Access to Health Care

Martin Gulliford,Myfanwy Morgan

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135282530
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

To what extent can we have truly universal, comprehensive and timely health services, equally available to all? Access to Health Care considers the meaning of 'access' in health care and examines the theoretical issues that underpin these questions. Contributors draw on a range of disciplinary perspectives to investigate key aspects of access, including:
· geographical accessibility of services
· socio-economic equity of access
· patients' help-seeking behaviour
· organisational problems and access
· methods for evaluating access.Access is considered in both a UK and international context. The book includes chapters on contrasting health policies in the United States and European Union. Access to Health Care provides both health care researchers as well as health professionals, managers and policy analysts, with a clear and wide-ranging overview of topical and controversial questions in health policy and health services organization and delivery.

Chapter 1

Introduction

Meaning of ‘Access’ in Health Care¹

Martin Gulliford, José igueroa-Muñoz and Myfanwy Morgan

Introduction

Access to health care contributes to the improvement of health and the relief of sickness. In low-income countries problems of access concern the availability of basic health services such as the ability to visit a doctor or to receive health care during pregnancy and delivery. In affluent countries where basic services are generally accessible, questions of access concern the degree of comprehensiveness that can be offered by health care systems, the extent to which equity is achieved, and the timeliness and outcomes of care.

Access to health care has been justified in economic terms through its benefits in improving the health of entire communities, leading to conditions that favour economic growth (World Bank 1993). This utilitarian, efficiency-driven approach may not be sufficient to ensure that the needs of vulnerable or excluded individuals, such as the very old, people with mental health problems, or prisoners, are met. Access to health care has therefore come to be regarded as a basic human right and social goal in the sense that all individuals are considered to be entitled to health care, even though consideration of the economic benefit of the wider community does not necessarily require that they should receive it (Dworkin 1977). This is recognised by the United Nations in its Covenant on Economic, Social and Cultural Rights which recognises ‘the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ and requires governments to create ‘conditions which would assure all medical service and medical attention in the event of sickness’ (Office of the High Commissioner for Human Rights 1996: Article 12). In the Universal Declaration of Human Rights the rights to health and health care are set in a wider context which acknowledges the social determinants of health. Thus ‘everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control’ (United Nations 1948: Article 25). Even in the United States, where access to health care is least secure among affluent countries, an amendment to the constitution has been proposed stating that ‘all citizens and other residents of the United States shall have equal access to basic and essential health care’ (Davidoff and Reinecke 1999: 692).

The United Nations’ approach identifies health as a basic human right. This right focuses attention on a number of rights related to the conditions necessary for promoting and protecting health. These include protecting people from violence and inhuman and degrading treatment, promoting conditions of life and lifestyles that reduce risks of disease, injury and accident, as well as providing access to preventive and curative health services. In the European Convention on Human Rights, which was incorporated into United Kingdom law in the Human Rights Act of 1998, there is no explicit ‘right to health’, but the ‘right to life’ has been interpreted as requiring that all necessary health care should be provided (Thomson et al. 2001). Daniels (1985) attributes the right to health care to the importance of health in achieving normal human functioning, so access to health care is therefore a prerequisite for equality of opportunity in society. From this perspective a right to health care derives from the right to equality of opportunity.

Opposing arguments have been based on a particular view of the right to individual freedom. Thus a narrow libertarian view, which opposes a universal right to health care, has been expressed in these terms.

Government can disguise the process by taxing the citizenry to reimburse the physician, pharmacy, and hospital. But the assault on the concepts of liberty and the pursuit of happiness is just as egregious. When their money is taken from them to pay for other people’s health care, people’s range of choices – that is, their freedom – is diminished.

(Hornberger 2000)

This ideological debate concerning the appropriate role of the government in welfare and the nature of welfare policies is reflected in the approaches to the provision of health care in different countries (Deakin 1994). There are variations in the extent to which health care is seen as a public good, involving redistributive principles through tax-based or social insurance systems, or a largely private good which remains the responsibility of individuals. It follows that the contribution of private expenditures, and the roles of public and private sector provision of services, will also vary.

A basic assumption underpinning the public funding and provision of individual health services is that health care, and specifically medical care, is an important determinant of health. However, since the 1970s it has been increasingly acknowledged that medical care does not guarantee health. Indeed, medical care may in some instances form a cause of ill health through clinical iatrogenesis, including hospital-acquired infections or adverse and unanticipated side effects of drugs. For many conditions medical care is not the major determinant of health. More important factors include wider public health measures to reduce water and airborne diseases, health and safety at work, the reduction of environmental pollution, good nutrition and health-promoting behaviours in terms of exercise, smoking, drinking and sexual behaviour. The social and environmental determinants of health are differentially distributed in society, with some groups experiencing poorer health and having greater health needs. These inequalities in health must thus be addressed by wider public policy measures aimed at reducing poverty, and providing better education, employment conditions, housing, transport or nutrition (Acheson 1998). Despite this, timely receipt of health care has been shown to make a difference to health outcomes, particularly when assessed in terms of morbidity and broader measures of quality of life (Bunker et al. 1994).

Health care has a more specific value that is not fully measured in terms of improving health. The first lines of the 1983 report, Securing Access to Health Care by the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical Behavioural Research (1983) stated:

The prevention of death and disability, the relief of pain and suffering, the restoration of functioning: these are the aims of health care. Beyond its tangible benefits, health care touches on countless important and in some ways mysterious aspects of personal life and invest it with significant value as a thing in itself.

(p. 1)

As well as improved health and well-being, health care provides information about diagnosis and prognosis, and health care is intimately concerned with how people’s lives will begin and end, and what opportunities they will have in between.

Health systems differ in the priority they give to universal access to health care. In the UK, a central principle of the National Health Service (NHS) in 1948 was the creation of a centrally funded system with universal eligibility to health care based on medical need, thus emphasising equity in terms of equal access for equal need. The NHS also aspired to comprehensive provision of care ‘from cradle to grave’. By contrast in the US, health care is treated more like other goods and mainly allocated on the basis of ability to pay, but supported by a system of safety net public provision of basic health services to cater for those who are not able to meet this criterion of service use. These differences in approach to health care are shaped by wider economic and political forces, historical circumstances and cultural values. The NHS is firmly embedded within the philosophy of a welfare state which embraces notions of solidarity, with all citizens regarded as having rights to health, education and relief from poverty. In contrast, more market-oriented systems emphasise individual responsibility for health care. Increasingly health systems reflect a mix of public and market-oriented philosophies and practices.

Important questions which influence access to health care concern how health care should be funded and, if health care is not to be allocated according to price, how it should be distributed. The mechanisms put in place to ensure that health care is appropriately distributed will then determine who gains access to health care. The UK NHS developed from a consensus that health care should be financed according to ability to pay, but distributed according to need. Equity, in terms of equal access for equal need, became a key objective of the health system. In the US, the President’s Commission (1983) argued ‘that all citizens [should] be able to secure an adequate level of care without excessive burdens’ (p. 4). Once these aims have been identified, there are difficulties involved in defining them more closely, and also in organising services that will deliver them. These practical problems form the main subject of this book.

In the UK, continuing public concerns about difficulties in gaining access to health care have led to two major programmes of health service reform in the last 15 years. Problems include delays in obtaining urgent appointments to see a primary care doctor, long waits for elective surgery, long waiting times in hospital accident and emergency departments, and difficulties accessing intensive care beds. Services sometimes seem not to meet adequately the requirement of groups with special needs. Some groups, such as old people, especially people with mental impairments and their carers, or people in institutions, may find that services are relatively inaccessible. For other groups, such as patients with sickle cell disease, services may not be sensitive to their requirements (Maxwell et al. 1999). There are also ongoing concerns about seemingly arbitrary geographical variations in access to health care, and wide social inequalities in health. In responding to these concerns, the UK government proposed that in future ‘patients will get fair access to consistently high quality, prompt and accessible services right across the country’ (NHS Executive 2001).

These concerns are widely shared. A recent survey of citizens’ views in Australia, Canada, New Zealand, the United Kingdom and the United States found that more than half of respondents were dissatisfied with their health services and thought that fundamental changes were needed (Blendon et al. 2002). In the UK, long waiting times for elective treatment were an important cause of dissatisfaction. In countries where individuals contribute to the costs of medical care, access problems were more likely to result from financial constraints. In the United States, more than half of people on below average incomes reported difficulty getting specialist treatment, having problems paying medical bills, or failing to take up tests or prescribed treatment because of cost. In all of the countries, difficulties were reported in accessing care at nights or on weekends and in obtaining dental care.

That concerns with access to health care are so widespread in countries with some of the most highly developed health services makes it relevant to explore the problems of access in more depth. This book does this from a range of disciplinary perspectives. But first we consider what is meant by ‘access to health care’. The following section summarises present understanding of the term, and suggests that four main aspects should be considered.

Meaning of Access

In one of the early discussions of access, Aday and Andersen (1975) suggested that ‘it is perhaps most meaningful to consider access in terms of whether those who need care get into the system or not’ (p. 14). They suggested that ‘access’ might describe either the potential or actual entry of a given individual or population group into the health care delivery system. Thus having access denotes a potential to utilise a service if required (service availability), while gaining access refers to the initiation into the process of utilising a service. Much confusion has resulted from lack of attention to these two distinct uses of the term.

Service Availability

Having access to health care requires that there is an adequate supply of health services available to a population. According to this dimension, access to health care is concerned with the opportunity to obtain health care when it is wanted or needed. The availability of services is measured traditionally using indicators such as the numbers of doctors or hospital beds per unit population. In most countries there are wide geographical variations in the numbers of general practitioners per head of population, the proportion of the population registered with dentists, or the proportion accessing specialist surgical services (Department of Health 2001). These variations raise questions about the level of resources required for health care, the methods used to allocate resources to different geographical areas, and the ways that services should be configured at regional and local levels in order to optimise the availability of both primary and specialist services (see Chapter 2).

Mooney (1983) suggested that, from a health economic perspective, the availability of services may be measured in terms of the costs to individuals of obtaining care. These costs might include the costs of travel and other inconvenience incurred in obtaining care, or the health benefits forgone by not obtaining care. When services are geographically distant, these costs will be generally higher. In this formulation, individuals facing equal costs have equal access. Mooney (1983) argued that ‘access is wholly a question of supply; utilisation is a function of both supply and demand’ (p. 182). He went on ‘It is important to stress that equality of access is about equal opportunity: the question of whether or not the opportunity is exercised is not relevant to equity defined in terms of access.’

Utilisation of Services and Barriers to Access

Service availability can be viewed as a rather limited measure of access to health care. A population group in need may often have access to services and yet encounter difficulties in utilising services. In other words, potential access may not be realised (Aday and Anderson 1981). Thus Donabedian observed that ‘the proof of access is use of service, not simply the presence of a facility’ (Donabedian 1972: 111). Pechansky and Thomas (1981) developed this idea and suggested that the concept of ‘access’ described the ‘degree of fit’ between clients and the health system. The ‘degree of fit’ might be influenced by the acceptability, affordability and accommodation of services. Pechansky and Thomas’ approach extended the concept of ‘access’ beyond measuring service availability, to consider the personal, organisational and financial barriers to service utilisation (Millman 1993).

Barriers to utilisation depend on the interaction of factors associated with the production of health care, such as the location of services, and factors associated with the consumption of health care, such as the ability to travel to obtain care. The value-laden term ‘barrier’ reflects the consumer’s perception of obstacles to gaining acce...