We have found that in this rural area, most people had seen a GP in the previous 12 months (93%), slightly higher than the 87% of people reported to had visited a GP at least once during 2015-2016 in Australia (20). There was evidence that the respondents who had not accessed a general practice in the previous 12 months were more often males, and unsurprisingly, younger people, and/or people reporting excellent health status, likely reflecting episodic GP care for acute health issues. These findings are in agreement with patterns reported in the Australian Bureau of Statistics’ Patient Experiences survey (21).The frequency of visits (6.5 in previous 12 months) was similar to the 6.1 visits per capita reported for 2015-2016 in Australia (22). The majority of respondents (78%) reported accessing only one general practice, which suggests continuity of informational care (information relevant to the patient’s care is readily available to the patient and healthcare provider). Over half of respondents had seen multiple GPs in this time, reducing relational continuity. The proportion of people attending multiple practices (14%) is similar to the proportion reported by other, albeit predominantly urban studies (11% (5), 19% (20), 28% (6)) and ours is the first study focussed specifically on a regional setting. Participants from the regional centre in this study were significantly more likely to access multiple practices than participants from the surrounding smaller towns. This may relate to a higher number of practices, practices offering a greater variety of services, increased accessibility, bulk billing and choice in the regional centre. In addition, respondents from the regional centre were more likely to live closer to their GP(s) than respondents from smaller towns, particularly for those who accessed multiple general practices.
Access of multiple general practices:
People who attended multiple practices tended to be younger, more likely to be bulk billed, have higher utilisation of ED and reported more frequent GP visits compared with people who attended a single practice. This may point to this group needing to balance a number of competing needs (balancing work or carer commitments, cost considerations), or seeking care from a number of sources. A similar, although predominantly metropolitan, study reported an association between utilisation of multiple general practices and younger people, metropolitan residence and higher education attainment, but no association with bulk billing, and concluded that use of multiple practices was driven by choice rather than cost (6). Our study suggests that the cost of GP appointments is a factor in a rural setting, perhaps due to the reduced availability of bulk billing compared with metropolitan areas and pockets of socioeconomic disadvantage. This is similar to national data which reports regional areas are more likely to incur out of pocket costs for GP services and were more likely to delay GP services due to cost (23). GP utilisation by rural men has also been reported to be lower than men in major cities (24).
The exercising of ‘choice’ may enable a better fit between the patient and the healthcare provider, but patient choice is complex and reflects a net balance of being willing, and/or able, to choose and actively making a choice of healthcare provider (8). According to an European based scoping review, patients with higher educational attainment, higher incomes, females, younger age and less established relationships with healthcare providers may be more likely to exercise choice (8). An Australian study of the characteristics of people utilising multiple general practices identified similar patterns (3). Utilisation of a subsequent GP practice is likely to be positive for some groups of patients, as their choices are likely to be meeting a specific healthcare need such as a women’s health check with a trusted (often same gender) provider (9), or an appointment for a relatively simple issue that fits around family or work commitments. For other groups of patients such as older people or people with chronic health conditions, care from a single practice appears optimal.
Reasons for accessing multiple general practices:
Reasons for visiting multiple practices primarily related to availability of appointments. In addition, many participants utilised a second practice for specific services such as women’s health checks or for appointments that they considered to be ‘simple’ such as to obtain a medical certificate or prescriptions, in keeping with previous research (25). (26)(27)(27)(27)(27)(27)
Rates of self-reported advice regarding common health behaviours were lower than a similar national study (5) but not significantly different between participants who accessed GP services at a single or multiple practices. Advice regarding exercise or weight loss was significantly less common among non-attenders compared with attenders of at least one GP practice.
Optimal continuity of care has been reported to be associated with decreased utilisation of EDs (27). Our results suggest an association between utilisation of multiple general practices and presentation to ED, in agreement with Wright and colleagues (6). Potentially, this may be due to acute, emergency presentations, injuries, after-hours presentations or need for comprehensive imaging or pathology services (28). Alternatively, utilisation of ED may be due in part to access barriers to GP services (for example; prohibitive cost of non-bulk billed GP services, extended waiting times or dissatisfaction), or that ED services met a particular need (for example, walk-in service or 24-hour care) (28). Respondents who visited no general practices in the previous 12 months were less likely to present to ED than respondents who attended at least one practice.
This study was conducted in one region in one Australian state, although differences between the regional centre and three smaller towns, each with unique features were assessed. Continuity of GP care is complex, and only limited aspects of practice continuity are explored in this paper. Information provided by participants is likely to be subject to recall bias in relation to utilisation of general practice and ED, and receipt of preventative health care. However, face-to-face data collection is likely to have allowed participation by a wider cross section of respondents than self-administered surveys. A small number of participants reported attending a general practice but not seeing a GP. This may be due to these respondents receiving care from a practice nurse or other health professional. The large sample size increases the generalisability of findings to similar rural areas of Australia.
Rural communities in Australia typically have older age structures and higher prevalence of chronic disease than metropolitan communities, and would arguably benefit from high continuity of GP care. However, rural areas of Australia face a multitude of barriers to achieving continuity of care including GP shortages and turnover. Hofer and McDonald have recently outlined practical solutions to increase health service continuity of care in rural Australia including appointment booking procedures that optimise continuity, identification of patients with complex, chronic health conditions, job-sharing and a focus on healthcare staff retention (29). Although it is difficult to achieve, initiatives that enhance continuity need not come at the expense of prompt appointment access for acute health issues, potentially by leveraging effective triage.