Table 2

Summary of themes identified with supporting quotes

Candidacy domainThemesIllustrative quotes
Identification ofCcandidacy
“My knee is sore, I need to do something about it”
  • History of knee problems

    • Downward trajectory

  • Physical and psychosocial functioning

    • Can’t cope anymore

Quote 1:I felt it just one day. It must have been – seeing what’s going on in the photographs – it must have been when the bone started hitting bone on bone because it was just – one day I was walking good, the next day bang. It was giving me a lot of pain but not as much as when you get the bone catching on bone. You can feel it actually grinding” (Interview 19, M, 65).
Quote 2: “Well, I used to be able to do so many things. Now I find I can't do it and it frustrates me. You know, sometimes I like to go out and do a little shopping of my own. Pick up a few things that I like when my daughter is not at home. Fend for myself… I can't” (Interview 5, F, 77 years).
Quote 3: “I’m scared it’s going to give way, that’s why I’ve got the crutches - It did 2 days ago when I was out shopping, I was holding onto the bench of a shop and then I couldn’t walk, so you become wary” (Interview 9, F, 60 years).
Quote 4:Yes, I can’t go anywhere because I can’t enjoy myself. All those sort of things that makes a life worth living” (Interview 13, M, 74 years).
Quote 5:You know I just need this fixed so I can get my life back” (Interview 26, F, 62 years).
“What services can I access for my knee?”
  • GP and social networks as information sources

  • Access to care (conservative treatments)

Quote 6: “The doctor just recommended – anti-inflammatory tablets, because there’s no point – I can’t go to physio because it’s sore in the knee. I can’t walk because it’s sore in the knee. So, they sent me for x-rays. My doctor said, “I think you need a new knee cap. I think your knee’s done”” (Interview 2, M, 79).
Quote 7: “He ( GP ) didn’t really say anything at that point. I hadn’t done any physio, he didn’t suggest it because he handballed it to…the specialist, first” (Interview 21, F, 52 years).
Quote 8: Well when I first started getting it, I remember I thought I'd have to be in a wheelchair. But then my sisters told me, or one of them, “Well why don’t you go swimming?” And with my knee pain, that helps a lot” (Interview 18, F, 72 years).
Quote 9:A friend of mine in his 70 s…he just had both of them done… and he reckons it's fantastic. I've spoken to quite a few people and it's – when you're in a place that is not very good for being able to do something as simple as walking down the street, any option is a better option than what you've got. I certainly don't think it's going to get better on its own” (Interview 3, M, 63 years).
Quote 10:Just go to the local GP and see what information…or Google it, mainly Google it just to see what people are doing” (Interview 6, F, 55 years).
Quote 11: “When I had sciatica, they sent me to the pool and I did a class and then I just carried on, on my own, just doing the same exercises as I'd done in the class. But the physio there, I asked her what I could do for my knees and she just told me to do this exercise and that exercise” (Interview 3, M, 63 years).
Quote 12:Actually ( GP ) has suggested the pool but there isn’t one really close and then it impacts on me financially because I’m not working, I’m on a disability pension, what I can do ( is ) very frustrating. You’re meant to be doing extra things but then you don’t have the money to do it, and it’s like, well, yeah” (Interview 9, F, 60 years).
Permeability of services
“How easy is it to access the services I need?”
  • Referral pathway for surgery is easy/linear

  • Referral pathway for conservative treatment is unknown and complex

Quote 13: “They haven’t really told me what to expect, because it's been so quick a process. I've seen ( GP ) and I went and saw him to go through to ( Hospital ) and then I've been on Friday for the pre-admission” (Interview 17, F, 66 years).
Quote 14: “The GP just sent a letter to ( Hospital), and that was it. The next thing I heard was from ( Hospital), and I went up to do all the tests, and so forth” (Interview 2, M, 79 years).
Quote 15: “I don’t know, they offered me some things to do and I couldn’t even do it. I said, “I’ll do what I can” but no, it didn’t work. My knee got worse, actually” (Interview 1, M, 65 years).
Quote 16:I haven’t been going to physios or anything like that…Because they probably don’t do much for you, because you've got to do it yourself. You've got to make sure that you do the right thing I suppose. Because that's all – they can't replace my cartilage” (Interview 18, F, 72 years).
Quote 17:I've decided that a knee replacement thing, and I've just gone along that path. There may be other things out there that are available, I personally can't think of any” (Interview 10, M, 70 years).
Appearances at health services
“Can I communicate the pain I am in and the impact it is having on me to the doctors?”
  • Communication of impact

    • Use of pain/opiate medication

Quote 18: (I said to the GP ) Look I can’t go on like this. I need something to be done.” And so he referred me to the orthopaedic people” (Interview 13, M, 74 years).
Quote 19:I said to ( the surgeon), put me on the general waiting list. I need to have it done. I can’t live. I mean, I was on so much Oxycontin, like you wouldn’t believe… I was on that for five years and not something I put myself on, my doctor put me on it. And then you get addicted and then you’re in all sorts of trouble” (Interview 21, F, 52 years).
Quote 20: “Yeah, I went and saw my doctor, my GP. Had the specialist’s name and phone number and I showed it to my doctor and said, “I’d like to see this specialist”. And he just said, “Yeah,” which is good” (Interview 22, M, 56 years).
Quote 21:I went back and saw him a couple of times. He said try and put it off for as long as you can. He recommended 65 and I sort of, I can't hang on another 10 years, oh my god. So I sort of put it off about two more times” (Interview 6, F, 55 years).
“What do the doctors think I need?”
  • Predominant health professional referral pathway GP-Surgeon

    • Communication

    • Comorbidities and age

Quote 22: “I went to see my doctor and they sent a letter off to (Hospital 1) and (Hospital 2), and (Hospital 2) were the quickest. They took me in and it was all done in about five or 6 weeks (Interview 2, M, 79 years).
Quote 23:I don’t even talk to the GP about the knee anymore, because they can’t do nothing for me. I just get the referrals” (Interview 1, M, 65 years).
Quote 24:I think there should be more consultation between the surgeon and your doctor. Prior to surgery and after surgery. At one point ( the surgeon ) mentioned about having steroid injections. My GP never mentioned it, I didn’t want to go down that path because she was just saying that. Now if that’s something that she thought might have worked, maybe that’s something that should have been passed onto to my GP from her, saying, “These are some avenues that we can look at.” Trying to resolve this at the moment, before going to surgery. There doesn’t seem to be that kind of communication, just, “Oh, we went in, we found this and that’s what it is.” End of story, just like a diagnosis” (Interview 21, F 52 years).
Quote 25: “Everything else, we’ve ticked the box, but I’ve got a slight mark on the back of my leg, which my doctor thinks it might be a melanoma, and I have to get a biopsy on it. I’m getting that done tomorrow. They only rang me up today to tell me that, yes, the operation’s okay if I find out what’s on the back of my leg and get it fixed” (Interview 4, M, 77 years).
Quote 26: “I’ve just been putting up with pain, just waiting – because virtually the doctors say I’m too young. But everyone in my family don’t live until – they all die before 70. So, what, am I going to live for the rest of my life in pain? My way of thinking about it is get it done, get on with life so I can get back to work. I want to work” (Interview 19, M, 65 years).
Offers and resistance
“Should I do what the doctors say I should do?”
  • Pain and physical activity

Quote 27: “No, not really, early on we tried - I tried walking and things like that, even getting on the exercise bike, but it got to the stage where it was just too painful” (Interview 10, M, 70 years).
Quote 28:It felt good at the time. But, after an hour, I was just back to square one. I thought, “I’m wasting the physio’s time and I’m wasting my time,” because it cures me for a couple of hours, and then, I’m back to square one…I just stopped going back” (Interview 2, M, 79 years).
Quote 29:Well she gave me exercises to do and everything like that, and I said, “Look, it’s not doing anything, and it’s actually made it worse – aggravated it” (Interview 1, M, 65 years).
Quote 30: “Not really. Even attempting to walk any wee distance is a lot of work. But, nothing else has – I mean, the doctor wanted me to try riding a bike. What the hell am I riding a bike for? It’s worse than the pain in my kneecap!” (Interview 2, M, 79 years).
Quote 31:Well, to me what’s the point in trying to do something when something’s worn out? I believe in nuts and bolts and if something’s worn out you pull it out and put a new part in” (Interview 19, M, 65 years).
Quote 32: “I go to the pool every morning. I go to the pool every morning and I walk in the pool and that really helps to keep it moving and keep the muscles warm. So, it does help” (Interview 25, M, 64 years).
Quote 33: “( CrossFit ) 3 days a week. And then the riding I’ve been doing as well so even if I’m not going on social rides I ride to the shops or things like that, I ride to CrossFit, that’s 11 km round trip” (Interview 7, F, 66 years).
Operating conditions and the local production of Candidacy
“I’ve decided to have a TKR,
When and where can I have it done?”
  • Familiarity with local system

  • Availability

Quote 34: “I was very happy with the care and the treatment I received from those people. I think all the nurses and the doctors, the specialist there, they spoke very confidently to me and to tell me the position I was in and what they’re going to do. So I felt very at ease. And knowing I'm in professional hands and those people know exactly what they’re doing” (Interview 25, M, 64 years).
Quote 35: “Oh well it’s partly because I’ve had one already and I know that it made a huge difference… So it’s probably an easier decision when you’ve already been there and done that” (Interview 8, F, 66 years).
Quote 36: “I was waiting and waiting for my name to come up I just felt that my life was on hold and I couldn’t plan anything” (Interview 12, F, 75).
Quote 37:Look, if it can be improved I’ll be happy about it but the thing is I don’t know the capacity of how many people a year, how much surgeries a year, how much operations they’re having. So, I can understand that sometimes they have to put you back a little bit” (Interview 25, M, 64 years).
  • GP, general practitioners; TKR, total knee replacement.