Inequality of access to primary and community health services: A scoping review

Introduction

The West Kent Home Treatment Service (WKHTS) is delivered by Kent Community Health NHS Foundation Trust (KCHFT) and provides hospital-level treatment at home for older people with frailty. Within the WKHTS it has been observed that fewer referrals are received for those in socioeconomically deprived areas compared to more affluent areas. This suggests there is a high level of unmet need amongst people with frailty in socioeconomically deprived areas in West Kent. KCHFT commissioned the Centre for Health Services Studies (CHSS) at the University of Kent to carry out a scoping review to explore inequalities of access to community frailty services, particularly in relation to socioeconomic status.

Methodology and Methods

The aim of the review was to determine socioeconomic (and other factors) influencing inequality of access to primary and community health services, including factors influencing GPs and other health and care professionals referral processes. There were too few studies identified which directly addressed access to frailty services, hence the review was widened to access to community services more generally. The review was carried out between November 2023 – March 2024 and included peer reviewed articles published in academic journals, websites and grey literature. 27 articles were included in the final review. Of these, 3 were reports, 9 were reviews, 6 were qualitative studies, 6 were secondary analysis of quantitative data, 1 was a mixed methods study and 2 were prospective cohort studies. Publication dates ranged from 2003-2023.

Results and Discussion

A conceptual model of ‘candidacy’ is a useful framework within which access to community health services can be viewed. It involves relationships, decision-making processes and beliefs (Dixon- Woods, 2006). The authors identify seven inter-related dimensions of candidacy: Identification; Navigation; Permeability of services; Appearances at health services; Adjudications; Offers and resistance; and Operating conditions.The literature is predominantly focused on GP referral processes. However, the WKHTS receives referrals from other health and care professionals and organisations such as SECAmb and the community ‘hubs’. Frailty may be normalised by patients and carers and seen as a natural process of ageing for which medical intervention is not useful. Also, the perceptions that the GP (or other health professional) is ‘too busy’ or ‘not wanting to be a bother’ may influence help seeking. There is some evidence to suggest that such beliefs may be more prevalent in those from low socioeconomic groups. Other factors impacting on identification of candidacy are low self-esteem which may be more prevalent in those with low socioeconomic status and those with complex co-morbidities which may include frailty.

There is good evidence that those with low socioeconomic status, particularly migrant populations do not have enough knowledge about the health and care ‘system’ to access it. Even once navigated, lack of available transport and associated costs disproportionately affects those with low socioeconomic status.GP services and the WKHTS have low permeability of access due to the need for referral and eligibility criteria. The permeability of the WKHTS may be increased by flexible points of access including self-referral and referral from a wide range of health and care professionals. In practice, there recent set-up of community ‘hubs’ in which a multidisciplinary team make joint decisions, is likely to enhance permeability of the service.

Low health literacy, language barriers, cultural differences may all impact on the quality of the interaction with the GP and other professionals and therefore referrals to the WKHTS. Availability of interpreters and translated materials written in ‘plain English’ both within primary care and the WKHTS may help.Professionals (GPs and other referrers) knowledge and attitudes to ageing and frailty may be important mediators for accessing the WKHTS. This includes the belief that patients are likely to benefit from the service. The perception that frailty is a natural part of ageing for which medical intervention is ineffective should be challenged. A multidisciplinary approach to decision-making and referral through the ‘hubs’ is likely to reduce the influence of individual beliefs and values as barriers to referral.

It may be that GPs with a special interest in gerontology and frailty and other professionals with specialist interest may be more likely to refer to specialist frailty teams including the WKHTS. Understanding the unique barriers and facilitating factors for referral is likely to increase referral rates, including for those with low socioeconomic status.

The capacity of the WKHTS to accept referrals, past experience of referring to the service by professionals, an understanding by referrers of what the service provides and the role of individuals within it (e.g specialist doctors, ACPs) are all likely to encourage referral. In addition, clear referral criteria and processes and personal relationships between the WKHTS and referrers may be important.

Conclusion

There is limited specific literature on socioeconomic factors influencing access to community frailty services. However, there is some evidence around the factors influencing access to primary and community services predominantly around access to GP services by vulnerable groups and onward referrals to specialist services. Although there is some explicit reference to socioeconomic status, most studies identify populations such as migrants, people experiencing homelessness, BAME populations, older people, those with multiple complex morbidities, people who are disabled and those with mental health conditions, as indicators of low socioeconomic status. The conceptual model of candidacy offers a useful lens through which equality of access to health services can be viewed. We can apply our understanding of the application of this model to people with frailty and frailty services, although conclusions are necessarily tentative based on lack of robust evidence. In addition to a presentation of the findings of this review, suggestions to promote equality of access to the WKHTS are offered.