Improving access to high quality primary care for socio-economically disadvantaged older people in rural areas: a mixed method study

Ford, John Alexander (2018) Improving access to high quality primary care for socio-economically disadvantaged older people in rural areas: a mixed method study. Doctoral thesis, University of East Anglia.

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Abstract

Objectives
The research objectives were to: 1) explore barriers to primary care access for socio-economically disadvantaged older people in rural areas; 2) develop an intervention to improve access for this group; and 3) test the feasibility of the trial design and intervention.

Methods
A mixed method design, drawing on realist principles and guided by a triangulation protocol, was used to explore barriers for this group using three studies: first, a realist review; second, a qualitative study of semi-structured interviews with older people and focus groups with health professionals; and third, an analysis of the English Longitudinal Study of Ageing using structural equation modelling (SEM). Findings were integrated using a mixed method matrix.

Two strong themes from the integrated theory, the booking system and transport, were identified for intervention. Based on stakeholder dialogues with health professionals and patient representatives, an intervention was developed which was explored in a cluster feasibility trial. The intervention allowed practices to develop their own service changes assisted by a £1500 grant, four development meetings and support manual. The feasibility trial recruited four general practices, with three randomised to intervention and one to usual care.

Findings
The realist review generated a seven-step patient pathway highlighting important contexts and mechanisms. The qualitative study explored barriers, such as engaged telephone lines and limited appointments, and proposed the concept of a social contract, where patients are careful not to bother the doctor in return for goodwill. The cohort study was restricted by limited data but demonstrated the potential of SEM to quantify realist theory.

Participant recruitment in the feasibility study was low (3%), but retention was good (91%) and data collection methods acceptable to participants. Practices were successfully able to develop their own service changes that gave them the freedom, time and resource to be innovative or provided an opportunity to implement existing ideas.

Conclusion
Some vulnerable older people face multiple challenges in accessing primary care. Practices were able to develop their own context-dependent solutions to address local issues.

Item Type:	Thesis (Doctoral)
Faculty \ School:	Faculty of Medicine and Health Sciences > Norwich Medical School
Depositing User:	Jennifer Whitaker
Date Deposited:	08 Jan 2019 10:19
Last Modified:	08 Jan 2019 10:19
URI:	https://ueaeprints.uea.ac.uk/id/eprint/69464
DOI:

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