Accessibility and spatial distribution of general practice services in an Australian city by levels of social disadvantage

The accessibility and spatial distribution of health services provided by the main source of primary medical care in Australia--the general practice surgery--was investigated by level of social disadvantage of local catchment areas. All 459 general practice surgeries in Perth, an Australian city of 1.2 million residents, were surveyed with a 94% response. Amount of service provision was measured using weekly doctor-hours, available from consulting rooms during opening hours, and associated nurse-hours of service. Access factors were defined as the distance to the nearest surgery, provision of Sunday and evening services, ease of making a same day appointment, bulk-billing, and whether the surgery offered a choice of gender of doctor. There were relatively more surgeries in disadvantaged areas and doctor-hours of service provision were also greater (41.0 h/1,000 most disadvantaged vs. 37.9 h/1000 least disadvantaged). Bulk-billing care, at no direct cost to the patient, was more likely to be provided in most disadvantaged areas compared with least disadvantaged areas (61 vs. 38%). However, populations living in the most disadvantaged areas were less likely to be able to see the local GP at short notice (91 vs. 95%), to have access to a local female GP (56 vs. 62%) or a local service in the evenings (42 vs. 51%). While the overall picture of accessibility was favourable, there was considerable variation in the type of services provided to different socioeconomic groups. Health care planners should investigate the reasons for these differences and advise Government to ensure that access factors affecting publicly funded services are equitably distributed.     

Expanding the definition of access: it isn't just about health insurance

Measurement of access to health care services is often limited to such variables as having health insurance or a usual source of care. We argue for an expanded definition of access measuring whether providers accept a particular form of insurance (overall accessibility), ease of contacting providers for appointments (contact accessibility), length of time it takes to get an appointment (appointment accessibility), and proximity of providers to patients (geographic accessibility). Interviewers posing as Medicaid beneficiaries telephoned providers in Florida's Medicaid primary care case management program, to determine whether the provider was accepting new patients, had weekend or evening hours, and how long it would take to get an appointment. Approximately 87% were accepting new patients, but only 68% were accepting new Medicaid patients. The survey also showed that beneficiaries may encounter difficulty in reaching physicians and making appointments: 22% of all calls were not answered on the first attempt and over two-thirds of providers had no weekend or evening hours.     

Determinants of the choice of GP practice registration in England: Evidence from a discrete choice experiment

There have been growing concerns that general practitioner (GP) services in England, which are based on registration with a single practice located near the patient's home, are not sufficiently convenient for patients. To inform the decision as to whether to change registration rules allowing patients to register ‘out-of-area’ and to estimate the demand for this wider choice, we undertook a discrete choice experiment with 1706 respondents. Latent class models were used to analyse preferences for GP practice registration comparing preferences for neighbourhood and non-neighbourhood practices. We find that there is some appetite for registering outside the neighbourhood, but this preference is not uniformly shared across the population. Specifically individuals who are less mobile (e.g. older people and those with caring responsibilities), or satisfied with their local practice are less likely to be interested in registering at a practice outside their neighbourhood. Overall, people feel most strongly about obtaining an appointment with a GP as quickly as possible. Respondents regarded weekend opening as less important than other factors, and particularly less important than extended practice opening hours from Monday to Friday. Assuming a constant demand for GP services, a policy encouraging GP practices to extend their opening hours during the week is likely to decrease the average patient waiting time for an appointment and is likely to be preferred by patients.     

Capacity census - a pilot study of general practices in Western Australia

The GP Super Clinics that will provide multidisciplinary primary care services are seen as a key feature of the Federal Government's health infrastructure development. They are designed to improve convenience for patients when accessing services – especially patients with multiple comorbidities requiring visits to multiple providers – as well as providing the space and equipment for teaching and research in primary care. In addition, Medicare Locals are seen as facilitating ‘investments in primary healthcare infrastructure, including GP Super Clinics’. Enhancements to existing private general practices to ‘support a broader team, teaching or visiting sessions from other health professionals’ are also seen as infrastructure development possibilities. Although no one model is provided for GP Super Clinics, it is intended that each ‘will bring together general practitioners, nurses, visiting medical specialists, allied health professionals and other healthcare providers to deliver better healthcare, tailored to the needs and priorities of the local community’.     

The effect of increased cost‐sharing on low‐value service use

We examine the effect of a value‐based insurance design (VBID) program implemented at a large public employer in the state of Oregon. The program substantially increased cost‐sharing for several healthcare services likely to be of low value for most patients: diagnostic services (e.g., imaging services) and surgeries (e.g., spinal surgeries for pain). Using a difference‐in‐differences design coupled with granular, administrative health insurance claims data over the period 2008–2012, we estimate the change in low‐value service use among beneficiaries before and after program implementation relative to a comparison group not exposed to the VBID. Our findings suggest that the VBID significantly reduced the use of targeted services, with an implied elasticity of demand of ?0.22. We find no evidence that the VBID led to substitution to non‐targeted services or increased overall healthcare costs. However, we also observe no evidence that the program led to cost‐savings.     

Adherence to behavioral therapy and psychiatry visits in a safety‐net setting in Virginia,USA

Little is known about predictors of adherence to outpatient behavioural therapy and psychiatry visits in those who experience homelessness. Yet, consistent receipt of services in the community is critical to preventing use of acute care psychiatric services, which cause a significant cost burden to the mental health system. This retrospective study examined sociodemographic, housing instability and health‐related factors associated with adherence to behavioural therapy and psychiatry appointments among 1711 clients served by an urban healthcare for the homeless centre in Virginia, USA. Clients ≥18 years old with a behavioural health condition who had an intake assessment and at least one behavioural therapy or psychiatry appointment scheduled during October 2005–September 2009 were eligible for the study. Of those with scheduled behavioural therapy visits, 27.7% were high adherers and 19.3% did not attend any appointments, whereas of those with scheduled psychiatry visits, 13.6% were high adherers and 22.1% did not attend any appointments. African Americans, when compared with whites, and those with a primary diagnosis of bipolar disorder were less likely to be high adherers to behavioural therapy. Women and being ≥35 years old were associated with a decreased likelihood of failing to attend psychiatry appointments, whereas African Americans, when compared with whites, and those with co‐occurring disorders were more likely to not attend any psychiatry appointments. Understanding factors related to adherence to behavioural health services can help homeless care providers tailor strategies for improving visit adherence.     

Co‐located welfare advice in general practice: A realist qualitative study

General practitioners (GPs) engage with patients about a variety of social issues distinct from direct clinical work (“non‐health” issues), such as health‐related benefits and debt. Co‐located welfare advice services could provide support to practices but have usually been considered in terms of patient rather than practice outcomes. We aimed to develop an initial programme theory for how the provision of co‐located advice supports specific practice outcomes, and to identify salient barriers and enabling factors. Twenty‐four semi‐structured interviews with general practice staff, advice staff and service funders in two UK urban localities were conducted between January and July 2016. Data were thematically analysed and a modified Realist Evaluation approach informed the topic guide, thematic analysis and interpretation. Two outcomes are described linked to participant accounts of the impact of such non‐health work on practices: reduction of GP consultations linked to non‐health issues and reduced practice time spent on non‐health issues. We found that individual responses and actions influencing service awareness were key facilitators to each of the practice outcomes, including proactive engagement, communication, regular reminders and feedback between advice staff, practice managers and funders. Facilitating implementation factors were: not limiting access to GP referral, and offering booked appointments and advice on a broader range of issues responsive to local need. Key barriers included pre‐existing sociocultural and organisational rules and norms largely outside of the control of service implementers, which maintained perceptions of the GP as the “go‐to‐location”. We conclude that co‐location of welfare advice services alone is unlikely to enable positive outcomes for practices and suggest several factors amenable to intervention that could enhance the potential for co‐location to meet desired objectives.     

Joint working. It's a stitch-up

A joint-working scheme aimed at keeping older people out of hospital with improved home support has reduced emergency admissions and cut the length of hospital stays. The initiative, involving four GP practices, a health authority, a community trust and social services department, included the appointment of a nurse co-ordinator and six support workers offering a 24-hour service. The scheme is now being extended by two primary care groups.     

Reasons for visiting Polish primary care practices by patients aged 18–44 years: the largest emigrating age group

Over 3% of the entire Polish population migrate for a job within the European Union, most are aged 18–44 years. The main destinations are Germany, the United Kingdom and Ireland. Immigration is connected with the use of many public services, including healthcare services. Assuming Polish immigrants require medical consultations in the countries they reside in, the authors have analysed the reasons for patients’ visits to general practitioners (GPs) in Poland in order to predict possible reasons why Polish patients living abroad may make appointments with GPs in other countries. Data from 22 769 visits to GP practices between June 2005 and May 2006 by Polish patients aged 18–44 years were collected electronically. Age was categorised into three groups (18–24, 25–34 and 35–44 years) and the reason for the visit was categorised according to the ICD 10 coding system. Among the 12 535 patients registered with GPs, 73.1% of women and 68.6% of men required consultations during the year the study was conducted. The highest percentage of visits was recorded for women aged 35–44 years, while men of the same age were the least likely to visit a GP. The mean number of visits per patient ranged from 1.89 for men aged 25–34 years to 3.11 for women aged 35–44 years. The means were similar for 18‐ to 24‐year‐old men and women. Women aged 35–44 years had a higher mean number of visits compared with women aged 18–24 years, whereas the opposite was true for men. The analysis of reasons for visits within the age groups indicated that the percentage of appointments for respiratory problems and general and unspecified problems dropped by more than half from the 18–24‐year‐olds to the 35–44‐years‐olds, while visits for musculosceletal, cardiovascular, and mental and behavioural problems increased by a factor of four. The presented results intend to enable healthcare services meet Polish immigrants’ healthcare needs.     

Refugee,Migrant and Asylum Seekers’ Experience of Accessing and Receiving Primary Healthcare in a UK City of Sanctuary

The World Health Organisation estimate there are about 1 billion migrants in the world today. The scale of population movement and a global refugee crisis presents an enormous challenge for healthcare provision, and too often the specific health needs of refugees and migrants are not met. This study assessed refugee, asylum seeker and vulnerable migrants’ (AMRs') experience of front line primary healthcare in a region of the United Kingdom designated as a ‘City of Sanctuary’. A questionnaire study explored the views of people seeking refuge and third sector workers supporting them. The majority of AMRs were registered with a GP and positive about their consultations. The views of third sector workers provided a less favourable window into their experience of primary care. In conclusion, the work highlighted patchy experience of primary care, even in a region of the UK designated as a ‘City of Sanctuary’ for people seeking refuge. There is a need for further education of rights to care in the UK, information for people on how to navigate local healthcare systems, consistent access to routine health checks and translation services.

     

Digital consultations for weight management in the NHS: A qualitative evaluation

Receiving digital healthcare consultations for weight management, in place of in-person appointments, has proliferated in recent years, accelerated by the COVID-19 pandemic. The objective of the present study was to investigate patients’ experiences of digital weight management services (DWMS) provided by the National Health Service (NHS). Particular emphasis was placed on examining the perceived benefits and limitations of DWMS so as to identify potential means of improving provision. Sixteen patients (eight male; eight female) accessing digital consultations at one of two West Midlands (UK) NHS trusts, participated in semi-structured interviews. Interviews were transcribed verbatim and analysed via thematic analysis. We identified three overarching themes and associated sub-themes that reflect the perceived benefits and limitations of service provision as identified by patients. These were technology acceptability (sub-themes ‘challenges’, ‘requirements/facilitators’, and ‘beneficial features’); treatment acceptability (sub-themes ‘treatment features’, ‘patient attributes’, and ‘practitioner skills’); and treatment efficacy (sub-themes ‘treatment features’, ‘patient attributes’, and ‘practitioner skills’). Themes identified in this study have informed recommendations intended to enhance acceptability of DWMS technology and treatment, potentially encouraging engagement and increasing treatment efficacy. Limitations of the present study and recommendations for further research are also presented.     

Ethnic and Indigenous access to early childhood healthcare services in Australia: parents' perceived unmet needs and related barriers

Objective: To evaluate the parents’ perceived unmet needs in early childhood healthcare services among Indigenous, non‐English‐speaking background (NESB) and English‐speaking background (ESB) children and the related barriers. Method: Data was from the Longitudinal Study of Australian Children (LSAC). Rao‐Scott chi‐square was used to examine the level of parents’ perceived unmet needs in three ethnic groups in early childhood healthcare services over a 12 month period. Survey logistic regression was used to assess the association between the groups of infants and the barriers to utilisation. Results: Ten per cent of Australian infants have at least one parents’ perceived unmet need in early childhood healthcare services. NESB (15.3%) and Indigenous (15.1%) infants were more likely than ESB infants (9.9%, p<0.001) to have parents’ perceived unmet needs in health care services. The barriers to service access include cost, transport problems, child care difficulties, service availability and family reasons. Parents of ESB infants were more likely to cite operating hours as the major barrier to accessing services. Conclusion: There were parents’ perceived unmet needs in a number of health services for all Australian infants, but at different levels by Indigenous, NESB and ESB groups. The most common barrier to services utilisation related to cost or private health insurance, availability and accessibility of service provision and other socioeconomic issues. Implications: Policy attention and operational changes are required to improve equity in accessing early childhood services, as well as to improve the overall access to healthcare services for all Australian infants.     

<Emphasis Type="Italic">"...they should be offering it":</Emphasis> a qualitative study to investigate young peoples' attitudes towards chlamydia screening in GP surgeries

Background  

Despite the known health and healthcare costs of untreated chlamydia infection and the efforts of the National Chlamydia Screening Programme (NCSP) to control chlamydia through early detection and treatment of asymptomatic infection, the rates of screening are well below the 2010-2011 target rate of 35%. General Practitioner (GP) surgeries are a key venue within the NCSP however; previous studies indicate that GP surgery staff are concerned that they may offend their patients by offering a screen. This study aimed to identify the attitudes to, and preferences for, chlamydia screening in 15-24 year old men and women attending GP surgeries (the target group).     

‘Underclassism’ and access to healthcare in urban centres

In this article, we draw on findings from an ethnographic study that explored experiences of healthcare access from the perspectives of Indigenous and non‐Indigenous patients seeking services at the non‐urgent division of an urban emergency department (ED) in Canada. Our aim is to critically examine the notion of ‘underclassism’ within the context of healthcare in urban centres. Specifically, we discuss some of the processes by which patients experiencing poverty and racialisation are constructed as ‘underclass’ patients, and how assumptions of those patients as social and economic Other (including being seen as ‘drug users’ and ‘welfare dependents’) subject them to marginalisation, discrimination, and inequitable treatment within the healthcare system. We contend that healthcare is not only a clinical space; it is also a social space in which unequal power relations along the intersecting axes of ‘race’ and class are negotiated. Given the largely invisible roles that healthcare plays in controlling access to resources and power for people who are marginalised, we argue that there is an urgent need to improve healthcare inequities by challenging the taken‐for‐granted assumption that healthcare is equally accessible for all Canadians irrespective of differences in social and economic positioning.     

NHS Direct: managing demand for primary care?

This paper considers how NHS Direct is affecting demand for primary care in particular out‐of‐hours services from GPs. This is reviewed through a 3‐year study of NHS Direct and HARMONI, the integrated telephone health helpline based in West London. It describes the policy background and development of the services on the site, and some of the outcomes of the HARMONI commissioned research to answer the question ‘Has NHS Direct increased the workload for HARMONI doctors?’. The research adopted both a qualitative and quantitative approach using cross‐sectional and longitudinal analysis of the data collected. The analysis of the data reveals the issues as both complex and dynamic in nature. The research shows that while there has been no significant change to the total volume of activity, changes within patient groups notably the elderly and children, and in individual GP practices may be significant. In addition, the changes in organizational arrangements may influence significant changes in referral patterns such as GP out‐of‐hours visits. This was confirmed in the interview data indicating a link between the change in nurses' role from gatekeeper to patient advocate, which happened when they ceased to be employees of the part‐time co‐op and began to work instead for the 24 hours, 7 days a week NHS Direct service. The conclusions drawn are that behavioural and organizational changes are at least as significant as the evidence‐based computerized decision support software in changing the demand for primary care. Further evidence cited is that a different demand pattern of calls was experienced by those local GPs not integrated into out‐of‐hours provision at NHS Direct West London at the time of the study. Copyright © 2004 John Wiley & Sons, Ltd.     

Rural general practitioner apprehension about work related violence in australia

Aims: To identify levels of Australian rural general practitioners’ apprehension about violence, factors effecting apprehension and the effect of apprehension on service provision. Method: Six focus groups were held with rural GPs from Western Australia, New South Wales and Victoria. A questionnaire was developed on the basis of the focus group data and all GPs in these three areas were surveyed. Results: The results indicated GPs were more apprehensive about providing after hours care than during business hours. Significant gender differences were found with women being more often apprehensive than men and more likely to withdraw after hours services. Conclusion: This study shows that that levels of apprehension about violence affect GPs’ willingness to provide after hours services. Future provision of general practice after hours services and home visits in rural areas requires the availability of a safe working environment to reduce GPs’ apprehension about workplace violence. What Is Already Known: Overseas research has shown that many GPs are apprehensive about workplace violence and that female GPs are more likely to be apprehensive about it than male GPs. No Australian studies about GPs’ levels of apprehension about workplace violence have previously been undertaken. What this study adds: This study showed that many Australian rural GP respondents feel apprehensive about work‐related violence especially after hours and when undertaking home visits after hours. Female respondents were significantly more likely to feel apprehensive about workplace violence than male respondents and to make changes to services because of the risk of violence than male GPs, most commonly by not providing services such as home visits or after hours surgery attendances.     

A Multilevel Analysis of the determinants of emergency care visits by the elderly in France

BackgroundRising numbers of visits to emergency departments (EDs), especially amongst the elderly, is a source of pressure on hospitals and on the healthcare system. This study aims to establish the determinants of ED visits in France at a territorial level with a focus on the impact of ambulatory care organisation on ED visits by older adults aged 65 years and over.MethodsWe use multilevel regressions to analyse how the organisation of healthcare provision at municipal and wider ‘department’ levels impacts ED utilisation by the elderly while controlling for the local demographic, socioeconomic and health context of the area in which patients live.ResultsED visits vary significantly by health context and economic level of municipalities. Controlling for demand-side factors, ED rates by the elderly are lower in areas where accessibility to primary care is high, measured as availability of primary care professionals, out-of-hours care and home visits in an area. Proximity (distance) and size of ED are drivers of ED use.ConclusionHigh rates of ED visits are partly linked to inadequate accessibility of health services provided in ambulatory settings. Redesigning ambulatory care at local level, in particular by improving accessibility and continuity of primary and social care services for older adults could reduce ED visits and, therefore, improve the efficient use of available healthcare resources.     

Does the English NHS have a ‘Health Benefit Basket’?

A ‘health benefit basket’ is a range of publicly entitled health-related goods and services. Primary legislation ensures the provision of broad categories of healthcare, but this provision is subject to political discretion. Case law has established that healthcare organisations may not operate a ‘blanket ban’ for particular services. This means that the English health basket currently has very few specific services explicitly included or excluded. Regulation may, however, be important in determining citizens’ rights. With reference to ‘services of curative care’, this paper explores whether the NHS is moving towards a more explicit definition of a health basket.