I use many words in this thesis without defining them. Readers interpret and form their own meanings of phrases within the subject context. These meanings should be similar to mine for common and non-technical words, despite the ambiguity inherent in language. Some terms are particularly prominent in the thesis, such as ‘access’, ‘opening hours’, and ‘patient experience’. I discuss my use of these terms below. My aim is not to prescribe what should be meant by these terms but only to clarify what I mean when I use them.
The empirical research reported in later chapters depends, by definition, on observation. Logical positivistsa associated with the traditional account of definitions in philosophy113 argue that empirical observation is key to analysing the meanings of words and propositions; if the observations needed to determine whether a proposition is true or false are known, then the proposition’s meaning is also known.114,b,c If an observation does not verify a proposition as true or false, then it is irrelevant to the proposition’s meaning. One proposition relevant to this thesis is ‘P was able to access general practice services’, where P denotes a person.
a Logical positivism is a set of ideas associated mainly with 19th and 20th century philosophers that is concerned with, for example, the relation of science and experience, the ability and need to verify propositions, and probability theory.
b Propositions, rather than individual terms, are key because many words take on different meanings in different contexts; for example, ‘feet’ in ‘stand on two feet’ and ‘ten feet tall’ are interpreted differently. This principle is central to the traditional account of definitions which maintains that terms must be defined within specific contexts; propositions can provide this context.
c For example, the phrase ‘Cowling was the author of this thesis’ is said to be understood if the reader knows the observation(s) that reveals whether it is true or false. This observation could relate to seeing the thesis being written and by whom.
Existing conceptualisations of access often disaggregate it into several ‘types’, ‘dimensions’, or ‘sub-components’.115-122 The constituent parts differ between authors. For example, in one prominent conceptualisation,122 ‘access’ has five dimensions: availability (volumes and types of services), accessibility (geographical locations of services and users), accommodation (organisation of services to accept clients), affordability, and acceptability (relations of user attitudes and personal/practice characteristics). Another framework118 posits four dimensions of ‘access’, termed ‘service availability’, ‘utilisation of services and barriers to access’, ‘relevance, effectiveness, and access’, and ‘equity and access’. Other conceptualisations include patient choice and continuity as dimensions.115 120 The opening hours of general practices could be seen as a measure of service availability or of how accommodating services are to patients’ expectations in these frameworks. Similarly, numbers of doctors per patient and travel times to services have been proposed as measures of access.115 118 121
However, I cannot consider the above ‘dimensions’ as collectively constituting the meaning of access, for two reasons. First, I do not make inferences about all of them from propositions such as ‘P was able to access general practice services’. For example, from this proposition, I do not infer the opening hours or number of doctors a practice has. Second, even if these and other variables were specified, I would not be able to say whether P was or was not able to access general practice services on a given attempt. There are numerous variables that may affect the probability of a patient being able to access care, but I see these variables as distinct from the meaning of access itself. Their true relationships must be determined through empirical research, which implies that access can be measured as a distinct entity.
When a patient receives care in general practice, I consider it necessarily true to state that the patient had access to general practice services. Access does not necessarily result in the receipt of care, however; a patient may try to get an appointment, be offered one, but decide not to take up the offer. I would still state that this patient was able to access services, because there was an opportunity to receive care in the offered consultation.
It could be argued that everyone registered with a general practice has the opportunity to receive care from these services and, therefore, has access to them. I do not adopt this view as it implies that access is constant within GP-registered populations and would therefore be
irrelevant to research investigating relationships in these populations.d Moreover, a registered patient may be unable to receive care on a specific attempt to do so, perhaps because appointments can only be booked on the same day and all were taken when the attempt was made. Patients’ abilities to access services may differ between appointment attempts; these attempts are a more appropriate unit of analysis for measuring access.
A patient may be offered an appointment on a given attempt but not accept it because the ‘conditions’ of access are unsuitable. These conditions could include the timing of the appointment and the health professional able to be consulted. Both of these factors can be objectively observed, but their suitability to the patient is subjective.e Two patients could access general practice under the same conditions but perceive their experiences very differently. I use the term ‘patient experience’ to refer to both the objective and subjective parts of patients’ interactions with their practices.f
Subjective parts of patient experiences can only be measured by eliciting them from patients, by definition. This could be done via surveys or in-depth interviews, for example. Objective parts of experiences such as outcomes of patients’ appointment attempts could be routinely recorded in general practice information systems, though this is not common. Alternatively, patients could report these aspects of their experiences too, as in the GP Patient Survey which measures both objective and subjective experiences of general practice.