Theme 4: Organisational issues in navigation

We generated two themes around which to organise our synthesis of organisational issues in negotiation:

• The permeability of services.

• Turbulent organisational contexts.

The permeability of services

We suggest that many of the patterns of use we have been describing in relation to socio-economic disadvantage reflect issues in the

organisation of services as much as they reflect a tendency to manage health as a series of crises on the part of disadvantaged people. We suggest that services that are well-known and easy to use are porous services. They are porous because patients require few qualifications of candidacy to use them, and because they require the mobilisation of relatively fewer resources. Services that are less permeable,

however, demand qualifications (such as a referral), and also demand a high degree of cultural alignment between themselves and their users.

We suggest that services that are less permeable tend to have high levels of default by socio-economically disadvantaged people. Our analysis suggests that non-attendance is highly significant in explaining access to health care by socio-economically deprived people. A recent systematic review of non-attendance in general practice reported that patients who miss appointments tend to come from lower social classes and to live in deprived areas (George and Rubin, 2003). The link with deprivation and non-attendance also applies in secondary care and other health care settings.

Non-attendance has been found by McClure et al. (1996) to be very high in paediatric outpatients clinic . In their study, 50 per cent of

appointments were not kept in social class V compared with less than 20 per cent in social class II, even though illness were rated as more severe among non-attenders. Macleod et al.’s (2000) study of

management of women with cancer found that significantly more patients from deprived areas failed to attend hospital appointments, though the difference was small.

Sharp and Hamilton (2002) provide an informal review of the evidence on non-attendance. They report that the main associations with

hospital non-attendance are being male, youth, length of time for an appointment, and deprivation. Non-attenders are less likely to own a car, have a telephone, or be employed. Questionnaire surveys affirm the link with deprivation. The commonest reasons cited for missing an appointment, after forgetting it, are family and work commitments.

People in lower paid jobs may have difficulty in arranging time off work or childcare to attend appointments. Appointment times that mean that patients are unlikely to be seen at the time they are booked intensify the difficulties for people in these groups. Goddard and Smith

NCCSDO © 2005 107 (1998) summarise evidence suggesting that those from more deprived social groups face financial costs of attending which, though not sufficient to dissuade them from using services when they are ill (i.e.

in response to a specific ‘event’), act as a barrier to attending

‘optional’ services related to health promotion and health prevention.

Time costs may be higher for those in manual groups because if they are not in paid employment they will not have an employer to

subsidise their attendance time. Even if they are employed, they may be in the type of job where they are less likely to receive subsidies from employers. Having to travel by public transport may impose particular time costs.

George and Rubin’s (2003) systematic review identifies that appointments systems can be a barrier to care. They may be especially difficult to use for members of communities in areas of social deprivation, because such systems require resources and

competences that are not necessarily available. People in these groups may have less predictable, chaotic lives that are not consistent with structured systems. They conclude that non-attendance can be viewed as the manifestation of a critical level of unsuitability in the agreed arrangements for an access episode. Heath (undated) argues that all barriers to consultation should be examined to ensure that those on low incomes are not disadvantaged, suggesting that an obvious example concerns those without a 'phone, who may be easily

disadvantaged if appointment systems are rigidly enforced and largely organised by telephone, or if there is increased use of e-mail. This is an important issue in the current move to ensure access to primary care, where arrangements by general practices often rely on being able to telephone the surgery during a specific period in the morning.

Services that use appointments systems rely on people having stable addresses and being able to read, and require people to present themselves in particular places at particular times. Such services include immunisation and screening programmes, outpatient clinics and elective procedures, and these, as we have already noted, have very high rates of ‘default’ by more deprived people. Some of this may be explained by the mobility of people in deprived populations. People who are in rented accommodation rather than owner-occupation may have much more frequent changes of address, and this puts them at risk of not receiving invitations. The Fourth National Survey of Morbidity in General Practice found that eight per cent of people registered with practices were not at their stated addresses and were not contactable (Martin and Sterne, 2001). At the more extreme end, people who are homeless or who live in travelling communities may not be sent or receive invitations to appointments at all (van

Cleemput, 2000).

Our analysis also suggests that the extent to which people feel alienated from the cultural values of health services and their satisfaction with services has important impacts on which services

NCCSDO © 2005 108 they choose to use. For example, in the study by Richards et al.

(2002) participants in the deprived group were more likely to report negative experiences and lower expectations from health professionals than the affluent group. The deprived group felt that the degree of social alignment with the doctor was poor and the extent to which knowledge was shared and adequate information was supplied from the consultation was limited. The affluent group in this study was more likely to report positive experiences. Rogers et al. (1999) similarly report that negative experiences of quality adversely

influenced patterns of use, sometimes encouraging people to withhold or delay in presenting symptoms. Services that are unattractive to people are, we argue, less porous.

We suggest that the more chaotic patterns of healthcare use among more deprived people, with high rates of use of emergency services and acute hospital admissions, illustrated earlier in our analysis, are most consistent with high use of highly porous services. For example, studies at St Mary’s in Paddington reported that nine per cent of all admissions were from homeless people (Victor, 1997). Deprived

people may have less control over their circumstances, and this makes their ability to attend at particular times in particular places highly contingent and dependent on the mobilisation of a wide range of resources that may be variably available. Permeable services, on the other hand, require less work from people to use them. Dodier and Camus (1998), in their French study, reported that the emergency service is used by homeless people and others because it poses least obstacles to use – it is a highly porous service in which people seek to constitute what the service will offer them; the service is relatively less able to constitute what services it will offer.

Turbulent organisational contexts

In the general synthesis in the previous section, we identified that new forms of organisation and provision in health services have created complex segmented environments and boundaries. These

organisations are staffed by diverse occupational groups, each with their own cultures, internal divisions and hierarchies, and are characterised by numerous difficulties of co-ordination and

management of role boundaries (Allen, 1997). Somerset et al. (1999) described the problems of coordinating care between GPs and hospital outpatients, highlighting difficulties in inter-professional

communication and continuity. Petrou et al. (2001), though unable to analyse social class, identified the impact that a fragmented care delivery process has on the level of ante-natal care provided to women, with increased fragmentation leading to fewer ante-natal visits.

Though these studies do not focus specifically on issues of social disadvantage, we suggest that negotiating a patient career across these complex forms requires competence and vigilance on the part of

NCCSDO © 2005 109 patients that may be especially difficult to maintain for those who are socially disadvantaged. They may be less used to or less able to co-ordinate the work of their candidacy over these multiple forms, and may be vulnerable to dropping out of the system at various stages.

Again, severely deprived groups such as the homeless may be most vulnerable. Vostanis (1998) suggested that homeless families are vulnerable to problems of interagency co-ordination, and that there are often different definitions of need and statutory obligations used by agencies. The House of Commons Health Committee report on inequalities in access to maternity services (2003) also highlighted the difficulties of maintaining contact with women over multiple

boundaries, quoting a witness as saying that:

‘We do have a lot of problems about going across social services

boundaries. If you need to be in contact with social services then once a woman moves out of one area into another that [contact] seems to break down. Unless the midwife is following that woman through, the other services do not seem to do that… you are going to lose women if they do not have the confidence to keep in touch with the midwife or the services they are getting.’

Summary: Organisational issues in negotiation

Socio-economically deprived people may be more likely to have patterns of entry to health service that are somewhat chaotic. There is a tendency for high use of easily permeable services and for ‘crisis’ presentations in the form of emergency admissions, possibly reflecting poorer overall health but also probably reflecting poorer health maintenance. Lower use of preventive services (for example asthma reviews) and non-attendance at out-patients appointments may reflect a lack of cultural alignment between the needs and priorities of people in socio-economically disadvantaged circumstances and the ways in which health services are organised.

3.2.5 Theme 5: Presentation, adjudication and