Nurses working in general practice are often the first point of contact for those seeking primary health services. The Nursing and Midwifery Council (NMC) (2018) emphasised that nurses' responsibility begins even before this point of contact and that nurses have a duty to act in partnership with those receiving care, helping them to access relevant health and social care. It is well known that gaining access to primary care services can be difficult for certain groups, for example, those living in low socioeconomic areas. This is partly due to the shortage of health professionals in low-income areas, as well as due to difficulties experienced by those who need access to the services (Hutt and Gilmour, 2010; Asaria et al, 2016; Lubenow et al, 2016). It is, therefore, of concern to nurses when their patients encounter difficulties in accessing the services available.
A review of the literature identified various factors that may contribute to difficulties in accessing primary health care by older people living in a lower socioeconomic area, many of which are interrelated. These are summarised in Figure 1.
Appointments may be missed because of
Furthermore, socially isolated older adults are at a higher risk of developing depressive symptoms (Okura et al, 2018), which may, in turn, may make it challenging for them to leave the house to attend healthcare appointments (Lubenow et al, 2016).
Another reason why appointments may be missed is reduced functional ability and autonomy among older people. These individuals are at a higher risk of developing conditions such as stroke and dementia, which may limit their functional and cognitive abilities (Lubenow et al, 2016). Ford et al (2018) found that engaged telephone lines and appointment unavailability are common difficulties that older people face when they attempt to arrange an appointment. Furthermore, an older person may experience difficulty articulating disease symptoms during a healthcare appointment (Ford et al, 2015; Lubenow et al, 2016). In addition, the difficulty of travelling long distances with limited medical transport programmes or public transport options and the complexity and expense of arranging private transport is well documented (Goins et al, 2005; Ford et al, 2016; Lubenow et al, 2016).
Reduced health literacy is another reason for missed appointments. Ford et al (2016) concluded that insufficient health literacy is associated with the inability of older people to recognise the problems they experience in relation to their health. For example, they may attribute the symptoms of disease to ageing, which may delay preventive or treatment interventions (Ford et al, 2018). Poor health literacy may result in the self-treatment of symptoms with alternative medication procured through informal sources (Magadzire et al, 2017). Further, it results in the person having low expectations about their health and the ability of services to support their needs (Ford et al, 2018). Martsevich et al (2018) concluded that a person's awareness about their health status is an important determinant of their decision to seek help from professionals and that such an awareness may enhance healthcare appointment attendance. Furthermore, the failure to provide information on available health services amounts to the exclusion of individual services (Lubenow et al, 2016).
It is important to enhance social support for older people living in the community through community-based interventions. In a systematic review of interventions to enhance primary healthcare access, Comino et al (2012) concluded that multiple linked strategies may be needed to improve access, which may include development of practice systems to identify and follow up patients who may need specific aspects of care and reorganisation at practice level to support and encourage effective multidisciplinary care. This extensive review included 75 evaluated interventions undertaken in a number of countries including Australia (n=25), the US (25) and the UK (15). The review reiterated the need for programmes that enhance the community's engagement in choosing appropriate services and patient support systems that remind patients about their follow-up needs in order to improve access to primary healthcare.
In an attempt to enhance the uptake of primary care services in a low socioeconomic area in the southeast of England, a buddying service-Appointment Buddies-was established by a local charity. This buddying service is run by local volunteers who support people in the community to book appointments, send reminders about the appointments, arrange transport to the appointment and accompany people to and from the health centre (and other healthcare appointments), provide advice on what to say and what questions to ask, wait with the patient, reflect on what the patient's been told and what to do next and collect the patient's prescriptions for them.
Interventions that might address some of these factors, such as the volunteer services provided by Appointment Buddies, are certainly to be welcomed. The authors were invited by the charity to evaluate the buddying service it provides. While the service seems an intuitively good idea, the authors were interested in the experiences of those who used the service and the impact it had on the way healthcare was accessed by those living in a low socioeconomic area.
Methods
The aim of this research was to answer the following questions: i) What are the experiences of those who use the buddying service? ii) Does the service seem to facilitate improved access to primary care services for people in a low socioeconomic area? iii) If so, how does it improve access to primary care services?
An instrumental case study method was used to explore the experiences of those who use the buddying service. A semi-structured interview using a topic guide was used for data collection, and a purposive sample was recruited from among service users meeting the recruitment criteria.
Inclusion and exclusion criteria
The inclusion criteria were use of the service, ability to provide informed consent and adequate physical wellbeing to attend the interviews. Any service users who were unable to speak English were excluded from the study.
Data collection and analysis
Six participants who expressed interest in participating were invited to attend a semi-structured interview. The interviews were conducted in a separate room at the local neighbourhood centre. They were recorded using an audio recording device. The interviews were completed over an 8-week period from September to December 2018. After all six interviews were completed, the recordings were transcribed verbatim by the interviewer (TG), and a thematic analysis was carried out at the manifest level.
Ethics approval
This research was undertaken as part of a MSc programme in adult nursing and was approved by the research ethics committee of Oxford Brookes University.
Findings
The need for support
All participants expressed how their personal circumstances had changed after illness and disability. They described the impact that this had on their lives and how they now needed support and assistance from others. Most participants experienced a lack of confidence in mobilising themselves. For some, this was because of previous falls, while, for others, this was due to age-related frailty or medical conditions. One participant described the dependency she felt on a family member following a prolonged period in hospital.
‘I was in hospital for 5 months. I went in expecting to be in for 3 days, and I was in for 5 months. It changed everything. Now I must adapt, and I must make it a different life. I depend on my daughter for everything.’
A few participants described how they felt vulnerable after a fall and became reliant on the help of others.
‘I'd lost my balance and my confidence after that fall. I couldn't even get there [to the surgery] on my own. I wanted somebody to take me because I was afraid to go alone in case I fell over.’
Declining health was sometimes associated with not being able to drive.
‘I don't drive now. I had decided not to drive anymore; I thought I'm actually not quick enough. It's quite isolated when you can't get into the car and go and visit somebody or even go in and walk about the shopping centre.’
For some, this need for support was accompanied by a sense of worthlessness.
‘When you get old, nobody wants you.’
There was a clear indication from the participants in the study that illness and disability had left them in need of support from others in a way that they had not experienced before.
Practical support
The practical support provided by the buddying service was described as helpful for reducing social isolation.
‘I really think it helps people, older people, getting to talk to the surgery. A lot of them don't want to go because they don't want to go on their own.’
The accompanying of service users to their appointments was particularly valued.
‘It was brilliant because, if I had an appointment done there at 10 o'clock, [the volunteer] used to be here about quarter to 10 and walk along with me, and then she'd stay with me. Then, we'd walk back, and then we would have a cup of tea, and then she would go.’
‘The service sent someone with me to the dentist, to the GP appointment. I'm happy that being sent with somebody to accompany [me] to cross that road, it's a very good thing for me.’
Moreover, participants reported that the buddying system helped them build self-confidence and improved their self-efficacy, which resulted in some participants discontinuing use of the service.
‘She walked along beside me, and I got my stick. I knew she was there if I needed to grab her. I was really grateful to have somebody to take me because, sometimes, if it had snowed or rained or whatever, I was afraid of falling. This lovely lady [pointing to the volunteer's photo] was my appointment buddy for 4 months, I think. After that, I was more confident in myself.’
One participant found that the tai chi club organised by the service helped them gaining confidence and rebuild their strength.
‘I think I benefit because of the situation I'm in. I would say if somebody is kind enough to come to your house and help you get physically stronger, I think it's great and it's very kind of them to do it.’
Most of the participants had memory problems, which they managed by writing things down in a diary or a calendar and keeping these items in a specific place. The service has been helping the participants by organising memory clubs and helping them write down appointments and lists and reminding them about appointments.
‘Sometimes, I don't remember things, and I was referred to the memory group.’
‘I write things down, and, sometimes, the volunteers write it down. I've got to write it down and put at one place I can remember.’
The participants clearly benefitted from the help provided by the volunteers who support them and appreciated this help. Given that the primary aim of the buddying service was practical support, which involved accompanying service users to their appointments, it also provided additional services, such as tai chi and memory groups. While the participants' appreciation of this aspect of the service may be expected, the data provides important testimony to this.
Emotional support
In addition to the practical support offered, the emotional support offered by Appointment Buddies was also valued highly by most participants.
‘For an older person like me, who've lost their confidence, I think to have somebody like that [a volunteer], especially somebody that's friendly … you need somebody to talk to outside of family … I think it's a good idea.’
Most participants experienced emotional distress due to their deteriorating health and various social issues. Sharing their worries with a volunteer made them feel better.
‘We had that communication flowing. “How is the day? How did you spend yesterday?” Instead of me being down, it lifted my morale, it lifted my confidence.’
‘I was very depressed. I was feeling very, very low. When you're low, you need somebody to talk to. I had [a volunteer], thank God, to talk to.’
These comments confirmed the value of the emotional support offered by volunteers, which, although not unexpected, validates this additional aspect of their role.
Discussion
In this case study, the authors identified the importance of the practical and emotional support provided by the buddying service audited. This study provided an understanding of the context in which this support was delivered and illustrated the importance of the support provided by the volunteers (buddies) to those who use the service. Overall, the participants validated the volunteers' roles in reminding them about their appointments and supporting them in attending the appointments as one of many valuable features of the service.
The findings confirm Choi's (2015) commentary that modern healthcare services provided through a multidisciplinary team can be associated with very brief patient contact, which may make healthcare-associated information difficult to obtain and assimilate. As a solution, Choi (2015) proposed the use of advocates who can negotiate the healthcare system for patients and families.
Furthermore, there is evidence that the practical support provided by Appointment Buddies brought a sense of empowerment in service users; some of those interviewed provided examples of feeling more confident to go to the GP independently and subsequently stopped using the service. This indicates that the service can enhance and restore the capacity of the individual to be less reliant on others. Wahlin (2017) and Akpotor and Johnson's (2018) research described empowerment as a restoration of skills, knowledge and power to individuals or groups. Coull et al (2004) argued that an effective partnership between healthcare providers, patients and volunteer groups resulted in patient empowerment and the improved health and wellbeing of those in the community.
Many participants perceived the volunteers as people whom they can trust and share information with. The volunteers acted as advocates for the local community. Tan et al (2016) argued that advocacy actions, such as verbal persuasion and conscience-raising, are effective at improving self-efficacy and concordance and fostering positive behavioural changes when they take the form of social support, because of their ability to offer opportunities for positive role-modelling.
Villalonga-Olives and Kawachi (2017) defined social capital as the resources available to an individual living in a community. They identified that social capital includes social support, social influence and social engagement/participation, all of which may influence the health of the members of the community. There is evidence that the role of the volunteers described in this study increased the strength of the social network for those in the community. Social relationships are seen as a valuable resource, and they enhanced the social capital within the community (Putnam, 1993; Agnitsch et al, 2006). Specifically, Okura et al (2018) argued that improving the social network of older people leads to their adherence to healthcare appointments and improves their ability to access the healthcare system (Greaves and Farbus, 2006), an argument reinforced in the present study. This also highlights the importance of social capital in support of low-income groups.
Limitations
This instrumental case study examined the experiences of the service users based on the data drawn from six in-depth semi-structured interviews. Although the plan was to include 10 participants in the interviews, only six interviews could be realised in the specified time. A larger study is needed to confirm the findings more widely and within different locations.
Conclusions
This small-scale case study highlighted the importance of the role of volunteers in supporting people from low-income groups in attending healthcare appointments. Evidence showed that the role extends beyond practical support and that the volunteers act as advocates for those whom they support. Further, service users are, in fact, ultimately empowered by the service. The findings provide important insights into the support needs of low socioeconomic populations and the ways in which they access healthcare, as well as how a volunteer service can support them. Nurses need to be aware of the socioeconomic background of their patients, from which certain difficulties in accessing healthcare might arise, and of the services that are available to support their patients in accessing and using the healthcare services. Further research may be needed to identify the service's impact in relation to the envisaged outcomes.