Access to Care

Access to Care

Access to care describes whether people can obtain appropriate healthcare when they need it and can continue using it for as long as it remains necessary. Barriers can arise anywhere between need and service use, and access has several dimensions that can be measured and improved.

Access is not demonstrated simply because a service exists or because a patient attended once. Effective access requires a workable match between the person's needs and circumstances and the location, capacity, cost, organisation and acceptability of available services.

The pathway from need to benefit

Access develops through a sequence of opportunities and actions. A person must recognise a need, know that care is available, be able to reach and afford it, enter the service, receive appropriate care and remain engaged when follow-up is required.

A simplified pathway runs as follows.

1. A healthcare need arises or is identified through prevention, screening or diagnosis.
2. The person recognises the need and has enough information to seek help.
3. An appropriate service is available within a reasonable place and time.
4. The person can reach and afford the service without an unacceptable burden.
5. The service accepts and accommodates the person through workable hours, processes and communication.
6. Appropriate care is received at the required level of quality.
7. The person can continue care when monitoring, rehabilitation or long-term treatment is necessary.

A barrier at any point can prevent need from becoming effective service use. Improving one stage may have limited benefit when a later stage remains inaccessible.

The main dimensions of access

Access is multidimensional because people can encounter different barriers even when they are seeking the same service. Frameworks use different labels and groupings, but the underlying dimensions commonly address availability, location, organisation, affordability, acceptability and timeliness.

• Availability means that sufficient services, staff, technologies and appointments exist for the population's needs.
• Geographical accessibility means that people can physically reach services using available transport, travel time and mobility support.
• Affordability means that direct payments, insurance contributions, travel costs and income losses do not create an unreasonable financial barrier.
• Accommodation means that service hours, booking systems, referral rules, waiting arrangements and communication methods fit people's circumstances.
• Acceptability means that services are culturally, socially and personally acceptable, and treat patients with respect.
• Timeliness means that care can be obtained within a period that is appropriate to the urgency and expected benefit.
• Information and awareness mean that people can recognise a need, understand available options and find their way through the system.
• Continuity means that patients can obtain coordinated follow-up and move between services without avoidable interruption.

These dimensions interact. A clinic may be geographically close but inaccessible because it has no appointments, requires unaffordable payment or does not provide appropriate language support.

Potential access and realised access

Potential access describes the resources and arrangements that make care possible, such as service capacity, insurance coverage and geographical proximity. Realised access describes the care people actually use.

Neither measure is sufficient alone. High service use can reflect good access, but it can also indicate high illness burden or inefficient care. Low use can reflect low need, effective prevention, patient preference or an unmet need caused by barriers.

Evaluation should therefore relate service availability and use to healthcare need. It should also examine whether the care received was appropriate and capable of improving health.

Measuring access to care

No single indicator captures every dimension of access. A credible assessment uses measures that correspond to the barrier and stage of the pathway being studied.

Measures may include the following.

• Travel distance or travel time.
• Provider density and service capacity.
• Appointment availability.
• Waiting time for assessment or treatment.
• Insurance coverage and benefit restrictions.
• Out-of-pocket expenditure.
• Catastrophic or impoverishing health expenditure.
• Forgone care because of cost, distance or waiting time.
• Unmet need reported by patients.
• Service use relative to estimated need.
• Completion of referrals or treatment pathways.
• Continuity and follow-up rates.
• Differences in access between population groups.

The denominator matters. A screening rate among all residents, for example, answers a different question from a screening rate among people who are eligible and able to benefit.

Unmet need

Unmet need exists when a person requires or could benefit from healthcare but does not receive an appropriate service. It can be identified through clinical assessment, service-use patterns, patient reports or comparisons with an evidence-based standard.

Reasons may include the following.

• Cost or lack of coverage.
• Distance or transport barriers.
• Long waiting times.
• Lack of available providers.
• Complex referral or administrative requirements.
• Language, literacy or communication barriers.
• Disability-related barriers.
• Fear, stigma or previous discrimination.
• Caring, work or education responsibilities.
• Limited awareness of available services.
• Distrust or lack of cultural acceptability.

Reported unmet need may underestimate barriers when people have adjusted their expectations or do not recognise that an effective service exists. Administrative data may also miss people who never enter the healthcare system.

Access, utilisation and quality are different

Access makes service use possible, while utilisation records whether a service was used. Quality describes whether the care was safe, effective, patient-centred, timely, efficient and equitable.

A person may have access to a low-quality service that produces little benefit. Conversely, a highly effective service may produce limited population benefit if the people who need it cannot reach, afford or accept it.

Access evaluation should therefore examine the complete pathway from healthcare need to appropriate care and health outcome rather than treating attendance as the final objective.

Equity in access

Equitable access does not necessarily mean that every person uses the same amount of care. People with greater healthcare needs may require more services (vertical equity), while people with similar needs should not face avoidable differences because of income, geography, ethnicity, disability, sex, gender, age or another characteristic unrelated to need (horizontal equity).

An equity analysis should compare access in relation to need and examine whether barriers are concentrated in particular groups. Population averages can conceal severe disadvantage when good access for one group offsets poor access for another.

Important distributional comparisons include the following.

• The groups that experience the longest waits or travel times.
• The groups that report unmet need.
• Who bears out-of-pocket and indirect costs.
• The groups that leave the care pathway before treatment or follow-up.
• Whether service expansions reach people with the greatest need.
• Whether digital or administrative changes create new barriers.

Financial access and financial protection

Affordability concerns both the price of care and the resources available to the person or household. The same payment can be manageable for one household and prevent care for another.

Financial barriers may include the following.

• User charges and deductibles.
• Insurance premiums and exclusions.
• Medicines, diagnostic tests and equipment.
• Travel and accommodation.
• Lost earnings and unpaid caring time.
• Costs of childcare or disability support.

Financial protection examines whether obtaining care exposes households to financial hardship. Insurance coverage can improve access, but nominal coverage may not provide effective access when benefits are limited, providers do not participate or substantial payments remain.

Time and geographical access

Travel and waiting impose costs even when care is free at the point of use. Rural populations, people with disabilities and people who depend on public transport may face particularly large burdens.

Geographical access should consider more than straight-line distance. Travel time, transport availability, road conditions, service hours, referral patterns and the frequency of required visits can determine whether a service is practically reachable.

Waiting time should be interpreted against clinical urgency. The same delay may be acceptable for a routine service and harmful for a rapidly progressing condition.

Digital access

Digital services can reduce travel and extend availability, but they can also create barriers. Access depends on devices, connectivity, digital skills, privacy, accessible design and the clinical suitability of remote care.

A digital option should not be assumed to improve access for every patient. Evaluation should examine who uses it, who is excluded, whether it substitutes for or supplements in-person care, and whether the quality of care remains appropriate.

The economic consequences of limited access

Access barriers can delay prevention, diagnosis and treatment, allowing illness to become more severe and expensive to manage. They can also shift costs from the healthcare system to patients, families, employers or other public services.

Economic consequences may include the following.

• Higher emergency and hospital use after delayed care.
• Reduced health gain from effective interventions.
• Patient travel and waiting costs.
• Lost productivity and income.
• Unpaid caregiver time.
• Administrative costs created by complex pathways and repeated referrals.
• Greater health inequality.
• Underuse of high-value care and possible overuse of more accessible low-value care.

Improving access requires resources, so an intervention should be evaluated against its additional costs and consequences. Expanding capacity may have little effect if affordability, referral or acceptability barriers remain.

Evaluating an access intervention

An access intervention should identify the specific barrier it is intended to remove and the population affected. Evaluation should measure whether the intervention changes the pathway to appropriate care rather than only whether a new service was created.

Relevant outcomes may include the following.

• Change in unmet need.
• Change in waiting or travel time.
• Change in service use relative to need.
• Completion of referral and treatment pathways.
• Patient costs and time.
• Health outcomes.
• Differences between population groups.
• Effects on other services.
• Implementation and operating costs.

Unintended effects should also be considered. Increasing demand without increasing capacity may lengthen waits, while moving services online may improve access for some people and reduce it for others.

A simplified example

In an illustrative case, a rural health system introduces mobile clinics to improve access to preventive care. The programme increases the number of available appointments and reduces average travel time.

Attendance rises, but the evaluation finds that people working standard daytime hours still have difficulty using the service. The programme has improved geographical availability without fully addressing accommodation.

Extending clinic hours may improve realised access, but the additional staffing cost and effect on other services should be evaluated. The example shows why access interventions should be assessed across several dimensions rather than through appointment numbers alone.

Common misunderstandings

Access to care is broader than insurance coverage, service availability or utilisation. Each describes only part of the pathway between healthcare need and appropriate care.

Common misunderstandings include the following.

• The presence of a nearby facility does not prove that appointments are available.
• Insurance coverage does not guarantee affordable or timely care.
• High utilisation does not necessarily mean that access is equitable or efficient.
• Low utilisation does not necessarily mean that need is low.
• Equal service use does not necessarily represent equity when healthcare needs differ.
• Digital delivery does not automatically remove access barriers.
• Increasing capacity does not correct every financial, organisational or cultural barrier.
• Receiving a service does not prove that the care was appropriate or high quality.

Interpreting evidence about access

Access measures should be interpreted in relation to healthcare need, service quality, population characteristics and the organisation of the health system. A change in one indicator may improve one dimension while leaving another unchanged or worse.

A complete assessment identifies where people leave the pathway, which groups are affected and whether removing the barrier leads to appropriate care and better health. Access is therefore both a health-system performance issue and an equity issue.

Sources

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• Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. International Journal for Equity in Health. 2013;12:18.
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• Culyer AJ, Wagstaff A. Equity and equality in health and health care. Journal of Health Economics. 1993;12(4):431-457.
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• Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press. 2001.