Theme 5: Presentation, adjudication and offers offers

Section 3 Socio-economic disadvantage and access to health care access to health care

3.2 Lines-of-argument synthesis

3.2.5 Theme 5: Presentation, adjudication and offers offers

We have earlier argued that most of the evidence supporting the hypothesis that more deprived people have poorer access to health care comes from a body of work on utilisation, which we have

suggested is potentially mis leading. Measures of receipt of services do not acknowledge how people present to services, how their candidacy is judged by professionals, what offers are made to people, or whether people choose to accept these offers. We generated the following themes around which to organise our synthesis of the evidence on these issues:

• Presentations.

• Categorisation and disposal: Adjudication.

• Adjudications: Judgements of technical candidacy.

• Adjudications: Moral and social deservingness.

• Referring and adjudication.

• Operating conditions and the local production of candidacy.

Presentations

We earlier distinguished between putting in appearances at health services (where people initiate a contact with services following their own identification of candidacy) and responding to invitations (where services ask people to attend in response to specified features of candidacy). Appearing at health services involves people in asserting a claim to candidacy for medical attention or intervention. The nature of this claim may be highly variable. For example, people may have only a poorly formulated, diffuse, and ill-defined issue for which they are seeking help, or they may have a long-standing problem and need help simply to execute a course of action on which they have already determined, and so on (Thorsen et al., 2001). Whatever the nature of the claim, making it clearly involves work that requires a set of competencies, including the ability to formulate and articulate the issue for which help is being sought, and the ability to present credibly.

More deprived people are at risk in these situations: they may be less used to or less able to provide coherent abstracted explanations, and may feel intimidated by their social distance from health professionals.

May et al.’s (2004) analysis shows that patients’ subjective

interpretation of experiences of themselves and their symptoms form the basis for engaging with the doctor. Sword (1999) points out that low income people may feel alienated by the power relations that often characterises encounters with professionals. Dixon et al. (2003) suggest that middle class people may be more adept at using their

‘voice’ to demand better and extensive services: they are more articulate, more confident, and more persistent. Cooper and Roter (2003) summarise the evidence in this area, suggesting that research has indicated that people from lower class backgrounds were less verbally active overall during medical visits, and that this was especially evident in patients’ presentations of their symptoms,

question-asking, and social talk. They further suggest that people from these backgrounds may appear diffident in asking questions, not because they do not wish to know about medical matters, but because the social distance between themselves and doctors discourages verbal assertiveness.

Gardner and Chapple’s (1999) study, based on semi-structured interviews with 15 patients with angina and their four GPs in a

deprived area of Liverpool, provides a good illustration of these issues.

They found that people had difficulty in describing their problems and offered vague accounts of their problems, and that doctors did not always pick up on the extent of patients’ suffering. Somerset et al.

(1999) reported that in making referral decisions, patients’ social status and their ability to articulate verbally were put forward as tacit

NCCSDO © 2005 111 influences that affected the likelihood of referral. Hart and Lockey’s (2002) study identified that midwives’ attempts to address inequalities were strongly influenced by midwives’ perceptions of women’s

expectations. This could mean that women perceived to be ‘savvy’

(likely to be middle class and seen as ‘demanding’) got more time and resources.

Presentations – the making of a claim to medical attention or intervention - are also likely to be affected by the time available in consultations. There is some evidence that people from more deprived areas tend to have shorter consultations (Stirling et al., 2001; Wyke et al., 1992). Stirling et al. 2001, for example, suggest that mean

consultation length falls as the prevalence of positive General Health Questionnaire rises across the deprivation categories, indicating that GPs in deprived areas have shorter consultations and see more patients with psychological morbidity.

A 1991 questionnaire study reported that GPs considered that they explained and listened less to more deprived social groups, and that they were less likely to examine and give advice to people in social classes IV and V, though these were not robust conclusions and small figures were involved (Martin et al., 1991). The reasons for this are unclear, but may be linked to a combination of under-supply of GPs in deprived areas and higher consultation rates among people in

deprived areas (described earlier). This combination of supply and demand may leave GPs working in deprived areas more pressed for time and less able to be attentive, but clearly further research would be needed to investigate this hypothesis. What is clear, however, is what we have earlier referred to as conversion – the ability of people in more socio-economically disadvantaged circumstances to convert a given unit of health care (such as a GP consultation) may not be a great as that for more privileged people. This in turn may influence processes of categorisation and disposal.

Categorisation and disposal: Adjudication

We introduced, in the general synthesis, evidence that the ways in which people are categorised within health care organisations shape their careers as patients. Once a patient has asserted their candidacy by presenting to health services, the professional judgements that are made about that candidacy strongly influence subsequent access to attention and interventions: the candidacy becomes something to be defined by health services, though individuals may continue to negotiate over this definition and its consequences. We use the term

‘adjudication’ to refer to the judgements and decisions about disposal made by professionals which allow or inhibit continued progression of candidacy. We also recognise, as we later make clear, that

adjudications can be challenged by people: they may find another way to gain access to a service they want, or they may choose to reject a service they are offered.

disadvantaged people is at risk of being judged to be less eligible, at least for some types of interventions, but that the evidence that this does happen is not particularly strong. In presenting this analysis, we invoke May et al.’s (2004) recent argument that doctors’ interactional behaviours and communication skills are exercised through their own contextual experiences of types of patients, types of problems, and types of disposal options – a repertoire of routine judgements about the possibilities presented by individual patients and the routinely available means of solving these. These typifications are, we suggest, strongly influenced by local conditions, including the operating

conditions in which practitioners work. Importantly, we also recognise the ways in which patients themselves influence these typifications.

Adjudications: Judgements of technical candidacy

Our analysis suggests that it is likely that professionals’ perceptions of patients who are likely to ‘do well’ as a result of interventions, possibly influenced by evidence-based guidance, may disadvantage people in more deprived circumstances. As Hughes and Griffiths (1997) identify, a problem with resource allocation by clinicians is that their decisions may rest on often implicit social criteria about which patients ‘ought’

to receive care. People in disadvantaged groups are more likely to smoke, to be overweight and to have co-morbidities, for example, putting them at higher risk for surgery and making them poorer candidates for many other interventions. In this way professional perceptions of the cultural and health capital required to convert a unit of health provision into a given unit of health gain may function as barriers to health care.

Hughes and Griffiths (1997) is one of the few studies to explore how doctors decide how to allocate resources to individual patients, but our analysis suggests that this is a key paper. The authors use a case study approach to investigate the selection of patients for cardiac surgery and admission to a specialist neurological rehabilitation centre. They found that the key question in cardiac catheterisation conferences, in which cardiologists present candidates for cardiac surgery for consideration by the cardiac surgeon, is the technical feasibility of surgery, and discourse in these conferences centres on the technical difficulties presented by cases and assessment of surgical risks.

Judgements of technical eligibility rely, clearly, on doctors’ knowledge and skills. Fuat et al. (2003), in a qualitative study of GPs’ beliefs, practices and decision- making in the diagnosis and management of suspected heart failure, found that GPs expressed considerable uncertainty about good practice, and that some had difficulties in interpreting echocardiography reports, that they had concerns about the appropriate indications and management of particular forms of

evidence.

Heath (undated) argues that healthcare that is increasingly driven by protocols derived from studies of single disease conditions seems likely to disadvantage those with multiple morbidity, which is more common in low income groups. Watt (2002) makes a similar

argument, suggesting that most evidence-based guidelines, health technology assessments, national service frameworks and health policies are based on the assumption that individuals have single conditions, but deprived people suffer from considerable co-morbidity.

He distinguishes the morbidity of socio-economic deprivation from multiple pathology, arguing that co-morbidity in deprived populations refers to the number, severity, and complexity of health and social problems that exist in families.

Although there is some evidence of increased risks associated with operating on socio-economically deprived people (Taylor et al., 2003), it is likely that much of this can be explained by confounding of

smoking status with social class, and that judgements of technical candidacy are in fact socially constructed. Reid et al. (2002) found that statins were less likely to be prescribed to smokers (OR 0.55, CI 0.32 to 0.96) although sub-group analyses have shown that statins are equally effective in smokers and non-smokers This study also found evidence for the importance of co-morbidities in influencing

judgements of technical eligibility: statins were also prescribed less often to people with angina, although the authors similarly point out that there seems to be no reason to withhold statins from patients with angina only.

Other evidence that points to the socially constructed nature of technical eligibility includes work which demonstrates the importance of professionals’ consideration of how technically interesting a case is (Pope, 1991; Dodier and Camus, 1998). Dodier and Camus (1998) describe ‘intellectually interesting’ cases as cases that are difficult to solve or unusual, but where there is hope of clarification, and where there is pedagogical interest. They give the example of a woman with an erythema nodosum who excites intellectual interest. However, poorly differentiated problems that are social in origin may be much less intellectually interesting, and vulnerable to being judged to have poorer mobilising worth.

Adjudications: Moral and social deservingness

Hughes and Griffiths (1997) suggest that in addition to issues relating to the technical feasibility of procedures, social and moral dimensions of cases could also be taken into account in some decisions. Goddard and Smith (1998), for example, summarise evidence suggesting that independent of the severity of the disease, some GPs are more likely to refer the economically active and those with dependants, and being economically active has been associated with shorter waiting times for

admissions conferences, in which a multidisciplinary team assess the suitability of head injury and stroke patients for neurological

rehabilitation. Issues such as how overweight someone was could influence decisions to admit, but so too could judgements about social support available on discharge, family circumstances, physical

suitability of the home, and prospects for an eventual return to work.

Clearly, there is potential for socially disadvantaged people to be disfavoured in such decisions. For example, cardiac surgeons in their study expressed doubt about the acceptability of cases where there was evidence of high risk, such as overweight and smoking, and where patients had not modified their behaviour:

Surgeon: ‘[…] Any patient of 20 stones plus is high risk for any chest surgery.’

Senior registrar: ‘Perhaps the best thing would be to bring him in for three weeks for monitoring and try to get his weight down […]’

Surgeon: ‘Donald, you’ve had four years to educate this guy […] There is no point in operating on this guy if he is going to carry on working in a smoky atmosphere, if he won’t modify his lifestyle.’

In some cases that Hughes and Griffiths studied, professionals used narratives designed to influence hearers by setting in play cultural norms for tactical ends, for example drawing on notions of family and

‘social deservingness’ to justify treating particular individuals. This moral framing can lead to patients being ruled out – denied candidacy – or ruled in – offered candidacy. Interestingly, one case they describe involved a well-off patient being denied candidacy (because it was perceived he was trying to ‘buy ’ candidacy).

A further illustration of how professionals’ judgements of candidacy may invoke social and moral judgements is found in Dodier and Camus’ (1998) analysis of what they call ‘social demands’ in a French emergency service. They describe how the category of patient who consults emergency services because of their inability to gain what they need elsewhere or difficulties in accessing medical care arouses complex reactions. These patients are vulnerable to being seen as having low mobilising worth – staff may be reluctant to mobilise resources around them, though differences and conflicts may arise between personnel about the right attitude to adopt. These can include recriminations with delayed or limited mobilisation during treatment. For example, homeless people are often pushed further down the list: the medical decision is at the same time a decision concerning allocation of rights.

There is, however, also evidence that in some areas of health care, there are few social class differences in the ways in which people are categorised. Richards et al. (2000) could find no link between the proportion of people with symptoms who received a provisional diagnosis of CHD and deprivation.

The question of whether socially disadvantaged people are less likely to be referred for specialist care was raised earlier in this section. In our analysis, referral is an outcome of processes of adjudication.

Clearly, lower rates of referral could explain why in some specialist areas deprived people appear less likely to have some types of interventions, and clearly, it would be important to understand what influences referral behaviours among GPs. O’Donnell (2000) provides a comprehensive review of the literature on GP referral rates. She concludes that the role of social class in the variation of referral rates is not clear-cut. It depends not only on the measure used to quantify deprivation, but also on whether the measure is based on the patients who actually consult a GP or on the practice population as a whole. For example, using the practice based Jarman UPA (8) score as a measure of deprivation, a study in Nottinghamshire found more deprived

practices to have high total referral rates and medical referral rates, but increasing deprivation was less associated with decreasing surgical referral rates (Hippisley-Cox and Pringle, 2000; Hippisley-Cox et al., 1997). However, since the Jarman score measures GP workload, it could be expected to be associated with higher rates of referral.

Macleod et al. (2000), in a retrospective review of primary and secondary care management of women with early breast cancer from affluent and deprived areas using hospital and general practice records, found that time between the date of the general practice consultation and the date on the referral letter did not vary between women in affluent and deprived areas suggesting that there were no differences in referral behaviour between GPs in deprived and affluent areas.

Offers and resistance

In much of the work on utilisation of health care, there is an

assumption that non-utilisation is a direct reflection of non-offer, and the implication is that adjudications must be flawed, or socially biased in some way. However, this type of normative analysis denies people agency, by failing to acknowledge that people may choose to refuse offers. There is a range of strategies that people can use to resist offers (perhaps because they do not agree with the judgement of candidacy made by professionals and the consequences of that judgement, or because the costs of accepting that offer would be too high, for example), and it is possible that patterns of resistance are socially patterned. A small body of work points to issues of acceptance and rejection of health care, as does the evidence on non-attendance mentioned earlier, but little is known about rates of acceptance and rejection and their influence on uptake of services.

Referral implies that a GP has identified particular features of

candidacy and is seeking to match those to a service that deals with that form of candidacy. There is interesting work to show how patients

NCCSDO © 2005 116 can choose to assert control over this attempt by GPs to define and act on candidacy. One strategy is to allow themselves to be referred but, as described earlier, not to attend. Another strategy is to resist being referred. Gardner and Chapple’s (1999) study, based on semi-structured interviews with 15 patients with angina and their four GPs in a deprived area of Liverpool, found that some patients concealed or downplayed aspects of their illness, and were resistant to being cast as candidates for referral to a cardiologist for assessment. GPs in a qualitative study of behaviour and decision- making in relation to heart failure identify that there is a group of patients who do not want to be hospitalised or referred (Fuat et al., 2003). Similarly, Britten et al.

(2004) report that ‘offers’ of medicines prescribed by general

practitioners are frequently refused, and moreover, that people do not express their aversion to medicines during consultations. For example, people accept prescriptions from doctors, but then do not ‘cash’ them (Schafheutle et al., 2002).

Operating conditions and the local production of candidacy A small body of recent research has identified what might be called local influences on the production of candidacy, and in our analysis these are hugely important. These are the contingent and locally specific influences on interactions between practitioners and patients, which may be emergent over time through repeated encounters.

Britten et al. (2000), among others, has shown that some decisions made by doctors are made not on the basis of rational clinical evidence but in order to preserve their relationships with their

patients. In a recent analysis of data collected in six qualitative studies of GPs’ constructs of chronic illness and their responses to them, May et al. (2004) highlighted the importance of the patient’s motives for

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