So far I have explored many of the factors documented within the literature that could interact to increase or decrease the likelihood that an individual would convert potential geographic access into the utilisation of the healthcare in times of need. Two dimensions remain to be discussed in detail, the first of which, accommodation, is very much a systemic dimension. On the other hand, acceptability might be interpreted as something rather more individualistic. An insight into the literature on each dimension will reveal the realistic possibility that closer is not always better.
Accommodation describes the extent to which services are structured to ideally facilitate patient utilisation, whereas acceptability might be the appreciation of this structure within an individual’s own circumstance. An obvious example is the provision of interpreters in GP practices for some migrant workers who are less linguistically competent in the mainstream language of their host country (Jones and Gill 1998), or dedicated personnel for supporting persons that have difficulties of communicating or other impairments (Carter and Markham 2001; Ubido, Huntington, and Warburton
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2002), helping to make healthcare more accommodating and acceptable. However, not every GP practice may be able to offer these services and, as previously suggested, sometimes individuals may need to forsake the convenience of proximity to increase the availability of more accommodating GP practices. Thus, it is conceivable that those individuals that can afford to do so may incur costs associated with travelling longer distances or journey times in order to expand the range of services available (Haynes, Lovett, and Sunnenberg 2003), hoping to find one that more acceptably meets the level of accommodation required. Evidently, for individuals living in more rural, remote locations and with restricted mobility, the increase in displacement to the next available GP practice or any other service location may be vast and the costs associated with its geographic access unaffordable and/or unacceptable.
Another clear example of accommodation is the opening hours of a GP practice, which might open during the evenings or at weekends to be more accommodating to those patients unable to attend otherwise. Time constraints imposed by employment contracts are an important factor for both making contact and then staying in contact with healthcare. For example, in a study of GP consultations by patients with asthma and diabetes, Field and Briggs showed healthcare-seeking behaviour was discouraged by employment-related time constraints (Field and Briggs 2001). Moreover, and in relation to the previous discussion of socioeconomic position and affordability, Field and Briggs found that employment-related time constraints were disproportionately suffered by those in manual occupations. Individuals in manual occupations, and more generally,
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those in less-favourable occupationally-based social classes are widely recognised to have less autonomy and control in their work, find it more difficult to get time off, and are more likely to incur financial penalties for taking time off work due to the nature of the employment contract (often short-term, paid hourly) (Bartley and Plewis 1997; Rose 1998).
Therefore, an individual may have potential geographic access, but if taking time off work is perceived to be unacceptable and the availability of the nearest GP is only between the hours of 9-5, it is easy to see how in this situation a person might delay in arranging a consultation, or look to an alternative GP practice with opening hours more convenient to that individual within an acceptable distance or journey time. As has already been suggested, however, it is likely that the burden of poor health is disproportionately suffered by individuals in less favourable socioeconomic positions that sometimes actually make it more difficult to seek medical attention. For many, the idea of travelling further may be unacceptable in financial terms.
Accommodation and acceptability are also important when considering the doctor- patient relationship. It is thought to vary geographically, with GPs suggested to have closer relationships with their patients, and enjoying greater integration and visibility within rural, remote communities (Farmer et al. 2006; Farmer, Lauder, Richards, and Sharkey 2003; Higgs 1999). This may be a double-edged sword for the patient, who could have a more tailored service with a GP they may know reasonably well.
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Conversely, individuals already diagnosed with a publically sensitive health condition, such as HIV or HCV, unfortunately stigmatised through association with IDU, may be uncomfortable with approaching their local GP for support and elect to consult elsewhere to maintain anonymity for fear of discrimination (e.g. (Zickmund, Ho, Masuda, Ippolito, and LaBrecque 2003)). In more remote areas where an individual must travel further to exercise choice, again, the ability to do so is likely to be the reserve of those that can afford to do so. For those not so affluent, this may result in the delay or complete withdrawal from seeking healthcare or maintenance of a treatment regimen (Chesney and Smith 1999; Hajela 1998; Hopwood and Southgate 2003).
There is a widely-known expression that goes: “following doctors orders.” Better known in medical literature as compliance, it has long been criticised for denoting obedience and conjuring negative imagery of noncompliant patients (Mullen 1997). In these terms, it is suggested that a patient that does not comply is in danger of being viewed as incompetent and unable to follow instructions, or even as deliberately self-sabotaging (Horne 2006). Again, this is also reflective of the HCV literature on attitudes within the medical profession towards persons with a history of IDU (Edlin 2002; Edlin 2004; Sylvestre, Litwin, Clements, and Gourevitch 2005). In the last ten years or so, there has been a sea-change in terminology, with the terms “adherence” and “concordance” also used. In contrast to compliance/obedience, adherence is “the extent to which the patient’s behaviour matches agreed recommendations from the prescriber” (Horne 2006), thus taking into account whether a patient agrees to commit to the doctor’s
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regime. Furthermore, concordance is an idea “relating to the patient/prescriber relationship and the degree to which the prescription represents a shared decision” (Horne 2006), therefore implying a more equal distribution of power between GP and patient. All well and good, but to what extent has the intention of these new labels have been translated into reality? Are GPs perceived to be more accommodating of their patient’s views when making decisions over referral or treatment prescriptions, or are patients still expected to just “follow doctor’s orders”?
Some evidence demonstrates that some patients, typically those with more favourable socioeconomic circumstances, enjoy greater involvement in their GP’s decision-making. For instance, in terms of whether an individual is referred to a specialist, Evans showed those GPs who referred a lot tended to be more likely to accommodate their patient’s request for referral (Evans 1993). Armstrong found those patients willing to put pressure on their GPs in order to gain referral were more likely to be referred than those that left the decision completely to the GP (Armstrong, Fry, and Armstrong 1991). As Hirchman previously argued, the more vocal, articulate, confident, persistent and demanding patients often get better treatment (Hirschman 1970). It seems that more affluent individuals are better endowed for engaging a GP in decision-making. In comparison, such concordance may be unimaginable or unacceptable to those occupying less favourable socioeconomic positions, who more likely to hide the full extent of symptoms from GPs, more often attempt to self manage pain due to concerns of having previously overused health services, and even harbour negative opinions of
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their own self-worth with regards to treatment and life expectancy (Gardner, Chapple, and Green 1999; Richards, Reid, and Watt 2002; Tod, Read, Lacey, and Abbott 2001). Moreover, recent studies have even shown evidence that many individuals who present later-stage colorectal and lung cancer at diagnosis are likely to have normalised their symptoms, even when severe, attributing them towards everyday aches and pains (Bain and Campbell 2000; Corner, Hopkinson, and Roffe 2006).
Ideally, GPs would be able to recognise all symptoms and make the correct decision every time for every patient. But in reality, some patients it seems may be less willing to take part in concordance with their GP, who may have to go to great lengths to encourage participation (Heath 2006). If there is a lack of communication due to a poor awareness on the part of the patient and/or the GP is unable (or unwilling) to accommodate and encourage, some information might be withheld whilst other parts might be misinterpreted, and inappropriate guidance awarded (Balsa and McGuire 2001). For instance, some findings have suggested that individuals in more rural areas experience greater delays between referral and treatment, especially if they are initially directed to a local, non-specialist hospital (Bain and Campbell 2000; Bain, Campbell, Ritchie, and Cassidy 2002). It is not known, however, to what degree these indirect referrals are the result of a lack of communication or awareness, or the outcome of sympathetic accommodation and cooperation, taking into account what a patient finds acceptable given the constraints on their situation.
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So, accommodation is a lot more than just being open during evenings and weekends and acceptability is not only whether patient is content with the circumstance. Very generally, each dimension can be viewed in terms of i) when a patient first seeks healthcare; ii) further experience in healthcare once contact has been established. Accommodation and acceptability can alter healthcare-seeking behaviour, prompting some to look further afield, whereas discouraging participation and increasing the propensity for delaying behaviour amongst others who are subsequently at a greater risk of presenting a poorer level of health at diagnosis. Accommodation is partly about communication and the level of input a patient has in a GP’s decision-making. For some, no input may be acceptable whereas others might demand greater involvement or alternative opinion, the latter of whom tending to occupy more favourable socioeconomic positions and seemingly get better healthcare for their persistence. Acceptability is about whether an individual perceives travelling long distances and travel-times to be worth the hassle (i.e. the pursuit for accommodation), or the willingness to continue attending treatment frequently over a sustained period of time. Thus, accommodation and acceptability are socially and geographically contextualised and will interact with other dimensions to influence whether an individual’s potential geographic access to healthcare translates into utilisation when they need it.
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