Availability

In the previous discussion of geographic access, the potential for choice was reflected upon. This is what Penchansky and Thomas referred to in an explicitly separate dimension entitled availability. Although more recent publications have seen fit to combine geographic accessibility with availability into a composite dimension of so- called ‘spatial accessibility’ (Guagliardo 2004; Luo and Wang 2003), hailing from the

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similar types of measures used in analyses of job accessibility (Peng 1997) and the framework proposed by Aday and Newman (Figure 8.1), this remains an embryonic conceptualisation in geographies of health research. Little debate has ensued over what is gained and what is lost in terms of our potential understanding of the geographies of health and the extent to which geographic accessibility might have an influence upon health outcomes. To this end, I elect to keep the concept of availability separate, in view that notions of availability sensu Guagliardo, Luo and Wang, and Peng too seem to be absolute (and deterministic, as explained in the next chapter) whereas it feels quite reasonable that the range of locations from which one individual picks and chooses their services from is likely to vary in geographical extent from one person to another with different socioeconomic circumstances, attitude and behaviour.

So availability, as intuitive as it might sound, is a reference to the extent to which multiple service locations are present, offering some degree of choice to the individual. For instance, availability is the range of supermarkets in the area for grocery shopping, or the number of automatic teller machine (ATM) cashpoints located nearby from which to withdraw money, or the number of alternative locations where a person could consult a GP. Therefore, like geographic accessibility, availability is inherently geographical, but instead of referring to some sort of displacement, rather, it is a measure of how many different possibilities there could be for any given service.

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But, equally importantly, availability may also be the degree to which a healthcare service has possession of the actual resources, equipment, technology, personnel and expertise that a patient might require. As Raine et al rather gravely suggest:

“A person cannot need health care if no intervention is available to improve their health. They may need health, but they do not need health care”

(Raine, Hutchings, and Black 2004)(p.228)

But the degree to which Raine and colleagues are correct depends very much upon scale. Not only geographical, but also temporal. For instance, a case in point is that of the recent patient from Scotland infected with the H1N1 (so-called “swine-flu”) virus, who was flown to Sweden (BBC News Online 2009) to utilise Extracorporeal Membrane Oxygenation (ECMO) technology. Briefly, ECMO is designed to circulate blood outside of the body during which it is oxygenated and then re-circulated back within the body. It is a modified heart-lung machine that provides better support for patients with severe respiratory or cardiac failure than other technology more widely available (Wolfson 2003). Crucially, why this is relevant is that ECMO technology is only available in one hospital in the UK (Glenfield Hospital, Leicester) and with a limited number of patients only able to use ECMO at any one time. If a patient in the UK requires ECMO, wherever they are, they are referred to the unit in Leicester. This means that geographic access to this particular form of healthcare varies extremely within the UK population, and with highly restricted availability in geographic terms.

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However, when all the available spaces are assumed, as was the case of the aforementioned patient, healthcare was required but unavailable within the UK at that moment. Availability is a temporal construct. Potential access to ECMO had not changed, but its availability had, so unable to convert that potential into utilisation. The only option was, literally, to travel to expand the usual geographical coverage or scale to a different country in order to achieve availability. This illustrates quite well (albeit, on a quite extreme basis) how availability is not only subject to the geographical, but also the temporal. It also shows how the geographic extent of availability for the ECMO unit in Leicester is vast, but at certain times a person will have to travel much further to get the healthcare their condition requires. Although the cost of transportation to ECMO service is provided by the NHS, in other more common situations such as for patients requiring consultation with a GP or frequent specialist attention for haemodialysis or HCV combination therapy, availability is case-dependent and geographically and temporally relative.

Delving deeper into the geographies of health literature, Shannon has suggested that academics interested in geographic accessibility ought to reduce emphasis purely on displacement, in favour of re-imagining the ways in which spatial interactions occur (Shannon 1980). In short, Shannon was encouraging a focus on territory in a way that withdraws attention from the spatial configuration of healthcare, to more about where the individual is actually situated at different times. It is the idea that traditional measures of geographic access to healthcare (as will be discussed in the next chapter)

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are actually surrogates for a wider web of relations between individuals and the places, or activity spaces, in which they live, work and play (Gesler 1992; Golledge and Stimson 1987; Patton 1975).

For example, it is highly conceivable (and I can personally attest) that an individual may perceive availability of a certain type of service, such as a dentist or a grocery store, to be the range of possible locations nearby their workplace, which may be quite some distance from their place of residence. Perceptions of healthcare availability may be no different. A recent study showed that only 56% of a population in Eastern England were registered with the GP practice located closest to their household (Haynes, Lovett, and Sunnenberg 2003). This might reflect ideas on activity spaces sensu Shannon and others, but with the study also demonstrating variation between individuals living in urban and rural areas (where persons in the latter were more likely to be registered with their nearest GP), the trend could also be driven by a geographic variation of health-seeking behaviour with individuals in more urban environments displaying a more consumerist approach to healthcare compared with persons in predominantly rural areas said to enjoy closer relationship with their nearest GP (Farmer, Iversen, Campbell, Guest, Chesson, Deans, and MacDonald 2006; Farmer, Lauder, Richards, and Sharkey 2003; Higgs 1999). The consumerist approach of city-based individuals may be driven by the generally shorter duration of GP consultations typical of more deprived urban areas (Furler et al. 2002; Mercer and Watt 2007; Stirling 2001), which could spur individuals to seek alternative opinion only a little further afield. Whereas the longer consultation

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times and closer relationships enjoyed by persons in more rural areas, coupled by the probable limited supply of alternative locations may mean that the closest GP practice is more acceptable from this point of view. Acceptability, however, is another dimension that I turn to later in more detail.

Furthermore, in addition to the absoluteness of whether a service is or is not available within a particular distance or travel-time (or activity space) and open within a convenient timeframe for the individual in question (accommodation), availability is arguably dependent upon information and awareness. In an interesting reference to Tudor Hart, Mead and colleagues coined the term ‘The Inverse Information Law’ whereby those individuals with the greatest need for a specific type of healthcare were least likely to know about it (Mead, Varnam, Rogers, and Roland 2003). A recent study has also found a poor level of agreement between GIS-determined distances to green parks and respondents perceived distances (Macintyre, Macdonald, and Ellaway 2008b), which therefore suggests, like the distinction between potential geographic access and utilisation, the potential degree of availability may be quite different to the perceived range of options available to the individual (and hence, utilisation). As mentioned in the previous chapter, this lack of awareness of treatment and where to obtain it is certainly thought to be the case for many individuals infected with HCV, particularly those with a history of IDU (Davis, Rhodes, and Martin 2004; Davis and Rhodes 2004). They, who are often diagnosed with HCV but rarely treated, are described in the words of Edlin, as the “elephant in the living room” (Edlin 2004).

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So, in discussion of availability, it seems that it too is a relative concept. Much depends upon where an individual lives and the spatial configuration of service locations surrounding them, but this does not necessarily reflect perceptions or knowledge of availability. Availability can vary through time and space and just because a person lives quite close to a GP practice (potential geographic access) does not always equivalise with the utilisation of that particular service location. Geographic accessibility and availability therefore, whilst obviously linked, cannot necessarily be grouped together in complete harmony as recent academics (Guagliardo 2004; Wang and Luo 2005) appear to suggest. And it is clear that other factors are important other than the range of service locations in determining whether an individual translates potential geographic access into utilisation. Following Penchansky and Thomas’s lead, our discussion turns to the remaining three dimensions of affordability, accommodation, and acceptability.