Title: Improving access to high quality primary care for socio-economically disadvantaged older people in rural areas: a mixed method study
Funder: Department of Health and Social Care

Abstract: Nine million people live in rural areas of England, of whom one in five is over 65 years old. In rural areas, the population of over 85 year olds is the fastest growing age group. Poverty is high in older rural people with a sixth of rural pensioners living below the poverty threshold (below 60% of median income). Access to primary care for rural older people is challenging with one in five living more than 4km from their GP practice and one in three not having access to a car. A review of equality of access to healthcare in the UK found that rural individuals, older people and those in lower socio-economic groups have reduced access to healthcare. There is likely to be a compounding effect when these co-exist. Poor access leads to preventable health inequalities, and increased use of urgent care services including unplanned hospital admissions. The aim of this study is to develop an intervention to improve access to high-quality primary care in socio-economically disadvantaged older people in rural areas and undertake a feasibility study of the intervention. The research questions are: What are the barriers to accessing high-quality primary care for socio-economically disadvantaged older people in rural areas and what are the underlying mechanisms? How and why do patient-side (e.g. social isolation, immobility) and provider-side (e.g. appointment booking system) access barriers interact to affect quality of care and clinical outcomes? What intervention will best improve access to high-quality primary care for socio-economically disadvantaged older people in rural areas? What information is needed to design the definitive RCT for this intervention? Stage 1 aims to understand the barriers, and their interactions, to accessing high-quality primary care in this group (research question 1+2). This will involve a) undertaking a rapid realist review, b) analysing the English Longitudinal Study of Ageing and c) discussing with patients, clinicians and commissioners in focus groups and semi-structured interviews. Evidence gathered from Stage 1 will be synthesised using a realist perspective. Stage 2 will include intervention development (question 3) and a feasibility study, to be called the Enhancing Older People's Access to Care (E-OPAC)' study (question 4). From an initial scoping review and patient and public engagement the intervention may involve the following three components, 1) creation of a risk register of older people that may have poor access based on distance, deprivation and healthcare use, 2) two nurse telephone consultations for individuals on the register aiming to re-engage them with primary care, identify problems early, provide solutions and discuss crisis management and 3) a community access advisor focused on supporting individuals with social barriers, such as lack of transport, and providing user feedback to GP practices. The six-month E-OPAC feasibility study will be a cluster randomised controlled trial of eight practices (research question 4). Four will be randomised to the intervention and four to usual care. The feasibility study will test randomisation, recruitment, intervention, implementation and outcome measures. The outcome measures will be based on Maxwell's six quality of care measures and include established quality indicators (primary outcome), number of consultations, patient reported ease of access, unplanned hospital admissions and costs. This research has the potential to improve access to primary care for some of the most vulnerable people in society. Through improving access and engagement with primary care, it is expected that patients will contact primary care at an earlier stage to facilitate early management. This will improve patient health, narrow health inequalities and reduce use of urgent care services.

Lay abstract: Deprived older people in rural communities often find it hard to get the help they need (e.g. many have difficulty travelling to their GP practice). This research will look at the problems preventing this group getting high-quality medical help, and will develop ways of overcoming these difficulties. It will begin by reviewing previous research, followed by analysing a twelve-year study of 17,000 older people. GPs, patients and healthcare planners will then be consulted. Solutions to make it easier for people to get medical help will be developed and tested in a small-scale study; pointing the way to a bigger study.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE