Service access to primary health for people living with disadvantage

Single Session Therapy (initial intervention)
My first piece of research into access to primary health was a Masters project on Single Session Therapy (SST) (Talmon). This taught me that having an initial session at first contact was beneficial as many people only contact a service once. Hence a single session approach that assumes this might be the only contact takes full advantage of a person’s motivation at contact.

Because many people are happy with what they can take from an initial session intervention around 30% then are not on a waiting list. The 70% who are have already had one session and intervention and are waiting for a subsequent not first meeting. They have received some information, support, encouragement for assistance in the meantime.

This has the effect of reducing waiting times, and in the case of our service, eliminated the waiting list.

From this research I learned that entry systems can inhibit or enhance the flow of service delivery. The service generally however did not learn this and reduced/eliminated the availability of walk in/phone in intake which significantly reduced pressure on staff. That is, reduced access.

Intake in rural community health social work
These observations and experiences led me to think more about service entry systems which I pursued with the support of NSW Health’s now HETI, Building Rural Research Capacity programme. For this I compared the intake systems of the Tweed/ Murwillumbah service and the Byron/Mullumbimby service.

Tweed/M’bah were using a centralised (in Tweed Heads) part time intake worker. Mullum/Byron was using the initial intervention walk or phone in system. I interviewed across all stakeholders: referring professionals, reception staff, person seeking service, social worker, local manager, area manager, and executive management.

The priority for people at the bottom or outer edge of the system (referring professionals, receptionists and people seeking services) was warmth of welcome and promptness, especially for the very disadvantaged. The priority of executive staff was throughput and ‘equality’ represented by call centres that could respond to people in the correct order and triage them according to the situation they were facing. Their degree of vulnerability, ability to make a phone call to an anonymous number or to sustain re-referral through layers of the system were not considered.

In effect, people were expected to understand and adapt to the entry system, rather than the entry system accommodating them. This is an example of middle class entry and service delivery systems privileging the middle class and tending to exclude the most needy (Tudor Hart; Gwatkin, Wagstaff, & Yazbeck).

Political pre-disposition
My polical pre-disposition is to see disadvantage as dominantly resulting from structural issues. Whilst people have some agency, the fewer resources we have, the less agency we have. This tends to be born out in Wilkinson and Marmots work on the social gradient and the social determinants of health.

Next endeavour
These views and experiences have led to my present project which explores more closely the experience of a group of disadvantaged people in accessing primary health care. For this I have relied on my longstanding, 14 years involvement with a homeless breakfast programme in my home town. I live in a a rural coastal town of 6,000 with around 200 people living homeless. This is now the focus of a PhD.

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