Something we can learn

There’s a word…

… it’s an important word that, until relatively recently, we haven’t had to bother with.

It’s a key determinant for all healthcare systems. 

A word to which the World Health Organisation attaches great significance. They describe the word as being ‘closely intertwined’ with health-system success.

For the NHS it’s been a given.

A word we haven’t bothered with… been pretty snobby about it… ‘… something ‘they’ have to worry about, not us’.

It’s a word for healthcare systems, underdeveloped… where there’s financial hardship, where poverty creates its own definitions.

Systems where, in Penchansky and Thomas’ framework, the word is portrayed as a ‘fit’ between the needs of patients and the capacity of healthcare systems.

Systems where the burden of disease is added to by the absence of what this word means.

Systems where it’s a key indicator. An obvious and visible determinant of success.

Don’t just think in terms of developing-world’ systems. Closer to home, across the EU, it is key and there are a variety of tools to measure it.

I’m talking about the word; access.

There are three types of access;

1. Availability access: do people have sources of care within reasonable reach?
2. Adequacy access: are these sources of care adequate to respond to the needs of the population? 
3. Acceptability access: are the sources of care acceptable from a social point of view, cost and waiting time?

Measured on these determinants, the NHS fails.

Might scrape under the bar with number one? Not if you are a child needing mental health care. Children and young people’s mental health beds are rarer than a bubble bath at Glastonbury.

Our NHS is based on the Secretary of State’s statutory duty to provide services to meet ‘all reasonable requirements’. 

What’s ‘reasonable’?

Is a stroke patient, waiting 3hrs for an ambulance… reasonable access to care?

Is a person, house bound, for three years, or more, for the want of a hip replacement… reasonable access to care?

Is a mental health patient in crisis, waiting hours in A&E… getting reasonable access?

Is a patient, marooned in a hospital bed for weeks on end, waiting for social-care to pick up the case… reasonable access to care?

Is a person, parked in the back of an ambulance for 12 hours, waiting for hand-over… reasonable access?

Is a patient on a trolley, in a corridor, in A&E for six hours… reasonable access?

Before you answer, remember, they will get ‘care’, eventually. But…

… it’s not a Penchansky and Thomas, ‘fit’ between need and the system’s ability to provide. 

Access to healthcare might be defined as; the ease with which an individual can obtain needed medical services.

Define ‘ease’? Well, it’s not waiting a fortnight for a GP appointment.

Access can be defined in five dimensions:

• approachability, 
• acceptability, 
• availability and accommodation, 
• affordability,
• appropriateness.

We fail on the first three… don’t we?

International comparisons are always tricky but the NHS’ plunge in the Commonwealth Fund rankings, from first in 2017 to forth, is almost entirely associated with lower performance on access.

If access is a fail it creates its own problems; complexity and exacerbation. Poor access means poor outcomes, failure demand and higher costs per case.

The answer?

First, accept we have a developing world problem.

Next, a relentless focus on access. 

It’s the singular most important issue for the NHS and should be the single focus of our energy. It is not insoluble.

For example. 

We have data, we know in March, there were 30.1m appointments in primary care and 44% were same day.

We know some practices do better than others.

Don’t think league-tables but do think about talking to practices who are providing better access.

• What’s to learn. 
• What’s to copy. 
• What’s to pinch, with pride?

It only has to be a tiny improvement, to scale up, to make a significant change.

There’s no silver bullet but there is silver buckshot.

We know ambulance handovers are a nightmare but there is variation. 

Can we learn from the places where the delays are even marginally better?

For just about every measurable part of access there’s data and it shows variation, which is always a hopeful sign of positive deviation.

Meaning, someone is doing something different… 

… something we can learn from.

News and Comment from Roy Lilley
Contact Roy – please use this e-address roy.lilley@nhsmanagers.net
Reproduced at thetrainingnet.com by kind permission of Roy Lilley.