A conceptual model of urgent care sense-making and help-seeking: a qualitative interview study of urgent care users in England
- 153 Downloads
Theoretical models have sought to comprehend and conceptualise how people seek help from health professionals but it is unclear if such models apply to urgent care. Much previous research does not explain the complex interactions that influence how people make sense of urgent care and how this shapes service use. This paper aims to conceptualise the complexity of sense-making and help-seeking behaviour in peoples’ everyday evaluations of when and how to access modern urgent care provision.
This study comprised longitudinal semi-structured interviews undertaken in the South of England. We purposively sampled participants 75+, 18–26 years, and from East/Central Europe (sub-sample of 41 received a second interview at + 6–12 months). Framework analysis was thematic and comparative.
The amount and nature of the effort (work) undertaken to make sense of urgent care was an overarching theme of the analysis. We distinguished three distinct types of work: illness work, moral work and navigation work. These take place at an individual level but are also shared or delegated across social networks and shaped by social context and time. We have developed a conceptual model that shows how people make sense of urgent care through work which then influences help-seeking decisions and action.
There are important intersections between individual work and their social networks, further shaped by social context and time, to influence help-seeking. Recognising different, hidden or additional work for some groups may help design and configure services to support patient work in understanding and navigating urgent care.
KeywordsUrgent care Patient work Help-seeking Sense-making Qualitative methods Healthcare utilization Healthcare service
‘999’ emergency ambulance service
Accident and Emergency Department
National Health Service
The health services research literature includes now classic studies that attempted to conceptualise how people seek help from health professionals [1, 2, 3]. Theorising about help-seeking has, in the past, focused on utilisation behaviour for specific conditions (e.g. mental health ; long term conditions ), lay referral networks ; or organisational factors [6, 7]. In the past these have been used to inform help-seeking for urgent and emergency care. These explanations predate the expansion of urgent care and the provision of a range of expanded services for unscheduled contact and also the activity that lies at the interface between lay and formal systems of healthcare. In this paper we develop a model which builds on earlier literature to conceptualize help-seeking as a social process, one that entails different kinds of work, and which is grounded in the temporal, spatial and social contexts people occupy.
Urgent care is typically defined as healthcare that is needed for a condition that requires prompt attention (‘same day’ or within 24 h) but is not a life-threatening emergency. These services are designed to assess and manage unscheduled conditions, which often arise outside core office hours [8, 9]. NHS (National Health Service) urgent and emergency services are free of charge in the United Kingdom (UK). A range of urgent care services is available in England alongside emergency departments and the 999 emergency ambulance service. These include general practice out-of-hours services, a telephone-based triage non-emergency service that can assess and refer patients to different services (‘NHS 111’), walk-in centres, and minor injuries units. This expansion in service provision arises partly in response to consumerism [10, 11] underpinned by rhetorics of patient choice [12, 13]. A further policy imperative has been an aspiration to use urgent care to divert people away from overcrowded emergency services and to encourage greater use of self-care . The impact of these structural changes has created an increasingly complex care landscape characterised by fragmentation and blurred boundaries between services . In the face of this complexity, there is a need to understand peoples’ help-seeking behaviours and the work that they do to make sense of urgent care.
Research about help-seeking for urgent and/or emergency care using surveys and qualitative interview methods [15, 16] has shown that people seek urgent care about symptoms that are perceived to be severe, unusual, worsening, or causing pain [17, 18, 19]. Users make contact for medical care and advice, and to seek reassurance . Much research reflects a pre-occupation with the ‘inappropriate’ use of emergency services [21, 22], often pointing out that people find it difficult to judge ‘appropriate’ contact and worry about using services unnecessarily [19, 23]. In a situation where contact with a service has yet to be made, appropriateness is negotiated in patient and professional interactions  and assumes a post-hoc attributed status . While help-seeking is influenced by previous experiences and perceptions of accessibility [16, 26], several studies suggest that people occupy a liminal space, not knowing where to go [17, 26, 27] in which they consider and have to eliminate different, uncertain options. For example, people may use emergency department services when general practice is not available , or to access more ‘specialist’ care , or because the emergency department offers shorter waiting times and ease of access [26, 29]. Additionally, patients are increasingly using online information which may also shape decision making and help-seeking behaviour . Many studies describe and categorise reasons for help-seeking but do not explain the complex interactions that influence why and how people process information and build understandings to make sense of urgent and emergency care and how, this in turn, shapes how they navigate and use services. This paper presents new data from a large qualitative interview study of urgent care users and proposes a conceptual model that attempts to capture the complex processes at play in peoples’ everyday evaluations of if, when, and how, to access urgent or emergency services.
Many factors have been shown to influence service utilization . Theories of cognition, decision making and learning, drawn from social psychology focus attention on individual beliefs as triggers to help-seeking. The Health Belief Model, for example, describes psychological and motivational determinants of health service use, where cues to action (e.g. pain) and the readiness to act may be modified by individual and demographic characteristics such as gender, personality and social class , Andersen and colleagues [3, 33] showed how service use was influenced by individual level predisposing factors (e.g. health beliefs, age, education, social position) but also by community and enabling resources (e.g. income, access to transport). While this work showed that individual factors were associated with particular service use outcomes it placed little emphasis on social networks and social interactions . While Andersen (1995)  suggests that these concepts broadly ‘fit into the social structure component’ of the model, they are not clearly explicated with the conceptual framework.
Work by medical sociologists has attempted to augment the understanding of help-seeking as a social process [1, 2, 35, 36] examining how and when help is sought, rather than service utilization per se . Early work by Freidson (1961)  showed how lay referral networks influenced help-seeking behaviour. However, much of this work still presented help-seeking as the outcome of rational decision-making. Later work by Pescosolido (1992)  challenged this, presenting help-seeking as a more dynamic and contingent process in which socially constructed interactions and networks, and context influenced help-seeking.
More recently, Wyke et al. (2013)  have argued that models of illness behaviour have been developed in ‘disciplinary silos’. Existing theories and conceptualisations typically provide a set of psychological and/or social determinants that can be enrolled to explain urgent care help-seeking, but they offer less insight about the work that people do to make sense of their care needs, and how they assess the care options available to them at different points in time and illness trajectory.
Our paper attempts to re-focus attention on the ‘work’ people do to make sense of urgent care. There are many theories that have conceptualised patient work e.g. [38, 39]. Previous theorising around patient work has tended to focus on chronic illness but it is a useful means of understanding patient help-seeking concerning urgent care, and we particularly draw on concepts of work by Corbin and Strauss (1985) . We also enrol the concept of sense-making as developed by Weick (1995) . Our aim is to explicate how people make sense of urgent care through the work that they do when they experience a health problem, and in turn how this drives action e.g. seeking help from services or choosing not to seek help. This enables us to avoid simple binaries of ‘appropriate’ or ‘inappropriate’ service use and understand the processes and effort entailed in thinking (sense making) and acting (help-seeking). Our paper distinguishes three types of work patients do to make sense of their urgent care needs and services and we explore how social networks, contexts and time influence urgent care help-seeking.
A typology of urgent care work and a conceptual model of urgent care sense-making and help-seeking was developed from analysis of serial semi-structured interviews that explored perspectives, experiences and decision making around urgent care. Ethical approval was granted from the NHS Health Research Authority (16/EM/0329).
Participants were drawn from four counties in Southern England. We purposively sampled to represent potential differences in urgent care need, and socioeconomic and demographic characteristics: people aged 75+ years, and those aged 18–26 years were chosen to reflect populations with known high use of emergency care and a third group, people from East and Central European communities, was chosen to capture the experiences of recent migrant populations. Whilst there are other groups that are known high users of services, such as parents of young children [26, 41, 42] the populations in our study were chosen because they are groups for whom we lack evidence about help-seeking and decision making around health service use. We recruited people using a combination of community-based and local media advertising, and from those attending NHS urgent and emergency care services. Interested participants were either sent an information pack or provided with this by a research nurse. To encourage participation a £15 gift voucher was given for each interview.
Number of interview participants by population group
Number of participants
Older (75+ years)
Younger (18–26 years)
Older (75+ years)
Younger (18–26 years)
First interviews explored peoples’ understandings of urgent care, how they distinguished between routine, urgent and emergency care needs, and their knowledge of available services. The second interview explored issues raised in more detail and focussed particularly on recent experiences and decision making about urgent or emergency care help-seeking. Topic guides were used (See Additional file 1 – Interview topic guides), informed by the literature and by citizens panels conducted in the wider project . Interviews were face-to-face, carried out by two female members of the research team (GM and JT] and lasted between 35 and 90 min. Most interviews were conducted at participants’ homes, but a small number were conducted at University offices or other premises. The interviews were digitally recorded, with consent, and transcribed verbatim as anonymised documents for analysis.
Analysis and developing the model
We used a thematic analytical approach, broadly following the stages described by Braun and Clarke (2006) . The research team (JT, CP, JP, GM, AR) initially read and open coded a sample of transcripts independently, then discussed emerging codes to form the basis for a coding scheme which was refined and applied to all transcripts. The team worked together to interpret data, building emergent themes and developing narrative and interpretive summaries, using Atlas.Ti to manage and access data. In the later stages we drew on the Framework approach  creating matrices and charts to aid comparative analysis. We also created typologies to map our interpretations and begin sketching the relationships and connections in the model, referring back to the data and thematic analysis throughout this process. We continued to use comparative analysis to identify factors that were common or contradictory in different care contexts and in different populations. From this work we were able to test emerging hypotheses about how sense-making and help-seeking related to each other, providing the framework for the conceptual model presented in this paper.
Typology of urgent care work
Concept of work
Social network level
Nature of the work
Assess and manage symptoms, regimens, and risk, and actions associated with these
Assess and manage symptoms, regimens, and risk, and actions associated with these across social network members
• Interpret, manage, evaluate symptoms and risk of symptoms
• Identify what is being sought from a service
• Decide if help is needed and/or level of care required
Assess and legitimate ‘appropriate’ service choices
Assess and legitimate service choices in comparison to others and influenced by others
• Decide what is appropriate use
• Construct self as credible, responsible and appropriate service user
• Balance moral positioning against health risk
Assess services available (choose) and decide which to access (use)
Assess services available (choose) and decide which to access (use)
informed by social network
• Know about, and choose, services, facilities and resources available at different times of day
• Decide the most acceptable or convenient choice
The work of making sense of urgent care
P19: I didn’t know what else to do at the time because I was in a state. Well not panic, but I was highly stressed. I thought ‘I don’t know what to do’ so I just dialled 999 [ambulance service]. (Older).
P66: I called my dad ... ‘Dad … can you bring a first aid kit and just give me an opinion on whether you think this is a bad enough cut?’ Because I just... I didn’t know... (Younger).
P52: Well it’d be you, wouldn’t it [husband]? Then [our] daughter and then the GP [general practitioner]. (Older).
P53: I think the most important one would be my mum, as well as my closest friends. The least, would be work. Yes, [and] the internet. (East European).
P93: The neighbours are brilliant. They are so important as they are invariably there. Or I could phone our really good friends who are a 10-min drive away…then the GP [general practitioner]. If I needed my son or daughter for anything … well, yes, if I needed them to come, I know they would come. (Older, married carer with children far away).
P54: I can definitely put my husband and mother [as sources of support] … She’s a Doctor … a paediatrician. (East European).
P65: My mum was really supportive. Friends…a little less so, because … just, especially at that age , I don’t think anybody really, had much of a clue. Couldn’t empathise properly with what I was going through … ‘oh, he’s always ill’ … ‘attention and whatever’. (Younger).
P54: I may use my mum sometimes but I just don’t really want to bother her because she’s just going to be so worried. I would probably prefer to do … online symptom checks. (East European).
P23: I think we were brought up in that generation, at the beginning of the war, and you had to get on with life  You just try not to bother people. I never go to the doctors, if I can help it  They’re [the ambulance service] up to their eyes. (Older).
P57: There would be an instinct in me [to use NHS 111] … I don’t want to make a fuss out of something that might not be a fuss, or I don’t want to annoy the doctor. (Younger).
P5: It was pretty easy to make the decision to go to the pharmacy, so I wouldn’t have bothered the doctor or even the nurse. (Older).
P13: People panic so much. They can have a little thing like ‘alright you’ve broken your arm, it’s going to hurt like hell, but it’s not a big deal, you’re not dying’ … You need to go to A&E [Accident & Emergency Department] when you are bleeding like severely, or something … fatal … Unfortunately, we were there for something that really was not quite an emergency … but I panicked. (Younger).
P68: I tend to play down a lot of how I’m feeling, because I don’t like going to the doctor and I don’t want to go to hospital, but my boss said ‘no, I think you need to call [NHS] 111, you’re clearly not right’. (Younger).
P70: It’s a nuisance to get to the hospital because it is an hour away but once you are there…
Interviewer: It’s all there?
P70 : At the hospital [laughs]
Interviewer: So here in town, there are different services [urgent care] at different places…
P70: Yes. And that’s a bit of a pain. (Older)
P5: I prefer to go to one of the drop-in centres, rather than up to [ED] because ... it’s usually overflowing, isn’t it, with people waiting to be seen ... It’s a pleasanter experience, anyway, at [the Walk in Centre]. (Older).
P1: It’s more difficult to go to walking-in centre because most times you wait … You fill in loads of forms and definitely it will take you at least two, three hours  I think the walking-in centre is good if you can’t get your appointment at GP [General Practitioner]. (East European).
P37: If you think something is not all that wrong but you still need to go to A&E, having the luxury of picking and choosing the time, like, go in the early hours of the morning because that might be a bit emptier, you’ll be seen quicker. (Younger).
P46: The A&E was very calm, they served us pretty quickly in, like, half an hour or so. (Younger).
P67: With the knee, I think Friday or Saturday night, we actually didn’t want to go to A&E because you obviously spend, sometimes a few hours and it wasn’t that serious  So we just rang them up and said ‘what is the approximate waiting time?’ … and they say ‘it is busy but you can try later on’ (East European).
P22: I knew it wasn’t really the correct place. I wanted a walk-in centre but there isn’t a convenient one … There’s the one in [area name] but trying to get [there] is murder, and the other one, it’s so far away you could die on the way. (Older).
P76: 111… you ring them up and they kind of assess you on the phone … you do not have to go all the way to hospital … talking on the phone beforehand [is] a better option because when you are in A&E you are around so many people who have different problems, a lot of it is people on drugs, or drunk … it’s a bit overwhelming (Younger).
P40: I tend to make my own decisions but sometimes I’ll ask my mum. But I know a lot of people … ask Facebook sort of thing. (Younger).
P28: If you’re on your own, it’s different. I mean, if I hadn’t had [friend] to talk to, I wouldn’t have gone to A&E at that stage. I might have left it a bit later. (Older).
P7: I’m lucky because I have backup around me, or even the neighbours. I mean, for my eyes, I talked to several people within the [street] … then there’s the U3A [University of the Third Age, an international movement for mainly retired members], [the] Choir and the Masons. (Older).
P2: The Polish community families, the new families, are quite fragmented. So it’s people who have got to know each other over here … normally, back in Poland, the community is very close … you tended to be born somewhere, find work, study around that area, and have family not far … Whereas here, I think people tend to panic a little bit … a young family, isolated from everybody. They don’t know who to go to, so go to A&E. (East European).
The relevance and influence of socio-temporal context
P2: [There is] the likelihood of me … over-stating … you know, exaggerating. Because it’s me, and I’m on my own. It’s me, me, me. Yes, especially at night things may seem, a lot more drastic than they really are. (East European).
P28: I knew [a friend] would take me. But she had to come over from [different area] ... If somebody’s taking me... she’s got to get here, she’s got to get back afterwards. (Older).
P23: My neighbour … I’ve only got to ring her and she was round … She is always there for me … But … I thought, ‘this is like 7, 7:30 at night, I’m not going to be able to cope with him [husband] on my own, [later] in the night, if it goes on like this’. I know … if I’d have rung [her neighbour] she can come around. But there’s something different about bothering them in the middle of the night to the daytime. (Older).
P1: When you’ve got children [when husband was ill], should I take them with me [to healthcare service]?  I don’t know if I could ask neighbours to come … because I never had to try that. But I can phone for example, my sister … (East European).
P32: Monday is quite a busy day [for health services] because everyone waits the weekend … I work nine to five so I would probably try to do it out-of-hours if possible or over my lunch break. (Younger).
P55: If it’s the weekend then I would contact them normally. But they’re not always around, you see? They’re all at work. You can’t rely on your family. (Older).
P23: [The bus] stops at the bottom of the road … then it stops outside the hospital. It’s free for me because I’ve got a bus pass … If I can, I get there under my own steam. My neighbour really gets angry with me because I don’t ask for a lift … I said, ‘all the time I can do it, I will do it’. (Older).
P47a: Is there like option [with NHS 111] … to avoid all the questions? Because … obviously people with less understanding English they get confused as well. (East European).
While our data does not represent other communities for whom language may be barrier, such as those with learning or communication difficulties, these are likely to shape choices in similar ways.
Our findings resonate with existing literature [24, 49] but illuminate the social processes relevant to urgent and emergency care help-seeking. We have shown that service users hold strong moral views and are highly sensitive to arguments about ‘inappropriate’ help-seeking in the emergency department. However, they often externalise these judgements such that moral rules are applied to others (e.g. characterising others as ‘time wasters’) [10, 23, 27]. We observed fewer moral judgements regarding the ‘misuse’ of urgent care services and this seems to reflect the dominance in public discourse about ‘overcrowded’ emergency departments and the idea that such services are sanctioned as needing to be available to all comers. We have also shown that people make choices influenced by what is accessible at a given time of day [25, 48]. Urgent care provision is variable, and there is inconsistency in provision across different areas. Waiting time is a strong factor in decision making. National Audit Office figures suggest that patients registered with general practices that are open fewer than 45 h per week attend the emergency department more often . Road and transport links may further influence accessibility of some services  and our data suggests that proximity is temporal as well as geographical (e.g. the hospital may be ‘nearer’ at night because of car and motorway access). These temporal and spatial features are highly socially patterned: older people for example relied more on others for transport than other groups, recent East European migrants may have less knowledge of services in their locality and this will limit their choices.
Strengths and limitations
We have drawn on, and extended, existing concepts of help-seeking and have applied these to acute rather than chronic illness. Data from our large interview sample allowed us to delineate a typology of the work entailed in sense making and help-seeking. This builds on the core concept of individual illness work, adding in moral and navigational work and extending the conceptualisation to emphasise the role of social networks and socio-temporal context. Previous research of this kind has often been limited by small sample sizes, and has tended to focus on particular determinants (e.g. waiting times or transport), and/or on specific patient groups. We have looked at how a large and diverse sample of service users make sense of, and use urgent care. We examined three specific population groups, determined not by the nature of their illness but by their demographic features. Elderly populations have been the focus of other studies  but younger and migrant populations have received less attention. Studying these three different populations allowed identification of group differences and a more holistic understanding of sense-making and the moderators of their decision-making processes.
We cannot be sure that the South of England fully reflects the full range of views and experiences across the UK and elsewhere. Whilst this setting is not the most socio-economically deprived when compared with other parts, the area includes pockets of deprivation and some areas are in the most deprived quintile nationally (e.g. parts of Portsmouth, Southampton, Reading), and contains areas that are in the most affluent categories (e.g. Wokingham, Aylesbury). The setting also includes major cities (such as Portsmouth, Southampton, Oxford) and a mix of urban and accessible, and more remote rural areas. It is possible that our three groups do not fully reflect the full range of views and experiences, for example, in the Eastern European group, those that participated had very good levels of spoken English and were well educated. It is not clear if we would have observed similar sense-making and help-seeking in a more diverse group, but it seems likely that lower levels of English language may lead to even greater difficulties in navigating urgent care. Similarly, our younger group were largely recruited through educational establishments and may thus have a higher level of education compared to the wider population. In addition the use of interviews enabled us to capture peoples’ self-reported accounts of service use, not actual use. To mitigate this the use of follow-up interviews provided some opportunity to probe accounts and explore encounters with health services that took place between interviews and this may have encouraged more reflexive insights about actual behaviours.
Our conceptual model frames the interaction between thinking (sense-making) and action (help-seeking) and emphasizes the work implicated (for individuals and their social networks) in accessing urgent care. It shows how the individual and their social networks work to interpret illness, make moral judgements and navigate services. Traditionally policy and research has focussed on service use outcomes, from which we infer ‘wrong decisions’ and ‘inappropriate help-seeking’. Our model suggests that to change outcomes, there needs to be a change to the work people do, collectively and individually. This understanding of work may mean that policy and interventions focus less on blaming ‘incorrect’ sense-making and ‘inappropriate’ decision making, and begin to support patient work. People do not deliberately make ‘wrong’ help-seeking choices, these choices are a product of the work that they do. Recognising that different or additional work may be required for different groups (e.g. different age groups, migrant populations) can inform service design and signposting, but must be directed at the work these groups have to do. For example, some migrant groups will have no experience of non-hospital based urgent care. They need support to navigate this different care landscape and health and local authorities might need to consider making service ‘maps’ available in relevant languages. Advertising and health education campaigns could better reflect the social and temporal drivers that might push people towards particular services, for example acknowledging that sense making and help seeking are different at different times of the day.
At a structural level the impact of the frequent reconfiguration and extension of urgent and emergency care services on patient work should be considered. Patient-centred co-design methods, could be enrolled to better demarcate the routes from self-care, to primary, urgent and emergency care in ways that the public can understand. Recent UK policy has proposed a single multidisciplinary Clinical Assessment Service within integrated urgent care services ‘to provide specialist advice, treatment and referral’, and ‘encompass both physical and mental health’ ; this may support some of the work we have outlined. Beyond this there are structural changes, such as standardisation of Urgent Treatment Centres opening hours and facilities  that will support the work entailed in sense-making and help-seeking. Policy and provision has increasingly focused on signposting and standardizing urgent care services. Such approaches may help reduce the complexity of urgent care work that patients are expected to engage in. It is clear that changing peoples’ help-seeking (action) is contingent on changing the nature of urgent care work, to encourage better experiences of urgent care and more effective health care use.
We would like to thank all participants who took part in this study. We would also like to thank Andrew Lennon and Rob Crouch (members of the wider research project team), and our patient group and advisory board members who informed this research.
JT designed the study, collected and analyzed the data, and drafted the manuscript. CP designed the study, analyzed the data, and contributed to the draft of the manuscript. JP designed the study, analyzed the data, and contributed to the draft of the manuscript. GM collected and analyzed the data, and contributed to the draft of the manuscript. AR contributed to the design of the study, analyzed the data, and contributed to the draft of the manuscript. All authors have read and approved the final manuscript.
The project was funded by NIHR HS&DR programme grant number 14/19/16. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the HS&DR programme, NIHR, NHS, or the Department of Health and Social Care. The research was conducted independently of the funding body. The funding body was not involved in the design of the study, or the collection, analysis, and interpretation of data or in the writing of the manuscript.
Ethics approval and consent to participate
Ethical approval was granted from the NHS Health Research Authority (16/EM/0329). All participants provided with a participant information sheet and provided written consent before taking part in the interviews.
Consent for publication
Catherine Pope, Gemma McKenna and Anne Rogers are members of the NIHR CLARHC Wessex.
Joanne Turnbull and Jane Prichard declare that they have no (financial or non-financial) competing interests in relation to this manuscript.
- 4.Pescosolido BA, Boyer CA. How do people come to use mental health services? Current knowledge and changing perspectives. In: Horowitz AV, Scheid TL, editors. A Handbook for the Study of Mental Health: Social Context, Theories, and Systems. New York: Cambridge University Press; 1999. p. 392–411.Google Scholar
- 5.Wagner EH. Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clin Pract. 1998;1(1):2–4.Google Scholar
- 8.NHS England. Transforming urgent and emergency care services in England - Urgent and Emergency Care Review. End of Phase 1 Report. Leeds: NHS England; 2013.Google Scholar
- 25.Rogers A, Hassell K, Nicolaas G. Demanding patients. Analysing the use of primary care. Buckingham: Open University; 1999.Google Scholar
- 36.Freidson E. Patients' Views of Medical Practice. New York: Russel Sage; 1961.Google Scholar
- 40.Weick KE. Sensemaking in Organizations. London: Sage; 1995.Google Scholar
- 44.Ritchie J, Lewis J. Qualitative research practice: a guide for social science students and researchers. London: Sage; 2003.Google Scholar
- 49.MacKichan, F, Brangan, E, Wye, L, Checkland, K, Lasserson, D, Huntley et al. Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice. BMJ Open. 2017;7:e013816. https://doi.org/10.1136/bmjopen-2016-013816.PubMedPubMedCentralCrossRefGoogle Scholar
- 50.National Audit Office. Improving patient access to general practice. London: National Audit Office; 2017.Google Scholar
- 52.NHS England. The NHS Long Term Plan. 2019. https://www.longtermplan.nhs.uk/. Accessed 2 Apr 2019.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.