Improving access needs a whole systems approach

A population that can do trivial things like shopping 24 hours a day in a variety of ways does not expect that doing serious things like accessing health care should be as difficult as it often is. Optimal access means providing the right service at theright time in the right place. Simplifying and improving access according to need is evident in recent initiatives by the British government, such as NHS Direct. Good access arrangements in the NHS will be central to averting crises in the millennium winter. Access should therefore be treated as part of a whole system of formal and informal care,¹ ensuring that links are made within and between public services of all kinds. From this perspective there are many ways in which access can be improved.

Firstly, ways of providing easier and more appropriate access to and between public services should be explored. Good access arrangements are vital at the interfaces of self and formal care and between primary and secondary care. Adoption of a whole systems approach in the winter of 1998-99 (involving better coordination between general practice, accident and emergency departments and admission units, and discharge from hospital) might have ameliorated the winter “crisis.” During that winter, pressure to meet demand for care was probably compounded by the lack of arrangements for managing predictable peaks in demand, such as promotion of self care, telephone access, and better cover arrangements for nursing and residential homes. Patients may have bypassed general practices and cooperatives as phone lines became overwhelmed; and accident and emergency staff often had no other options but to admit a patient. Recent initiatives (on managing winter pressures and health improvement programmes) have encouraged health and local authorities to collaborate in providing appropriate services as part of a whole system of care. This means changes in institutional rules and arrangements. Joint funding of initiatives such as social services in admission units and jointly funded discharge systems and posts (such as directors of social services being jointly appointed by social services and the NHS) should be encouraged and evaluated. The strategies that primary care groups develop will be crucial in addressing system wide access to health and social care.

Secondly, a knowledgeable, informed public may be better able to improve its own health and manage its progress through the whole system without necessarily overwhelming the system. The NHS could do much more to support individuals in making informed decisions and choices about when and how to use the NHS. This could be by ensuring information and advice is easily available and harnessing the potential of information technology, of which NHS Direct is the most obvious example. Self care initiatives, including the actions that lay people take in managing illness, such as use of alternative practitioners, self help groups, information from a range of sources, and use of community pharmacies, need to be recognised and taken account of in strategies to maximise and enhance existing resources. These have the potential to improve health outcomes and enhance the appropriateness of demand for health care.²

Thirdly, professionals are in a powerful position to shape need and demand for health care and therefore access.³Traditional models of professional behaviour do not always promote high quality user led access to a complex system of health care. Professional changes which would enhance access to care include a consistent and seamless approach to advice, a multiskilled workforce (allowing greater access to knowledge and assistance), and a culture in which interprofessional rivalry is minimised and where real communication happens. Additionally, authorities and primary care groups need to target health services and improve access in areas with high deprivation and high morbidity rates.⁴ Socioeconomically disadvantaged groups not only have greater needs^5–7 but also have less access to help, demonstrating the persistence of the inverse care law.⁸

So how can matters be improved this millennium winter and beyond? In preparing for winter each primary care group could consider methods of access to advice and care as an important tool in shaping demand. By concentrating only on the possible increased demand from the small number of “worried well,” we may lose sight of improving matters for the vast majority of the population through implementing a wider access strategy.

We should consider explicitly how people access care. Starting with public involvement and working across the whole system, a coordinated strategy should include joint working arrangements with social services, education, NHS ambulance trusts, and pharmacists. There is room for promoting self care advice and information about services in the form of posters, booklets, recorded phone messages, and newspaper adverts, and making greater use of Teletext and the internet. These arrangements need to be patient centred and avoid inducing fear or blame.⁹ Equally important is the need to develop a range of options, such as nurse led schemes to prevent hospital admissions by providing emergency services in the community.¹⁰ Actions at a national level include getting extra cash into the system early so that such changes can be in place to cope with changes in demand.

An enduring and highly valued aspect of the NHS is its availability free at the point of need, but the NHS’s assumptions and arrangements about accessing services require modernising. Health policymakers, practitioners, and the public need to put access centre stage in health and social care arrangements.