The accessibility of UK primary medical care : problems, practice and potential

• Main Author: Campbell, John Lennox
• Published: University of Edinburgh 1998
• Subjects: 362.10941
• Online Access: http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.712227

This thesis addresses issues relating to the accessibility of primary medical care within the context of the National Health Service. A review of the literature is undertaken which identifies access as a key issue for patients, doctors, and health care planners. A basic framework using the geographical, organisational, and psycho-social elements of access to care is adopted for a detailed consideration of these distinct elements of accessibility. Five studies are described. The first of these relates to the provision of out-of-hours care by five general practitioners in one practice in central Edinburgh. The association of reduced access (a completely booked appointment system) with an increase in subsequent out-of-hours workload is reported. A case study of upper respiratory illness presenting out-of-hours investigates the impact of doctors' choices made regarding the management of out-of-hours contacts on subsequent consultation patterns. While the first study considered the operation of the appointment system as a factor influencing out-ofhours workload, the operation of a practice appointment system was studied in more detail in the second study. This work investigated the consequences of increasing appointment length on clinical workload, appointment system operation, patient "flow" (waiting and consultation times), and consultation and doctor behaviour. Changing from booking eight patients per hour to six patients per hour was associated with an increased matching between supply and demand for appointments, increased numbers of patients requiring to be fitted in as "extras", and reduced waiting time for patients seen under the new arrangements. Surgeries in which an undergraduate medical student was present were observed to be different from non-teaching surgeries with respect to a number of measures. Variations in the operation of appointment systems have been judged by some to have important sequelae in the decisions made by patients as to where they might receive care. Such judgements form the basis for the central study of this thesis where the impact of varying doctor accessibility on the decision taken by patients to self refer to a hospital Accident and Emergency Department was investigated in nineteen of twenty six practices in the West Lothian district of Lothian Health Board, Scotland. Information was collected about practices and their appointment systems over an eight week period and a questionnaire survey of patients attending participating practices or the local Accident and Emergency Department was undertaken. This study highlighted the importance of distance from Accident and Emergency as a factor influencing the use of Accident and Emergency services, and also highlighted the importance of patients' perceptions of doctor availability as a contributing factor in patient's consulting behaviour. The relationship between patients' perceptions of doctor availability and practice list size was investigated using data obtained from the questionnaire survey of patients attending West Lothian practices during one week of 1994. Practices rather than patients formed the unit of analysis in this investigation where patients' perceptions of doctor availability were reported for urgent and non-urgent situations separately. A significant negative association between practice list size and the perceived availability of general practitioners is described and regression modelling used to investigate the association between patient satisfaction with doctor availability, patients' perceptions of doctor availability, and practice list size. The final two studies describe the potential for using geographical information systems (GIS) technology in investigating the accessibility of primary care. Some of the features of GIS technology (mapping of geo-referenced information, construction of polygons, buffers and convex hulls, contour plotting and construction of spider maps) are demonstrated using data obtained from West Lothian as a case study. Plotting of polygons representing practice areas is used in the final study, which investigated the accessibility of general practitioners as, reflected in the size of their practice catchment areas. Using this approach, an association between quality of primary care and the size of practice catchment area is described and questions are posed regarding the lack of available guidance for general practitioners in relation to defining the size of the area in which they provide services. Access to primary medical care requires a consideration of the quality of services to which access is being provided. Health service planners, doctors, and their patients must ensure that quality in relation to service delivery is matched by quality in relation to the arrangements by which that service is accessed. This work contributes to and informs that relationship.