Post on 30-Dec-2015
transcript
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What do we mean by access?
A presentation for Faculty of General Dental Practice (UK),The Royal College of Surgeons of England
Author: Dr Benedict Rumbold
May 2011
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An initial definition
Access to health care is concerned with the
relationship between need, provision and
utilisation of health services.
‘Having access’ denotes a potential to utilise a
service if required.
Having equal access is about equal opportunity
not equal utilisation:
‘The question of whether or not the opportunity
is exercised is not relevant to equity defined in
terms of access’. (Mooney, 1983)
May 2011
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The relationship between service providers and clients
So, access is about the relationship between service providers and clients which determines patterns of utilisation
This can be described as the ‘degree of fit’ between clients and the health system (Pechansky and Thomas,1981)
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The obligations of the provider
Since access is a ‘degree of fit’ between clients and the health system, the provider’s
obligation to ‘facilitate access’ could be understood as a duty to ensure the greatest
possible fit with the greatest number of clients.
Two possible sources of this obligation:
• Obligations arising from contracts
Individuals have paid for a service to be provided (privately, through insurance, or
through taxation), therefore providers are under an obligation to honour that contract to the
greatest extent possible.
• Obligations arising from a general duty to promote equality of opportunity:
Providers have a social obligation to protect the opportunity range open to all individuals,
hence we have obligations to promote and protect health for all. (Daniels, 2007)
May 2011
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The relationship between providers and clients
Pechansky and Thomas’ five dimensions of accessibility:
1. Availability - refers to the adequacy of supply given by the relationship between volume and type
of services (provision) and volume and type of needs (demand).
2. Affordability - applies to the cost implications to the patient in relation to need; this includes both
direct and indirect costs and perceptions of value.
3. Acceptability - refers to attitudes and beliefs of users and providers about each other’s
characteristics.
4. Physical accessibility - is defined by the suitability of the location of the service in relation to the
location and mobility of the patient (geographical and physical barriers).
5. Accommodation - refers to the way services are organised in relation to the client’s needs and
the patient’s perception of their appropriateness (opening times, booking facilities, waiting times).
May 2011
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1. Availability
Availability is about the relationship of the
volume and type of existing services (and
resources) to the clients' volume and types of
needs.
It refers to the adequacy of the supply,
whether of physicians, dentists or other
providers; of facilities such as clinics and
hospitals; and of specialized programs,
services and technologies (e.g.
pharmaceuticals)
May 2011
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2. Affordability
Affordability is about the relationship of prices of
services and other costs to the clients' income and ability
to pay.
E.g. patients may experience costs in terms of user
charges, higher premiums on insurance, or as a result of
time lost from work or in travelling to and from a clinic.
Client perception of worth relative to total cost is a
concern here, as is clients‘ knowledge of prices, total
cost and possible credit arrangements.
E.g. a patient may not utilise a service because of a
belief about its notional worth, regardless of their ability
to pay.
May 2011
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3. Acceptability
Acceptability is about the relationship of clients‘ attitudes about
personal and practice characteristics of providers to the actual
characteristics of existing providers, as well as to provider
attitudes about acceptable personal characteristics of clients.
This is often taken to refer to specific consumer reaction to
such provider attributes as age, sex, ethnicity, type of facility,
neighborhood of facility, or religious affiliation of facility or
provider.
In turn, providers have attitudes about the preferred attributes
of clients or their financing mechanisms. Providers either may
be unwilling to serve certain types of clients or, through
accommodation, make themselves more or less available.
May 2011
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4. Physical Accessibility
Physical accessibility is about the relationship between the
location of supply and the location of clients, taking account
of client transportation resources and travel time, distance
and cost.
Haynes et al (1999) showed distance to hospital produced
17% reduction in acute episodes, 37% reduction in
psychiatric episodes and 23% reduction in geriatric episodes
in the NHS over the range of distances observed.
This raises questions about the methods used to allocate
resources to different geographical areas and the way
services should be configured at regional and local levels.
It also concerns the environment services are provided in
(e.g. disabled access).
May 2011
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Military Sealift Command hospital ship USNS Comfort © Getty Images
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5. Accommodation
Accommodation is about the
relationship between the manner
in which the supply resources are
organized to accept clients
(including appointment systems,
hours of operation, walk-in
facilities, telephone services) and
the clients' ability to
accommodate to these factors and
the clients' perception of their
appropriateness.
May 2011
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Cairns Base Hospital, A&E at night
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The patient’s perspective is crucial
The ‘degree of fit’ between clients and
the health system will always be largely
dictated by the patient’s current situation
and personal history.
‘An individual’s probability of utilising
services depends on the balance
between the person’s biological and
psychosocial perception of need and his
or her attitudes, beliefs and previous
experiences with health services.’
(Gulliford et al, 2001)
May 2011
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One size won’t fit all
The health problems of different groups are
diverse, health care needs for similar health
problems vary and different groups have
their own priorities and values. Groups with
different needs require access to services
that are appropriately differentiated in terms
of volume and quality. (Gulliford et al., 2002)
For example, the impact of user charges
and other cost s of accessing care affect
different socio-economic groups in different
ways. Equal costs do not necessarily give
equal access.
May 2011
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Ensuring accessibility for a variety of groups
May 2011
Is it acceptable? Is it affordable? Is
it available? It is physically
accessible? Is it accommodating?
Is it acceptable? Is it affordable? Is it available? It is physically accessible? Is it accommodating?
Is it acceptable? Is it affordable? Is it available? It is physically accessible? Is it accommodating?
Is it acceptable? Is it affordable? Is it available? It is physical lyaccessible? Is it accommodating?
Is it acceptable? Is it affordable? Is it available? It is physical lyaccessible? Is it accommodating?
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Providers can’t do everything, nor should they
Certain aspects of accessibility may be
beyond providers control (e.g. some aspects
of affordability, physical accessibility, etc.)
Equally, providers shouldn’t feel they have to
respond to all patients preferences to
improve a service’s acceptability or
availability.
For example, patients may have
unreasonable expectations about availability
of services (accommodation); or make
unacceptable demands about the sex, age or
ethnicity of their physician (acceptability).
May 2011Road side dentist Banaras, India © Anil Risal Singh
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Some Difficult Questions
• Where does the limit of a provider’s obligation to facilitate
access lie? How far should they go to ensure the ‘best fit’ with
their clients? How important is access? Should professional
ethics take precedence over what a patient deems
acceptable? Should efficiency take precedence over
accommodation?
• How can the different demands of different client groups be
balanced against each other? Should certain groups (e.g. the
poor) get priority? If so, how much priority?
• Is restricting access (‘demand management’) an acceptable
form of rationing healthcare?
• What are the responsibilities of the patient in ensuring they fit
the health service rather than the health service fit them?
May 2011Golconda , Rene Magritte
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Conclusions
• The provider has a duty to ensure the
greatest possible fit with the greatest
number of clients.
• Five dimensions of accessibility: Availability,
affordability, acceptability, physical
accessibility, accommodation.
• The patient’s perspective and situation is
crucial: one size won’t fit all.
• Providers can’t do everything, nor should
they.
• There are a lot of remaining questions.
May 2011
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References
• Daniels, N, ‘Justice and Access to Health Care’, The Stanford Encyclopedia of Philosophy (Spring 2011
Edition), Edward N. Zalta (ed.), URL = <http://plato.stanford.edu/archives/spr2011/entries/justice-
healthcareaccess/>.
• Gulliford et al (2001), Access to Health Care: Report of a Scoping Exercise for the National Co-ordinating
Centre for NHS Service Delivery and Organisation R & D (NCCSDO)
• Gulliford et al. (2002), What does 'access to health care' mean? J Health Serv Res Policy; 7: 186-188
• Haynes R, Bentham G, Lovett A, Gale S. (1999) Effects of distances to hospital and GP surgery on hospital
inpatient episodes, controlling for needs and provision. Social Science and Medicine 49: 425–433
• Mooney G. H. (1983) Equity in health care: confronting the confusion. Effective Health Care ,1: 179–185
• Pechansky, R. and Thomas, W. (1981) ‘The concept of access’ Medical Care 19:127–40