Improving access to primary care for rural, socio-economically disadvantaged older people: the I-ACT cluster feasibility trial

Problem

Access to primary care can be challenging for rural populations with one in five living ≥4km from their general practice and one in three pensioner households without car access. A review found that rural individuals, older people and socio-economically disadvantaged groups have reduced healthcare access, and hence a compounding effect is likely when these co-exist. Furthermore a previous systematic review identified a lack of targeted interventions to improve access for vulnerable groups.Building on our previous realist review and qualitative study, we have developed an intervention to improve primary care access for rural socio-economically disadvantaged older people and in this study we test its feasibility.

Approach

We undertook a cluster randomised feasibility study. Two theoretical intervention pathways were selected from our review– booking an appointment and transport. Four GP surgeries were recruited; three randomised to intervention and one to usual care. Intervention practices received £1500, an evidence summary and four meetings to develop local, innovative solutions to improving the booking system and transport. Patients who were ≥65 years and without household car access were recruited to complete a questionnaire when booking an appointment and/or attending the surgery. The main trial outcome measures were change in self-reported ease of booking and transport at 6 months. Other outcomes included primary and secondary care use and quality of life. A process evaluation included practice profiling, reception observations, group interviews with practice staff and semi-structured interviews with patients.

Findings

Intervention practices successfully developed a range of service re-designs: Practice 1 - installing a stacked phone system (instead of an engaged tone, callers are told their place in a queue) and promoting community transport; Practice 2 - training receptionists and establishing a formal arrangement with a local taxi firm and; Practice 3 – active signposting, improving appointment flexibility and promoting the role of receptionists. Thirty-four patients have been recruited from all practices (26 female, 8 male, median age 82 years (IQR 75 to 87)). At baseline, patients scored the experience of booking an appointment lower (median 53 out of 100 (IQR 41 to 80)) than transport (median 81 out of 100, IQR 48 to 92). To date 48 booking questionnaires and 52 appointment questionnaires have been received. Follow-up data, available from June 2018, will be presented at the conference.Process evaluation findings so far, based on audio-recorded development meetings, suggest that practices use a range of evidence, such as personal experience, practice philosophy and anecdotal, to make decisions.

Consequences

This feasibility study has successfully supported GP surgeries to develop their own novel, context-dependent interventions to improve access. This study design may facilitate a shift from homogenous, one-size-fits-all approaches to complex problems in primary care to solutions which are more context-sensitive.