EDITORIAL

Accessibility in family medicine: re-examining a core concept

John Yaphe, MD*

Associate Professor, Community Health, School of Health Sciences, University of Minho.

Endereço para correspondência | Dirección para correspondencia | Correspondence

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“If you want to limit your workload as a family doctor, make sure your clinic is open only from 2 to 3 a.m. on a Wednesday morning.” Dr. Arthur Furst, a pioneer of modern academic family medicine in Israel, made this provocative challenge to highlight the conflict surrounding accessibility in family medicine. Our patients’ needs are end-less yet our resources and our abilities to meet them are limited. How do we find a happy balance? In order to answer this question, we need to re-examine access as a core concept in family medicine.

Accessibility is one of the 4 A’s of the profession along with ability, affordability, and affability. We need to be good doctors and good people. We also need to provide an affordable service that our patients can use easily. This also fits in with the 5 C’s of family medicine. We work in a community-based specialty, with continuous and comprehensive care, excellent communication with the patient, and attention to the family context. However, we need to critique the value of accessibility so that attention to access, at all costs, does not jeopardize the others.

Accessibility can be defined as: “the ease with which a person can obtain needed care (including advice and support) from the practitioner of choice within a time frame appropriate to the urgency of the problem”.¹ This definition wisely takes into account the doctor, the patient, the problem, the care needed, and the time involved.

Both patients and doctors value good access. Patient satisfaction with primary care is predicted by easy access.² Expert panels of doctors also rate access highly on their lists of performance indicators of the quality of organization of primary care.³

What are the benefits of accessibility? We can look at hard outcomes like mortality, morbidity, and costs of care or at softer outcomes like patient satisfaction. We may also explore the effects of different types of access to the doctor and factors that enhance and impede access. This view can help guide our practice and suggest further fruitful avenues for health services research.

There are seven factors that make up accessibility.⁴ These include availability (the volume and type of service related to needs, like the number of doctors per population), geographic access (the distance need to travel to reach care), accommodations to need (including organization of appointment systems, out of office hours care, and home visits), affordability (including financial barriers like co-payment), acceptability (patient satisfaction), utilization (how much care people consume), and equality. Each of these factors can promote or inhibit access to care with important effects on outcomes of care. Better access is associated with increased continuity of care, comprehensiveness, quality of care, equity in health, population health, professional quality of life, patient satisfaction, decreased costs, and the strength of primary care. With consistent evidence from multiple sources in many countries, it makes sense to pay attention to access.

How can we improve access to our services? Clinics in the US and the UK have adopted the Portuguese policy of open access to clinics with good results.⁵ The ‘consulta aberta’ means that patients with urgent problems will have access on the same day to their own physician or to a physician designated to see the patients of the other members of the team (called ‘inter-substitution’). Continuity of the electronic medical record is helpful in this regard.

Another approach is to work longer hours. Most clinics are open during daytime business hours but all have an out of office hours (OOH) service policy. Medicine is a 24-hour a day affair. This is especially important for younger, working patients with long commuting times to work who feel that they have poorer access to general practice services.⁶ Out of office hours services are important because they have been shown to decrease unnecessary emergency room visits and hence hospital admissions. We showed how 24-hour access to the same physician over time significantly reduced hospital admission rates from a general practice, especially for infants and the elderly.⁷

However it is not just any OOH service that will do. Patients prefer to see their own doctor, or members of the medical care team that they know, if they need to use night or weekend services.⁸ Some patients value continuity over rapid access. They prefer to see their own doctor for routine care of chronic conditions, though anyone will do in an emergency.⁹ While patients may define their need for some care as ‘urgent’, an analysis of the content of these visits shows that familiar conditions are represented, largely acute respiratory infections and common musculoskeletal complaints.¹⁰

Technology, both simple and complex, can improve access to care and clinical outcomes. Medical care by telephone has been well-studied. Bunn showed that 50% of calls to the doctor can be effectively managed on the phone alone and that the telephone can reduce the number of office visits.¹¹ The quality of telephone care may be no worse than office care. Telephone review of asthma patients can increase access because more people are assessed with shorter consultation times. There are no differences in clinical outcomes or satisfaction between those followed in the office or by phone.¹²

Effective telephone triage by an experienced health professional has been shown to reduce visiting rates to after hours’ services but patients are often dissatisfied with telephone contact.¹³ This is especially true if telephone triage is seen as a barrier to seeing the physician. It may also be because telephone contacts may be more bio-medically oriented and less patient centered.¹⁴

Telemedicine is the new frontier for increasing access to medical care through technology. In Northern Ontario in Canada, where long distances and a harsh climate in winter impede access to medical care, telemedicine services with live video chat from studios in remote location with doctors in the South has been shown to improve access, clinical outcomes, and patient satisfaction.¹⁵

The rising popularity of electronic communication between doctors and patients has given a boost to easy access.¹⁶ Doctors using asynchronous communication like e-mail have the option of responding to a patient’s request at a time and place that is convenient to them. The complete text of the exchange is recorded and can be integrated into the medical record. This form of communication has been found to be therapeutic if appropriate writing techniques are used. Payment systems need to take the value of this form of service into account.

Improving access to medical care is on both the public and the professional agenda. We need to devote more energy to demonstrating the benefits of improved access as well as investing in practical research to develop new methods to help patients get the care they need. Reports of studies of this nature will find a platform for publication in this journal.

 

REFERENCES

1. Haggerty J, Burge F, Lévesque JF, Gass D, Pineault R, Beaulieu MD, et al. Operational definitions of attributes of primary health care: consensus among Canadian experts. Ann Fam Med. 2007;5(4):336-44.         [ Links ]

2. Altin SV, Stock S. Impact of health literacy, accessibility and coordination of care on patient's satisfaction with primary care in Germany. BMC Fam Pract. 2015;16(1):148.         [ Links ] doi: 10.1186/s12875-015-0372-0

3. Barnsley J, Berta W, Cockerill R, MacPhail J, Vayda E. Identifying performance indicators for family practice: assessing levels of consensus. Can Fam Physician. 2005;51:700-1.         [ Links ]

4. Kringos DS, Boerma WG, Hutchinson A, van der Zee J, Groenewegen PP. The breadth of primary care: a systematic literature review of its core dimensions. BMC Health Serv Res. 2010;10:65.         [ Links ] doi: 10.1186/1472-6963-10-65

5. Solberg LI, Maciosek MV, Sperl-Hillen JM, Crain AL, Engebretson KI, Asplin BR, et al. Does improved access to care affect utilization and costs for patients with chronic conditions? Am J Manag Care. 2004;10(10):717-22.         [ Links ]

6. Kontopantelis E, Roland M, Reeves D. Patient experience of access to primary care: identification of predictors in a national patient survey. BMC Fam Pract. 2010;11:61.         [ Links ] doi: 10.1186/1471-2296-11-61

7. Furst A, Yaphe J. [Continuity of care and hospitalization rates: a survey from a rural family practice]. Harefuah. 1993;125(1-2):26-9.         [ Links ] Hebrew

8. Howard M, Goertzen J, Hutchison B, Kaczorowski J, Morris K. Patient satisfaction with care for urgent health problems: a survey of family practice patients. Ann Fam Med. 2007;5(5):419-24.         [ Links ]

9. Locatelli SM, Hill JN, Talbot ME, Schectman G, LaVela SL. Relational continuity or rapid accessibility in primary care? A mixed-methods study of veteran preferences. Qual Manag Health Care. 2014;23(2):76-85.         [ Links ] doi: 10.1097/QMH.0000000000000028

10. Carraça I, Gala AB, Gago HS, Gameiro L. Atendimento complementar e acessibilidade [Ambulatory out-of-hours clinic and accessibility]. Rev Port Clin Geral. 2002;18(5):271-80. Portuguese

11. Bunn F, Byrne G, Kendall S. Telephone consultation and triage: effects on health care use and patient satisfaction. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004180.         [ Links ]

12. Pinnock H, McKenzie L, Price D, Sheikh A. Cost-effectiveness of telephone or surgery asthma reviews: economic analysis of a randomised controlled trial. Br J Gen Pract. 2005;55(511):119-24.         [ Links ]

13. Leibowitz R, Day S, Dunt D. A systematic review of the effect of different models of after-hours primary medical care services on clinical outcome, medical workload, and patient and GP satisfaction. Fam Pract. 2003;20(3):311-7.         [ Links ]

14. Innes M, Skelton J, Greenfield S. A profile of communication in primary care physician telephone consultations: application of the Roter Interaction Analysis System. Br J Gen Pract. 2006;56(526):363-8.         [ Links ]

15. O'Gorman LD, Hogenbirk JC, Warry W. Clinical telemedicine utilization in Ontario over the Ontario Telemedicine Network. Telemed J E Health. 2016;22(6):473-9.         [ Links ] doi: 10.1089/tmj.2015.0166

16. Yaphe J. Electronic counselling: taking e-mail communication with patients one step further. Rev Port Med Geral Fam. 2012;28(3):159-160.         [ Links ]

 

Endereço para correspondência | Dirección para correspondencia | Correspondence

E-mail: yonahyaphe@hotmail.com

 

Acknowledgement

Thanks are due to Monica Granja for sharing her extensive collection of papers from a recent literature search on this subject.

Conflict of interest

None