1. © Nuffield Trust 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

2. © Nuffield Trust 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 © Getty Images

3. © Nuffield Trust 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) May 2011 © Getty Images

4. © Nuffield Trust 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 © Getty Images

5. © Nuffield Trust 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

6. © Nuffield Trust 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 © Getty Images

7. © Nuffield Trust 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 © Getty Images

8. © Nuffield Trust 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 © Getty Images

9. © Nuffield Trust 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 © Getty Images Military Sealift Command hospital ship USNS Comfort © Getty Images

10. © Nuffield Trust 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 © Getty Images Cairns Base Hospital, A&E at night

11. © Nuffield Trust 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

12. © Nuffield Trust 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 © Getty Images

13. © Nuffield Trust 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?

14. © Nuffield Trust 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 2011 Road side dentist Banaras, India © Anil Risal Singh

15. © Nuffield Trust 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 2011 Golconda, Rene Magritte

16. © Nuffield Trust 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 © Getty Images

17. © Nuffield Trust References Daniels, N, ‘Justice and Access to Health Care’, The Stanford Encyclopedia of Philosophy (Spring 2011 Edition), Edward N. Zalta (ed.), URL =. 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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