Dear Editor

We were interested to read of the positive feedback that Zaldi et al. received from patients attending Saturday morning Ophthalmic clinics at Hillingdon Hospital.[1] The authors raise some interesting questions that we are delighted to be able to address. We feel it is important to highlight the differences between this and our two-centre study.[2] Whilst both groups aimed to address the same issue, the cohort of individuals questioned, the delivery of the questionnaire and the nature of the questions that were asked differed in the two studies.

Zaldi et al. questioned a group of patients attending a Saturday morning clinic in London. This was a select group and excluded all those individuals who either failed to attend or attended during Mon-Fri. In contrast, we invited all patients attending out-patients over a 2 week period to participate in an effort to minimise bias from selecting just one day of the week. Secondly, we conducted our survey at two centres, one in the North (Leeds) and one in the South West (Bristol) in an attempt to more accurately reflect public opinion across the UK. Zaldi et al. point out that in London there is a unique weekday congestion charge that might bias the results from their study in favour of attendance at a Saturday morning clinic.

In the London study the questionnaire was verbally administered by the examining ophthalmologist which might have introduced a ‘desire to please’ from the patients and therefore bias the results. We felt that by allowing individuals to remain anonymous we might obtain more accurate responses to our questionnaire.

Finally, and perhaps of most importance, is the fact that the questions differed in the two studies. The London group directly asked their patients to state whether they had a preference for either a Saturday morning or a 9am-5pm weekday clinic. This produced the figure that 50% did not mind when they attended and 41% preferred a Saturday morning. By contrast in our study we asked individuals to state whether their appointment time was ‘convenient’ or ‘inconvenient’. We found that 89% individuals found their weekday appointment time convenient. A further 7% preferred a different time within the existing 8am-5pm weekday framework. Only 4% stated that a weekday appointment between 8am-5pm was inconvenient. We then asked patients to comment on whether they would find alternative clinic times convenient or inconvenient. We did not ask patients to rank these alternatives in order of preference. From this question we found that 52% would find a Saturday morning appointment convenient. Although the questions are slightly different in the 2 studies, our figure of 52% is in broad agreement with the London study which showed 50% individuals did not mind whether they attended on a weekday or a Saturday morning.

We conclude by stressing that only 4% individuals found their 8am-5pm weekday appointment time inconvenient and 48% would find a Saturday morning appointment inconvenient. Given that the Government supports ‘patient choice’, we feel that these figures justify an expansion of the existing framework rather than the introduction of regular ‘out of hours’ clinics.

References

(1) Zaidi FH, Lee N. Public opinion favours out-of-hours clinics: interviews challenge multi-centre questionnaire [electronic response to Churchill et al. Public opinion on weekend and evening outpatient clinics] bjophthalmol.com 2003 http://bjo.bmjjournals.com/cgi/eletters/87/3/257#133

(2) A J Churchill, C Gibbon, S Anand, and M McKibbin. Public opinion on weekend and evening outpatient clinics. Br J Ophthalmol 2003;87:257-258.

Dear Editor

We read with keen interest the recent article by Churchill et al. that reports a multicentre questionnaire studying out-of-hours clinics.[1] The authors are to be commended for their initiative in performing the first appraisal of patient’s attitudes to government proposals to introduce out- of-hours clinics and operating sessions.[1]

However, it is still left unclear to us as to the accuracy of a key concluding remark of the authors, which we believe is contentious, potentially misleading, and should benefit from clarification by the authors to prevent any confusion. Specifically, we are concerned with the statement that the study found that only 4% of patients will ‘opt for’ out -of-hours clinics. This is a statement of considerable import, which we find extremely surprising given our personal experience of patients attending Saturday morning clinics and based upon a series of interviews we have conducted. When earlier reporting their results the authors also use the figure of 4% to quantify the number of patients reported to have stated that an appointment between 8am and 5pm, Monday to Friday, was inconvenient. Since we are so surprised by the sense of the statement that only 4% of patients will ‘opt for’ out-of-hours clinics, we question whether the authors might not have interpreted this figure of 4% by transposing it from the 4% that found a routine weekday appointment inconvenient, in which case their statement becomes very misleading. Clarification is needed both for the regular readership and beyond, for this is the first study of its kind in a key area of clinical debate, and is thus influential. Even if substantiated, this figure of 4% that are stated to ‘opt for’ out-of-hours clinics might mislead, as the study’s own breakdown of results shows that 52% of patients found Saturday morning clinics ‘convenient’. This breakdown also states that 58% found Saturday morning clinics ‘inconvenient’. But a study we conducted disputes these findings, and suggests instead a spectrum of opinions which by and large resonate with the government’s proposals in this regard.

In a series of interviews conducted by us, 102 consecutive patients who actually attended out-of-hours Saturday morning eye clinics at the Hillingdon Hospital were specifically asked by the examining ophthalmologist whether they preferred a Saturday morning clinic appointment, a routine 9-to-5 weekday clinic, or if they did not mind one way or the other. The results are strikingly different to that suggested by Churchill et al. A slight majority, or 51 patients (50%) simply did not mind whether they were seen on a Saturday morning or in a routine weekday 9-to-5 clinic. The second largest group of 42 patients (41%) said that they actually preferred a Saturday morning clinic, while the smallest group were 9 patients (9%) who said that they preferred a weekday 9-to-5 clinic appointment. Total number of female patients was 65, and male patients 37. Of those preferring Saturday morning clinics 41 % were female and 59% were male. Mean age of patients who preferred Saturday morning clinics was 62, while of those who preferred a weekday appointment it was 70. Reasons for preferring Saturday morning clinics included the following: it was easier for working people and students, which accounts for the younger mean age of patients preferring Saturday morning clinics; reduced traffic; car parking was easy; the hospital was relatively quiet on a Saturday morning making access easy, which was especially important for older people; finally, recent introduction of the weekday ‘congestion charge’ in central London meant that a Saturday morning clinic best suited older patients as friends or relatives saved on the cost of the journey by avoiding travel through central London to pick up the patient and transport them to the hospital – however, this is a factor at present unique to London. Amongst those who were not concerned whether they had a 9-to-5 weekday appointment or one on a Saturday morning, the overwhelming majority, or 86%, were retired. Reasons given for preferring a 9-to-5 weekday clinic appointment were, with six young mothers, children under the age of 12 at home, as the children were at school or nursery during weekdays but not weekends; hospital transport was felt to be easier to obtain on a weekday; surprising reasons were found in two patients who said that they preferred a 9-to-5 weekday appointment so as to have an extra day off work by going to the doctors, while one patient felt a Saturday morning hospital appointment was an infringement into ‘leisure’ time.

While this interview study has fewer patients, there is no missing data for all patients responded at interview - unlike the multicentre study in which only 54% of the despatched questionnaires were used for the analysis. Importantly, these interviews might also be more realistic in that they take into account the experiences of people who have actually attended an out-of-hours clinic. Alternately, it is possible that the markedly different results have arisen as we interviewed patients attending only Saturday morning clinics, while the concluding statement of the authors concerned out-of-hours clinics in general. However, even if this is the case, interviews suggest that the attitude amongst the public to Saturday morning clinics is positive.

Reference

(1) Churchill AJ, Gibbon C, Anand S, McKibbin M. Public opinion on weekend and evening outpatient clinics. Br J Ophthalmol 2003;87:257-8.