Measuring access to health services : deprivation and transport measures in urban and rural settings

Abstract

Three ideas are brought together in this thesis: that geographical access to health services may be unequal; that any such inequality is thought to disadvantage the residents of rural areas more than those of urban areas; and that within those areas which are most affected by poor geographical access to health services it is likely to be the poor who are most disadvantaged, resulting in inequity as well as inequality of access. A comprehensive and structured review of the literature found that there is limited reporting of the distances that people travel to health services; there is limited reporting of the differential impact of distance on different groups in the population; the assumption that poor geographical accessibility of health services is a feature of rural rather than urban or suburban areas has not been well tested; and there has been little comparison of different access measures. Little was known about the circumstances under which more complex measures would be worth calculating and those under which simple measures would give a representative view of geographical accessibility. In particular, very few studies had attempted to use public transport as a measure of geographical accessibility. Empirical work based in the South West peninsular of England (an appropriate setting in which to examine differences in accessibility, as it combines scattered settlements, long travel distances and rurality with problems of low pay, unemployment and other aspects of deprivation) showed that, whilst access to primary care is generally good, rurality is not necessarily a feature of areas with poor access. Drive time appeared to be a more accurate measure of accessibility in peripheral and rural wards of the far South West than straight-line distances, and indications of lower levels of car ownership in the wards furthest from hospitals indicated that available measures were not giving a realistic picture of accessibility for people in these areas. Traditional measures of deprivation such as the Townsend score were not effective in identifying areas of health care need in rural areas, and whilst the Index of Multiple Deprivation 2000 was a better proxy for need, the 'access to services' domain of the index was not the underlying reason for this. Accessibility measurements that use complex matrices of public transport information are rare. With the advent of powerful GIS they are, however, likely to become more usual. Electronic databases of transport timetable information (A TCO CIF files) have recently become available and provide a source of detailed data on public transport networks. In this thesis I describe the creation of a measure of geographical access to health services that is based on electronic public transport data, and use it to describe access to secondary health care in Cornwall. I discuss the potential and the limitations of the measure, and set out an agenda for future developments.

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