Access to primary care

What brings you here today?

Doctor: As your headaches have become worse, the neurology registrar suggests magnetic resonance imaging (MRI) of the brain, and will see you in the outpatients clinic.

Patient: Oh no! I can’t pay for an MRI. I can go to the emergency department; I’ll wait, but I’ll see the specialist tonight

General practitioners (GPs) in Australia are confronted on a daily basis with a mixture of hope, uncertainty and frustration that patients display when faced with problems with access. Despite these issues being health-related problems, it is uncertain how clinicians should respond. For instance, GPs engage daily with the influence of cost on healthcare. Where treatment is affordable, perhaps because of bulkbilling, does access correspondingly improve?¹ Does private insurance unlock a resource sphere with lower demand and higher supply?²

Clinicians have a long history of innovative solutions to the problems posed by the unequal distribution and availability of doctors.^3,4 They also recognise that the burden of multiple diseases has an impact beyond the sum of its parts.⁵ Factors such as opening hours, carer commitments and medication regime become explicit in every consultation. GPs commonly bundle many elements of care into a single visit, sometimes at the price of running late.⁶ They also help integrate patients into a broader care network of other health professionals, community supports and online treatments.⁷

Apart from being available, services also need to be acceptable – to provide a ‘good enough’ intersection with the cultural and social factors that influence how and where a person seeks healthcare. One common illustration is using translators to overcome a language barrier. Many practices have adapted to the ubiquity of smartphones by providing online booking of appointments and reminder SMS messages. Aboriginal Community Controlled Health Services and street health clinics⁸ are examples of primary health facilities that are explicitly shaped by the populations they serve. 

However, there remain many access constraints beyond the individual GP’s or clinic’s control. As these contraints are not amenable to control, one argument is that there is little benefit in analysing or debating the attendant concepts. On the other hand, experiences in clinical practice suggest that an accurate diagnosis, even without a cure, can be powerful.⁹ Consequently, it may be worthwhile for all clinicians to explore the conceptual frameworks that describe access to healthcare.¹⁰ Such frameworks may provide a better language with which to describe influences that help or hinder patients. Naming is the start of discovery and can help identify relationships and affiliations.⁹

Patient demand and service type both propel the domains of access:¹⁰ approachablity, availablity, affordablity, acceptablity, appropriateness. Various elements act as barriers or facilitators to each domain. As GPs tend to focus on individual care, these paired patient and service determinants can further inform the scope of history-taking and management strategies needed, especially in complex, multidisciplinary or chronic health presentations. It also illustrates how aspects of access are inter-related and will change with different episodes of care. This may then illuminate patient or clinic-specific initiatives that are evidence-driven, contextually relevant and sustainable.¹¹