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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.

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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.

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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.

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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

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