless she was worried about it. Now, after-hours you get half a dozen plus of these calls. You can make judgments... on people, the way they speak, their address, we have to do that...' (MD04-05).
'I think... if you have to... break bad news, for example, or if you perhaps decide to take a line of management the patient wasn't expecting, I think it's probably much easier to reach agreement with the patient and his family if you know them well than if you don't know them at all' (MD03-04).
'... [not giving personal care is] defensive medicine, you have to cover everything... it's dangerous and uncomfortable, really... where patients go to see somebody new and, then, quite often they get shunted off into all sorts of investigations or tests or treatments or things which I think, in retrospect... were inappropriate really... because of fear of missing something' (PD01-01).
'... if they came in off the street, you would tend to be more concerned about symptoms ...do more tests. ... [In out-of-hours] I'm sure there's a lot more intervention done. ...we get sheets back and you think, "Oh, we didn't need to do that" because, if somebody's seen them cold they would be more concerned about things that we would say, "No, that's alright". [If] you don't know the people at all... not knowing the history... you're pressurized [and this] probably leads you to admit more people... their own GP wouldn't necessarily admit them' (MD03-06).
When Personal Care is Valued
Having the choice of consulting with the known and trusted GP who adopted a particular consultation style generally was deemed to be very important by both patients and doctors. However, participants described circumstances when it was considered very important and others where it was considered less so. Seeing a known doctor was sometimes traded-off against competing priorities or was deemed irrelevant and, in a few cases, it was thought to be undesirable.
As indicated by the above extracts, participants described personal care as being at a premium when patients are suffering from ambiguous or complex problems. It was also thought to be important when a diagnosis is elusive or if patients have multi-faceted, psycho-social or long-term mental health problems. Patients suffering from physical conditions that are chronic, serious, life-threatening or terminal, and for some, though not all, problems of a more personal nature were reported to place a high value on experiencing personal care. Pregnancy was reported to be a time when personal care had a high level of importance. Patients also stated it had particular importance when in a caring role, either as parents of young children or with adults suffering from chronic and debilitating health problems. For instance, such care was thought to be of particular importance when parenting young children as the known GP would be more likely to believe and take them seriously, resulting in their children receiving the care they needed. It was, in effect, described as being one element that supported and sustained family life, especially in difficult life circumstances.
Most patients and doctors reported personal care to be less important for acute and also for more common, everyday problems. Patients stated that they regularly traded-off such care for speed of access to any healthcare practitioner for emergencies or for minor and self-limiting illnesses where 'any doctor will do'. Doctors agreed that personal care has lesser importance for patients in these situations. However, many thought that seeing patients in these situations was still useful for building up a relationship with patients and, so, could contribute to their ability to provide care they experience as personal. Patients prioritising speed of access over seeing the preferred doctor was particularly evident amongst those registered with large practices where more trading-off activity was described than in small ones. This may be explained by the logistical problem of surgeries being held by a larger number of (potentially unknown) doctors than is the case in smaller ones. No differences were noted in this respect by practice deprivation score.
Patients described some situations where seeing a known doctor was undesirable, including for some embarrassing or intimate problems such as gynaecological examinations where gender of doctor was an issue or about sexually transmitted diseases. The problem was identified as being known by and knowing the doctor too well. Patients sometimes wanted to maintain certain boundaries around how they were known by the GP(s) from whom they usually sought personal care. At such times, patients seeing a doctor in the practice with no previous contact with them or having anonymity from another part of the healthcare system, such as a Well Woman Clinic, was preferred. Doctors also acknowledged that providing personal care to patients, whilst being the source of their vocational satisfaction, also carries the risk of them feeling stressed and 'burnt-out', particularly when dealing with patients considered 'problematic'.
The following extracts from patients' data illustrate some of these points regarding when personal care was and was not valued:
'...if it was to do with a lump in my breast, or something like that, I think I would prefer to go and see either [own doctors] because that's the two I'm really close with. ... if I found a lump... or if I felt I was having a miscarriage or something like that, yes, I would definitely go to [doctor who knows her] about those things, more in-depth. But, if it was just a case like... back pain or something, then, I would go to any doctor.... If it was something more personal to do with myself or to do with depression..., then I would prefer to see my own doctor' (MP02-01).
' [Personal care is important] when you have children, in particular... because one of the things that I think that's based on is the fact that the doctor has to trust me. I'm a parent and I know my children inside out, and I know if there's something wrong... so, I think that it's very important that the doctor has to trust my judgements... So...I feel if they trust me to know when... somebody should be seen by the doctor, then that also has to be reciprocated, if they say to me, "Oh, she's fine, just do this, do that, she's ok, don't worry", then I believe them, because the trust is a two way thing' (MP 04-02).
'...where you think it's just a viral infection and temperature and being sick, it would be more important to see any doctor that day because I wouldn't wait for a particular doctor and things like, yes, can you confirm this is chickenpox? ... I don't think it would matter which doctor' (MP03-04).
'....It [seeing a doctor who doesn't know her] could be useful for something where you wanted to be anonymous, if you had a sexually transmitted disease or something.... And, equally, for me, if there was anything like that that I didn't want to go to my GP for, I would go to the Well Woman Clinic..., it's [seeing the known doctor] more just uncomfortable' (MP04-02).
The following extracts from doctors' data similarly illustrate some of these points regarding when personal care was and was not valued:
'For people with chronic problems it's [personal care] really important... I suppose the elderly, just partly because they tend to have more things going on, em, people who have lots of appointments about the same thing, you know, for ante-natal patients, for instance' (MD 03-06).
'I suppose there's probably a group of patients for whom not having personal care is completely ok, ...people, who come in for episodic things... "You've got a sore throat. Yes, it will take time to get better. No, there isn't much I can do about it", the sort of easy reaction to the symptom, prescription and kind of out of the consultation...' (MD 04-01).
'Mainly, [personal care is most important] if someone has been managed for illnesses that might have a psychological component, mental depression or any of the chronic conditions... usually things that require the art of medicine as well as the science. You know, someone comes along and they've got tonsillitis, and... it's just like having a car serviced, if you like, it doesn't matter who changes the clutch. But, if you have to make a diagnosis or management which involves more complex, psycho-social element things, I think it should be the same person...' (MD02-02).
'...one patient I saw every few weeks for years who had a big drug problem and who could be incredibly aggressive ... and I'd go home in the evening, I would feel completely drained, like he'd sucked out all the life-force out of you.... I don't know how to express that, really, because it's a personal resource that's drawn out of you in the process..., which is very satisfying as well... but, you also feel kind of burnt-out, slightly' (PD 01-01).