Article Text

Original research
First contact with the health system: a survey study in northern Portugal
  1. Mónica Granja1,2,
  2. Luís Alves1,2,
  3. Sofia Correia1,2
  1. 1EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
  2. 2Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Universidade do Porto, Porto, Portugal
  1. Correspondence to Dr Mónica Granja; monicagranja66{at}gmail.com

Abstract

Objective The objective of this study is to characterise the self-reported first contact with the health system and the reasons stated for each choice, testing associations with population characteristics.

Design Cross-sectional survey.

Setting Primary care department of a local health unit in northern Portugal.

Participants Random sample of 4286 persons, retrieved from all registered adults.

Outcomes Participants who stated they usually see the same doctor when a health problem arises were considered to adopt first-contact care and were asked to identify their regular doctor. Participants were asked why they adopt first-contact care or why they choose to do otherwise. Associations between personal characteristics and the adoption of first-contact care were tested using logistic regression.

Results There were 808 valid questionnaires received (19% response rate). The mean age of respondents was 53 years, 58% were women and 60% had a high school or higher degree. Most (71%) stated always seeing the same doctor when facing a health problem. This was a general practitioner (GP) in 84%. The main reasons were previous knowledge and trust in the doctor. When this doctor was not a GP, the main reason was the need to obtain an appointment quickly. Participants who chose first-contact care were less likely to have university degrees than those who did not (OR 0.31; 95% CI 0.13 to 0.76). Being registered with the same GP for over 1 year increased the odds of adopting first-contact care: twice as likely for those registered for 1–4 years with the same GP (2.07; 95% CI 1.04 to 4.11), and three times more likely for those registered for over 10 years (3.21; 95% CI 1.70 to 6.08).

Conclusions The high adoption of first-contact care and the reasons given for this suggest a strong belief in primary care in this population. The longer patients experience continuity, the more they adopt first-contact care. The preferences of higher-educated patients regarding first-contact care deserve reflection.

  • Primary Health Care
  • Health Services Accessibility
  • Organisation of health services

Data availability statement

Data are available on reasonable request. The datasets generated during and analysed during the current study are available from the corresponding author on reasonable request.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • This is the first study exploring how and why patients make their first contact with the health care system in Portugal.

  • We used a large random sample from the list of all registered persons of a primary care-based population, irrespective of user status. However, conclusions cannot be drawn for the whole Portuguese population.

  • We used a non-validated questionnaire, with the first-contact question drawn and adapted from the ‘Quality and costs of primary care in Europe (QUALICOPC) patient experiences questionnaire’.

  • The response rate was low. The online response rate was 35% but the paper survey achieved only 10%. However, the paper questionnaires improved the representation of participants who are typically underrepresented in survey studies.

Introduction

Primary care-based systems require the existence of a point of first contact to enter the system whenever care is needed.1 Most often, this point of first contact is a general practitioner (GP).2 Repeated access to the same provider is one aspect of continuity of care. Continuity of the team and of the medical record are also important for high-quality care.3 Continuity improves both patient outcomes4 5 and patient satisfaction.6 It is believed to reduce unnecessary diagnostic and treatment interventions,1 7 to allow for more rational use of limited healthcare resources,8 and to increase the effectiveness of both GPs and hospital specialists.8 9 By seeing their patients over time and in their natural context, GPs are more likely to distinguish psychosocial suffering from a biomedical disease,8 self-limited conditions from those that need treatment, and symptoms that can be safely relieved without investigation from those that warrant a diagnostic workup.

The organisation of first-contact care varies across health systems.10 Gatekeeping is the term usually applied to mandatory first-contact, meaning that a patient must visit a GP before seeing a secondary care specialist.11 Mandatory gatekeeping is less satisfactory to patients,11 is seen as a potential cause of delay in diagnosis and treatment12 and has less sound evidence for its beneficial effects on health outcomes.11 Nevertheless, in countries with no mandatory gatekeeping in place, many patients still choose a GP for first-contact care.13

The Portuguese National Health Service provides universal coverage for a wide range of services. In the public sector, gatekeeping is mandatory for access to secondary specialty care. In the private sector, patients who can pay have the choice to access secondary care whenever they believe it is needed. Primary care, mental health and oncology care are free and low user fees apply for access to public secondary care. However, among members of The Organization for Economic Cooperation and Development (OECD), Portugal ranks as the fifth worst country regarding out-of-pocket health expenditure.14 Households spend 4.7% of their consumption in healthcare compared with the OECD average of 3.1%. Private outpatient services make up 52% of this, which is the highest in the OECD.14 In the private health sector, fragmented secondary specialist care often supplants first-contact care. Indeed, like most of western Europe countries, Portugal seems to be reducing first-contact care.15 This hinders the benefits of continuity and challenges the commitment to the principles and values of primary care. In Portugal, out-of-pocket health expenses are not reimbursed for the general population.14 They can be deducted from income tax, but many affected households belong to the poorest income quintile and are already tax-exempt.14 Partial reimbursement is possible for the 28%–33% of the population who purchase private health insurance14 16 and for the 12% who are beneficiaries of an insurance-like fund17 available for some public servants.

The way patients reach the health system in Portugal has received little attention. International research has found that older, less educated patients and frequent users of healthcare value first-contact with a GP and continuity of care, compared with younger and more educated patients who value direct access to secondary specialist care and timeliness of access.18 These findings need to be reassessed as the population ages and following the challenges posed by the COVID-19 pandemic. Understanding how patients contact the health system and knowing the reasons for their choices are necessary for health systems to adapt the ways they provide care.

The objectives of this study were to characterise the self-reported types of first contact with the healthcare system in the study population, to describe the reasons for each choice and to test the associations between the choice of service for first contact and patient characteristics and views.

Methods

This study is part of a larger cross-sectional study on patient access to GPs.19

Questionnaire development

A self-administered, structured, anonymous questionnaire was designed by the researchers. The development of the questionnaire comprised three phases: (1) a literature review and first version by the three authors; (2) an iterative process of improvement involving other researchers, GPs and laypeople and (3) a pilot study.

In stage 1, comparable studies and questionnaires were reviewed20–30 to ensure appropriate inclusion of all relevant domains, and to provide examples of wording and layout. Most questions were phrased by the authors, but a few were adapted from two questionnaires. For the ‘first-contact question’ used in this study, participants were asked what they would do when a health problem arises. We adapted the original question from the ‘QUALICOPC patients experiences questionnaire’,28 to cover a wider range of options (such as not seeing any doctor and not having experience of any health problems). If participants answered they usually see the same doctor, they were considered to adopt first-contact care and were asked to identify their regular doctor as a public service GP or another provider. We added another question to explore why they chose to see a particular doctor for first-contact for their health issues or why they chose to do otherwise. In stage 2, we conducted an iterative process of improvement involving a convenience sample of other researchers and GPs who gave their feedback on the structure of the questionnaire, on the wording of the questions, and on its content validity. The wording of the first contact question was discussed with a convenience sample of 17 lay persons, two of whom reviewed the full questionnaire regarding wording, length and cognitive burden. In stage 3, the pilot study, a convenience sample of 104 primary care patients, from 4 different family practices, answered both the paper (n=81) and the online (n=23) versions of the questionnaire. The comments provided by these patients, as well as field observations and analysis of the responses, led to changes in the final version of the questionnaire. The study questionnaire is included in online supplemental file.

Sampling and recruitment

Using the Oracle random number generator, a random sample of 4286 individuals was obtained from the adult population (n=151 081) registered in the Primary Care department of Matosinhos Local Health Unit. This is a group of 14 public family practices in Matosinhos, northern Portugal. Matosinhos is a municipality with 172 557 inhabitants, displaying an age distribution similar to the Portuguese population, with differences in educational levels. Illiteracy affects 4% of Matosinhos inhabitants, compared with 6% of the national population. Matosinhos Local Health Unit has nearly full coverage of public sector GPs, with 98% of registered patients having an assigned GP in 2021, compared with 90% of the national population in 2021.

Sample size was calculated for an expected proportion of 50% on most outcomes (the most conservative approach), with a confidence level of 95%, and a margin of error of 5%. Considering the population size, the number obtained was 384, which was further increased to 600 to allow power for inferential statistics. It was further increased to cover an expected response rate of 14%. The response rate considered an expected rate of updated address information of 70% and a response rate of 20% among those who would receive an invitation to participate. Applying a 14% response rate to the 600 persons, we obtained a target sample of 4286 persons to invite.

Between May and June 2021, selected patients were invited by email to complete the questionnaire online, if they had an email address on their record. If they had no email address, they were sent a paper version of the same questionnaire. Two weeks later, one reminder invitation was sent to participants with an email available. Due to budget constraints, no reminders were sent to participants who had been sent a paper questionnaire. Sampling and recruitment procedures were handled by Matosinhos Local Health Unit Information Technology department, so the researchers had no access to any personal data of the selected sample.

Analysis

Descriptive statistics were used to characterise the study sample by age, sex, education and job status, as well as internet access, years registered with the same GP, and perceived health status. Study participants were compared with the target sample regarding anonymised information provided by the information and technology department. Data on sex and age were available for the target sample, whereas education was recorded for 52% (n=2236). Participants were also compared as to mode of questionnaire response. A sensitivity analysis was conducted to assess the impact of the mode of questionnaire administration on the association between sociodemographic and health characteristics and adoption of first-contact care. For that, we restricted the analysis for the group of patients who answered the questionnaire online. Comparisons between groups were tested with Student’s t-test for continuous variables and with χ2 and Fisher’s exact tests for categorical variables. Significance was set at a level of p<0.05. Logistic regression analysed the association between participant characteristics and the adoption of first-contact care, adjusting for sociodemographic and health characteristics (self-perceived health status and years registered with the same GP). ORs with 95% CIs were calculated for all models. Missing data were deleted pairwise. IBM SPSS Statistics for Windows, V.27.0. was used for the analysis.

Patient and public involvement

Laypeople were involved in stages 2 and 3 of the development of the questionnaire.

Results

A total of 808 valid questionnaires (556 online and 252 paper responses) were returned. Out of all posted questionnaires, 73 were returned as not delivered, resulting in an overall response rate of 19% (35% for the online questionnaire and 10% for paper forms). The question about first contact was answered by 792 participants (98%), of which 540 were online and 252 were paper responses. Responders’ ages ranged from 18 to 93 (mean 53.4 years, SD 17.37) and 58% were women. Most participants were employed, had at least a high-school degree, had internet access, were registered with a GP for at least 5 years and perceived their health status as good or very good (table 1).

Table 1

Sociodemographic characteristics of 792 patients registered in primary care in Portugal, according to the mode of questionnaire administration and comparing with the original sample (2021)

Online participants were significantly different from participants responding to the questionnaire on paper. Paper participants were older, more often males, retired, with lower education levels, less often with internet access, were registered with a GP for a longer time and had poorer self-perceived health status (table 1). Compared with the total sample, respondents were more likely to be females, and attained higher education levels (table 1).

Most participants (71%) stated they usually see the same doctor when they have a health problem. This was the case for 100% of paper participants and 58% of online participants. Most often (85%), the same doctor is the responder’s GP. A total of 18% of participants stated they would see different doctors, while 9% stated they do not usually have health problems (table 2).

Table 2

Responders’ conduct when they have a health problem, according to the mode of questionnaire administration (2021)

The reasons most often stated for seeing the same doctor were that the doctor knows the person, and is trusted (table 3), with 75% of participants stating at least one of these two reasons. However, among responders who see a doctor other than their GP, the reason most often stated is it is a means to obtain an appointment quickly (67%), followed by being known to the doctor (56%), trust (37%), and convenient visit hours (28%). The third and fourth reasons given to have a GP as a point of first contact were being affordable (23%) and nearby (23%), while having no choice was stated by 7%. Most reasons given to see the same doctor did not differ according to the mode of questionnaire administration.

Table 3

Reasons stated by responders to see a particular doctor when they have a health problem, according to doctor seen and mode of questionnaire administration (2021)

The reasons most often stated for seeing different doctors (all cases were online responders) were looking for a doctor specialised in the problem of concern (56%) and depending on the visit being due to an urgent problem or routine (32%) (table 4).

Table 4

Reasons stated by responders to vary the doctor they see when they have a health problem (2021)

Responders who usually see the same doctor when they face a health problem differ from those who vary the doctor they see (table 5). Participants with a university degree were three times less likely to report adoption of first-contact care than those with an education level of 4 years or less (OR 0.31; 95% CI 0.13 to 0.76). Being registered with the same GP for over 1 year increased the odds of adopting first-contact care. This is a ‘dose–response’ relationship: those registered for 1–4 years with the same GP were twice as likely to have a point of first-contact (2.07, 95% CI 1.04 to 4.11), while those registered for over 10 years were three times more likely to have a point of first-contact (3.21, 95% CI 1.70 to 6.08).

Table 5

Results of logistic regression models estimating the association between adopting first-contact care and sociodemographic and health characteristics in 792 primary care patients in Portugal (2021)

The results of the sensitivity analysis were similar to those of the main analysis (online supplemental table 1). The only difference found when comparing the online subsample with the whole sample was an attenuation of the ‘dose–response’ effect observed for the association between the number of years with a GP and adopting first-contact care.

Discussion

Main findings

This study of access to healthcare in Portugal found that most participants had a regular point of first contact with the healthcare system and, most often, this was with a GP in the public sector. The main reasons stated for choosing this option were that the GP has previous knowledge of the person and their health problems, trust in the GP, affordable costs and the presence of a GP nearby. A few respondents stated they had no other choice than the GP for first access to care. For participants whose point of first contact was a doctor other than a GP in the public sector, the reasons most often given were getting an appointment quickly, ‘being known’ to the doctor and trusting the doctor. Participants with a university degree were less likely to adopt first-contact care. Being registered with the same GP for a longer time had a ‘dose–response’ positive relationship with the odds of adopting first-contact care.

Strengths and limitations

To our knowledge, this is the first study exploring how patients make their first contact with healthcare in Portugal and the reasons for their choices. In the absence of published data on patient response rates in Portugal, we adopted a conservative approach for sample size calculation. We recruited a good size random sample from the list of all registered persons of an adult primary care-based population, irrespective of user status. However, conclusions cannot be drawn for the whole Portuguese population. Another limitation is that the questionnaire used was not validated. It was constructed after a literature search for validated questionnaires, an iterative process of face and content validity and a pilot study. The first-contact question was drawn from the ‘QUALICOPC patients experiences questionnaire’,28 adapted to include a wider range of options. There are concerns about the response rate. The original sample size calculation suggested that a sample of 384 was required and this was exceeded with 808 valid responses received. A more conservative sample size calculation was used to allow for various reasons for non-response, giving a response rate of 19%. The online response rate was 35% but the paper survey achieved only 10%. This may be partly explained by the fact that, due to budget constraints, we were not able to send a reminder to paper participants, a technique known to improve response rates.31 Nonetheless, paper questionnaires increased the representation of more male and less educated participants, minimising the typical non-response bias in surveys. This bias, that typically leads to an over-representation of females and of higher educated participants, was confirmed in our study when comparing participants with the original sample. However, our sensitivity analysis suggests that the mode of questionnaire administration did not affect logistic regression results. To further minimise non-response bias, the analysis controlled for participants’ characteristics typically associated with selective non-response including sex, age, education and self-perceived health status. However, we cannot rule out other unknown characteristics associated with selective non-response, including those that may be related to first contact with the healthcare system. Finally, the possibility of information bias must be considered, as in any survey-based research.

Comparison with existing literature

There may also be concerns regarding the applicability of our findings in other countries. Comparison with published findings from other settings reveals striking similarities. The reasons most often stated for the choice of first-contact care reflect three core features of general practice: continuity of care (with previous knowledge of the patient), trust (a therapeutic relationship) and accessibility.18 32 They also match patients’ preferences in the general practice context33 and show a connection between continuity and access.

Our study confirms the negative association between higher education and the adoption of first-contact care, found in previous research.13 18 34 More educated patients may be unaware of the benefits of continuity of care, may value their autonomy more, or may fear delayed diagnosis and treatment.12 First-contact care by the GP is mandatory in Portugal only in the public setting. This may convey the message that gatekeeping is used for cost-saving purposes and that, if one can afford it (as is likely with higher-educated persons), better care is believed to be provided by other specialists. In our adjusted models, age, job status and health status did not maintain significant associations with the adoption of first-contact care, in line with previous research.13 This suggests confounding. These variables are also highly interwoven. For instance, age is strongly associated with education in Portugal, where illiteracy rates declined from 33% in 1960 to 3% in 2021.35 Illiteracy is also associated with unemployment, while being retired is more likely as people age. Education is a marker of socioeconomic status, which, in turn, is an enabler of internet access. Older persons are more likely to suffer from any disease.

Only 6% of participants stated they had their GP as a point of first contact because they felt they had no other choice. We also found a positive ‘dose–response’ relationship between the duration participants were registered with the same GP and the adoption of first-contact care. These findings may mean that first-contact care with a GP is an individual choice and that the longer patients experience GP continuity, the more they make that choice. Patients may value continuity of care even though they could afford other choices, seeing GPs more as guides than as gatekeepers.36 This voluntary commitment of patients to their GP was also found in countries without mandatory GP gatekeeping.13

Implications for research and practice

The proportion of patients reporting first contact with a GP for access to healthcare and the reasons stated for this suggest the existence of a strong primary care culture in Portugal. The existence of a two-tier system, with different rules in the private and the public setting, may undermine the strength and confidence in primary care as the foundation of the Portuguese healthcare system. Fostering the use of the GP for first contact with healthcare and recommending it as a healthier, safer and more equitable option, in both public and private settings, could empower patients to make more informed choices, increase their satisfaction with care, and help to achieve better health outcomes.

The study identified higher-educated patients as less likely to adopt first-contact care. The experiences, motivations and preferences of these patients might be explored in further research. Their preferences for specialist care and their need for rapid access to care require clarification. Interventions targeting these patients may be effective in making family practices more appealing to them and in providing information about the benefits of continuity of care.

Further research is needed to study the benefits of first-contact care by GPs in the Portuguese context, and to gather evidence on its benefits and harms, both in mandatory and optional settings.

Conclusion

The high proportion of patients choosing first-contact care and the reasons given for this suggest a strong belief in primary care in this population. The longer patients experience GP continuity, the more they adopt first-contact care. The preference of higher-educated patients to find alternatives to first-contact care deserves further reflection.

Data availability statement

Data are available on reasonable request. The datasets generated during and analysed during the current study are available from the corresponding author on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by Matosinhos Local Health Unit Ethics Committee. This committee reviewed and approved the study protocol on 10/07/2020 (nr. 59/CE/JAS). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors wish to thank: All the people who participated in the pilot and in the main study. Matosinhos Local Health Unit for supporting the random sample process and the expenses of the paper questionnaire. The researchers, GPs and laypeople who participated in the face and content validation of the questionnaire. The principals of the four family practices where the pilot study was run. John Yaphe for the English editing and the critical review of the manuscript.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Presented at The study was presented and awarded as an oral presentation on the 40th General Practice/Family Medicine National Metting, in Portugal, 2023 https://apmgf.pt/2023/04/03/nos-40-anos-da-apmgf-a-qualidade-cientifica-da-especialidade-da-provas-de-estar-mais-forte-do-que-nunca/reply .

  • Contributors MG conceived and designed the study protocol, including objectives, building of the questionnaire, recruitment strategy and analysis, collected the data, performed the analysis, wrote the paper and is the guarantor of the study. LA conceived and designed the study protocol, including objectives, building of the questionnaire, recruitment strategy, and analysis, and critically reviewed the paper. SC conceived and designed the study protocol, including objectives, building of the questionnaire, recruitment strategy, and analysis, and critically reviewed the paper. All authors reviewed the manuscript, read and approved the final manuscript.

  • Funding Instituto de Saúde Pública, Universidade do Porto, covered the costs of printing the paper questionnaires. Matosinhos Local Health Unit (National Health Service, Portugal) supported this study by covering the costs of stamped institutional envelopes for sending and returning the questionnaire. This work is financed by national funds through the FCT- Foundation for Science and Technology, I.P., within the scope of projects UIDB/04750/2020 and LA/P/0064/2020.

  • Disclaimer The funders had no role in the protocol design, in the analysis of the data nor in the writing of this manuscript. No such roles were played in the original study on which the present article is based.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.