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CHAPTER SIX. ACCESS TO SERVICES

6.1 In recent years there has been a strong drive to promote improved access to health care and services both within and across the primary and acute sectors. 'Our National Health' published in 2000, described a need to improve the patient's journey, with specific core aims of achieving better, fairer access to services, reducing waiting times and improving communications. Various initiatives have been put in place since the paper was published including the introduction of NHS 24, and the development of Primary Care professionals to expand roles and responsibilities, thereby freeing up GPs to spend more time with those who really need their clinical skills.

6.2 Initiatives such as The Scottish Primary Care Collaborative are working to redesign the way that general practice operates to improve access and reduce delays for patients, by liaising with almost 1,000 practice staff over two years, using innovative approaches such as rescheduling pre-booked appointments to avoid Mondays, and using telephone appointments instead of seeing a GP face-to-face. In addition to these initiatives is a guarantee that from April 2004 patients in every part of Scotland can get access to an appropriate member of the Primary Care profession in no more than 48 hours. This survey provides a baseline against which future performance can be assessed.

6.3 For five of the NHS services examined in detail in the survey, various questions were asked in connection with the issue of access - specifically, the ease of getting access to the service, an exploration of any difficulties that people experienced accessing services, and also, an investigation of people's experience of waiting times.

OUT-of hours service

6.4 Those people who been to an Out-of-hours site as opposed to having a home visit or a telephone consultation outside surgery hours were asked how easy or difficult it was for them to get to this location - in some cases this would have been their own local surgery while in others it would have been a different location. Nearly eight out of ten (79%) said that it was either very or fairly easy to get to, with the remaining fifth saying that they experienced some difficulty - see Figure 6.1.

Figure 6.1: How easy or difficult was it for you to get to the out-of-hours service?

Base: All who have been to the out-of-hours service in the last 12 months = 178

6.5 The fifth of people who said that they had experienced difficulty getting to the Out-of-hours service were asked to give the reasons for this. Again, due to the small number of people questioned who had experienced difficulty reaching the facility, small base sizes do not allow for meaningful analysis. Reasons mentioned included:

• poor public transport,
• not having their own transport,
• the site being too far away,
• and the location being hard to reach due to injury or illness.

6.6 Three in ten (31%) of those who had used the Out-of-hours service reported that they were seen by someone immediately after arriving, with a further quarter (24%) saying that they were seen within 15 minutes of their arrival. However, more than 40% of the Out-of-hours users reported that they had had to wait over 15 minutes, including 22% who said that their wait had been more than half an hour.

6.7 The majority (84%) of Out-of-hours service users had contacted the service as their need was urgent, with the remaining 16% using it simply because normal surgery hours weren't convenient for them. This finding suggests that, for some people, surgery hours are not suited to their lifestyles or working hours.

PRIMARY CARE - OWN GP, OTHER GP AND PRACTICE NURSE

6.8 When asked about the ease of getting to the surgery to see their own GP, the vast majority (89%) reported that it was easy, including six out of ten who said that it was very easy to get there. One in ten users found getting to their local surgery difficult - see Figure 6.2. As would be expected, the figures were much the same for respondents who saw another GP or a Practice Nurse at their local surgery, with 92% of respondents in both cases saying that they found it easy to get to the surgery, and 8% of both groups reporting that they found it difficult. Given the similarity of the results, Figure 6.2 shows the data only for contact with the respondent's own GP.

Figure 6.2: How easy or difficult was it for you to get to the surgery on that visit?

Base: All asked about own GP = 707

6.9 The relatively small numbers of users who were living in the more rural areas limits the geographic analysis of this question. However, people who self-reported that they had a limiting disability or illness and also women aged 65+ were more likely than other groups to say that they had had difficulty in reaching the surgery. Perhaps related to this, those who had also received a home visit in the last twelve months were significantly more likely to say they had experienced difficulty in getting to the surgery.

6.10 As with the Out-of-hours service, small base sizes make it impossible to conduct a detailed analysis of the reasons why people experienced difficulty reaching their surgery, but explanations given included difficulties due to:

• the injury or illness,
• the time of the appointment not being ideal,
• poor public transport,
• poor access for the disabled or elderly
• and the surgery/location being too far away.

OUTPATIENT SERVICES

6.11 A third (34%) of people questioned had attended an appointment at an Outpatient clinic in the last twelve months. Nearly eight out of ten said that they had found it easy to get to the clinic, with four in ten reporting that they found it very easy. One fifth had found it difficult to get to the site - see Figure 6.3 - and it will be interesting to see how this fraction changes across time, given the move towards new ways of following up patients such as telephone appointments and more localised provision of specialist services such as community outpatient appointments with Primary Care practitioners with a special interest.

Figure 6.3: How easy or difficult was it for you to get to the outpatient clinic the last time you visited?

Base: All who have been to an appointment at an outpatient clinic in the last 12 months = 856

6.12 Those at the highest (75+ years) and lowest (16-24 years) ends of the age spectrum were more likely than other people to say that they had found it very easy to get to the clinic - see Table 6.1. Whilst it is not surprising that younger respondents reported that it was easy to reach, the high reporting among those aged over 75 may be due to use of Patient Transport Services. As with visits to the PHCT, those with limiting disabilities/illnesses and those with self-reported bad health were also likely to experience difficulties. The multivariate analysis showed a link between easy access and higher levels of satisfaction with the appointment.

Table 6.1: How easy or difficult was it for you to get to the outpatient clinic the last time you visited?

Base: all who have been to an appointment at an outpatient clinic in the past twelve months = 856

6.13 Four in ten (43%) of those who had found getting to the Outpatient clinic difficult said that this was because it was too far away. Just over a quarter (26%) blamed poor car-parking facilities, saying that it was difficult to park their car, and poor public transport was also cited by about a quarter of people questioned (26%). Other reasons for experiencing difficulties included not having their own transport (12%), injury or illness (10%), or in a smaller percentage of cases, that it was hard to find, or they didn't know where the clinic was located (7%).

6.14 Those whose last appointment was referred by their GP were asked how long they had had to wait for the appointment to take place. Forty-one percent reported that they had waited for up to one month, while a further 18% had waited between one and two months and 11% had waited between two and three months. Some 14% of respondents had experienced a wait of six months or more - see Figure 6.4.

Figure 6.4: How long after you knew your GP was referring you for an appointment (had written to the hospital) did you have to wait for the appointment to take place?

Base: All whose last appointment was referred by GP = 411

6.15 As might be expected, those who were seen within a month of GP referral were more likely to be very satisfied with the NHS overall - nearly half of this group were very satisfied with their overall use of the health service, compared with only about a fifth of those who waited more than three months. Reducing waiting times should improve the way in which patients view their journey through the health service in Scotland.

INPATIENT SERVICES

6.16 About one-sixth of people interviewed (17%) had been admitted to hospital as an inpatient in the last twelve months. The clear majority (79%) of these patients had found getting to the hospital easy, though one-fifth said that they had found it hard. There did seem to be a correlation between ease of getting to the hospital and age, with older respondents being more likely to say that they had found it easy - see Table 6.2. As with outpatient services, this could be due to the increasing use of Patient Transport Services (or lifts) as people get older or less mobile.

Table 6.2: How easy or difficult was it for you to get to the hospital?

Base: all who have been admitted as an inpatient in the last twelve months = 411

6.17 There was also a correlation between ease of getting to the hospital and overall satisfaction with the NHS, with those who said they found it easy being more satisfied overall with the health service in Scotland - see Table 6.3. Again, this demonstrates the importance of improving access to NHS services. There were no differences between planned and emergency admissions.

Table 6.3: How easy or difficult was it for you to get to the hospital?

Base: all who have been admitted as an inpatient in the last twelve months = 411

6.18 The sample size for those having a difficult journey to hospital was too small for detailed analysis however reasons included the hospital being too far away, poor public transport, the nature of the injury or illness, absence of own transport and lack of car parking spaces.

6.19 Almost two-thirds (62%) of the elective inpatients said that they waited less than three months from the time their name was put on the waiting list to the date they were actually admitted to hospital. Of the remainder, 33% reported that they had to wait longer than three months for admission.

Summary

6.20 Relatively few patients reported difficulties in getting to the surgery to see any members of the Primary Care team - however, about a fifth of those who went to a more centralised site (i.e. Out-of-hours, hospital or clinic) found a problem in access, even after allowing for the use of Patient Transport Services. Bringing outpatient services into more local settings could improve access and lead to higher levels of satisfaction from patients.

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