Access to primary care for socio-economically disadvantaged older people living in rural areas: a qualitative study
Poor access to primary care may worsen health inequalities and is a particular problem for socio-economically disadvantaged older people in rural areas. Our aim was to identify barriers and facilitators to accessing primary care for this group.
We undertook 15 semi-structured interviews with patients and 4 focus groups with health professionals (GPs, practice managers, community nurses and physios). Interview participants had to be over 65 years old, live in a rural area and receive a means tested benefit. They were recruited through parish newsletters, adverts in local amenities, such as shops and post offices, a radio interview and invitations in pharmacy bags. Participants were offered a £20 shopping voucher. Health professionals were recruited from GP practices and community health services through the local Clinical Research Network. Thematic analysis was used to analyse data.
The nature of the relationship between a patient and GP was important – acting at times as both a barrier and facilitator to access. Some patients reported thoroughness of, and confidence in their GP as facilitators usually co-existing with continuity. Others reported feeling devalued, sidelined and poorly understood as barriers, which arose from negative previous experiences, such as not feeling heard, failure to deliver an agreed plan or a delayed diagnosis. This group consistently admired and had affinity for the NHS. Most felt some personal responsibility not to overuse the system or waste time and this seemed particularly important if they perceived older people to be a burden on health care. System barriers included engaged telephone lines, receptionist behaviour, long waiting times, use of telephone consultations and declining frequency of home visits. Transport was particularly important to some patients. The influence of families and friends was a common trigger to accessing primary care.Health professionals focused mainly on health system issues as barriers, such as appointment systems, capacity, home visits and communication among professionals, and facilitators, such as receptionists, telephone consultation and triaging. They described having to manage patients’ misconceptions and expectations and wanted better patient education on these issues. It was clear that families and friends played an important role in how health professionals view access to primary care and this could be positive or negative. Health professionals also identified patient isolation, transport difficulties, cost and fear of care home admission and loss of independence and practice capacity as potential barriers.
This research highlights the importance of GP-patient interactions for hard-to-reach groups with poor access to primary care. Overcoming system barriers such as number of available appointments and telephone access will improve access and will certainly require more resources. Interventions to improve access should be aimed at those most in need to promote better primary care engagement and healthy ageing.