1. Maria Goddard Professor of Health Economics Director Centre for Health Economics University of York Access to care: Are there lessons from medicine?

2. Outline Access in health care context. Equity focus. Economics perspective.

3. What is Access? / Equity of Access? Equal access to care for people in equal need. NOT necessarily the same as: –equal provision –equal expenditure –equal inputs –equal utilisation –equal outcomes

4. Access Utilisation is usually the proxy. Does it capture quality? Use of alternatives? Is “more” necessarily “better”?

5. Need Level of illness or capacity to benefit? Clinical concept only? How to measure health status? At what stage to measure?

6. Differences between health and dental care and other services Health care is "different" from other services/goods: –demand for health care unpredictable –lack of knowledge of individual about quality –"externalities", eg, communicable disease Dental care is "different" from health care: –less frequent occurrence, more predictable –infrequent “emergency” aspect –more "experience" based –major preventive focus –role of price

7. Demand for dental care may therefore be more responsive to price than demand for health care.

8. Stylised demand and supply S D “Price” “Quantity”

9. Demand Real price/cost of access. Perceptions: –price/costs; –availability; –efficacy. Health beliefs and behaviour. "Voice". Availability of alternatives. First contact versus subsequent care.

10. What do we know about demand for health care? Different picture for acute and preventive care. Preventive: –beliefs/motivation "candidacy" –information, communication –time and access costs –follow-up, completion of treatment –distance “navigation”

11. Supply Exclusion of whole groups. Costs of access. Quality may vary. Lack of information. Professional gatekeeper role. Incentive structure.

12. What do we know about supply of health care? Role of incentives for providers. “Too little” versus “too much” care. Role of professional beliefs “candidacy”. “Permeability” of services. Registration may not always be effective.

13. Interaction of demand and supply “Inverse Prevention Law”. Increases in “supply” have variable impacts. “One size fits all” interventions can increase inequities of access.

14. Lessons? Prevention versus acute. Demand, supply and their interaction. Candidacy, navigation, permeability. “More” not necessarily “better”. Incentives matter