Why minorities still stand out from the primary care crowd

Patients from black and minority ethnic communities are considerably less happy with their access to GPs than white patients.

Asked to rate their satisfaction on a range of factors for the national patient experience survey, published last week, scores for some ethnic minority groups were more than 20 percentage points lower than for white British patients (see 'Johnson wants competition to prop up poor GP access').

The survey reveals that BME patients are less satisfied across the board: telephone access, appointments within 48 hours, advance booking, the scope to see a specific GP, and opening times.

The fact that the overall average levels of satisfaction were arguably higher than expected, particularly in light of the emphasis prime minister Gordon Brown has placed on improving GP access, only throws the results for ethnic minorities into sharper relief.

The results raise questions, not least over whether enough is being done to tackle the issue. Some of the worst health outcomes are in BME communities, so surely it is unacceptable that in an outcome-focused NHS, those same communities are saying they have the biggest access problems.

Health secretary Alan Johnson appears to think so. He announced a working group, chaired by Royal College of GPs chair Dr Mayur Lakhani, to get to the bottom of the issue and feed the findings into junior health minister Lord Darzi's review of the NHS.

On its own, the survey provides no clue as to what is behind the findings. Indeed, as Mr Johnson puts it: 'We are not sure what the problems are or why they occur.'

One of the difficulties is isolating the effect of ethnicity from other factors leading to lower satisfaction, particularly deprivation. Patients living in deprived or urban areas also reported greater difficulties seeing their GP, as did younger people and those registered with a large GP surgery.

NHS Confederation primary care trust network director David Stout says we could be seeing a 'satisfaction version' of the inverse care law, which suggests that those most in need of healthcare are least likely to get it.

'There's a relationship between deprivation and ethnicity - in other words it may be the same factor compounding,' he says.

He would like to see Dr Lakhani and his colleagues examine the issue beyond primary care. He points to the Healthcare Commission's report last November, Variations of the Experiences of Patients in England 2004-05, as evidence of a wider trend that ethnicity is a factor in satisfaction.

'This would appear to be not just an access question but something more general. This is not only a primary care issue and that should be borne in mind.'

However, that could be difficult, given weaknesses in ethnic monitoring at primary care level. King's Fund health policy fellow Ruth Thorlby says there is very little data considering all the millions of GP appointments.

Race for Health works with PCTs to make care fairer. Director Professor Helen Hally says: 'Ethnic monitoring in primary care is an issue. It's one of the tricks that was missed with the GP contract.'

Offering just one point in the quality and outcomes framework for complying with ethnic monitoring is 'frankly too little', she says.

Dr Katy Gardner, a Liverpool GP who was involved in pioneering work championing ethnic monitoring, says there should be no choice. 'If it was part of the registration, people would just do it.'

Uncomfortable questions

Practice staff would need additional training too. Professor Hally says people need to 'stop worrying about the sensitivity of asking people about their ethnicity and recognise that it's no more intrusive than asking about people's date of birth'.

Pauline Mitchell, patient profiling development officer at Liverpool PCT, where all GP surgeries are collecting data, says: 'People feel uncomfortable about asking until they've got the tools to do that and an understanding of why it needs to be collected.'

But even without the full range of data that ethnic monitoring would bring, it is possible to suggest reasons why BME groups are less satisfied with access to their GPs.

Ms Thorlby says it could just be a question of there not being enough GPs in the areas where those people are living, or it could be opening times and the way clinics are run.

'For ethnicity there can [also] be issues about women wanting to see women doctors.'

David Stout says based on his previous experience as chief executive of Newham PCT there is sometimes a tendency for patients to 'cluster' - registering with GPs of their own ethnic origin. 'Often it was to do with whether people spoke their own language,' he says.

It is also possible that ethnic minorities are tending to go to GPs who are simply less good, he says. 'There's a question of what GP they are registered with rather than their ethnicity.'

Registering with a GP can be difficult, particularly for migrants or people who have limited English. Stephen James, head of partnerships and diversity at Ealing PCT, says it is not just language barriers that can pose problems for these groups, but a lack of knowledge of how to access health services in the UK. 'They will need interpreters and mentors and guidance through the system.'

Some patients come from countries where there is little or no primary care. 'When you are ill you queue up at a hospital. That's not going to work well in England,' he says.

Staff need to know what they are dealing with too, he says. 'There's a whole range of issues about staff and their knowledge of patients' different needs, of diversity of communication, cultural sensitivity and so on.'

Aside from barriers to access, the patient experience survey also raises the spectre of discrimination. Mr Stout says it is possible there are biases against people from different ethnic communities. 'Institutional racism is a possibility,' he says.

And Mr James insists the government and Dr Lakhani's group must not shy away from the issue. He says that whether it is conscious or unconscious, there is anecdotal evidence from BME groups that sometimes they feel discriminated against. For example, people who do not speak English need longer consultation times.

'The charge against some GPs is that rather than provide that longer consultation time, they will try to find ways of not registering that patient in their practice.'

Mr James adds: 'I think it's worth bringing in the concept of discrimination because I tend to think it's still there. Unless it's given a name and we ask honestly whether there's discrimination then we are not going to find it and we are going to be skirting around the issue.'

Finding solutions

However, while we will have to wait until the autumn to learn what Dr Lakhani's team concludes, there are plenty of examples of good practice that can be disseminated in the meantime. Professor Hally says PCTs must look at places that are recognising the problems and providing innovative solutions.

'They need to be looking at whether there are two dimensions. One is about access, physically understanding the process. They also need to look at the quality and appropriateness of provision.'

It is less a matter of educating people about how to access existing services, more one of tailoring services to meet patients' needs. To treat people equally may mean they must be treated differently, she says.

She highlights work in Luton, one of the Race for Health PCTs, to provide services tailored for the South Asian community.

Luton teaching PCT chief executive Regina Shakespeare describes the research and work done in the area on access to maternity services and the high rates of stillbirth within the Bangladeshi community.

'If I had to pick out two areas, one would definitely be language and the other would be about the confidence and assertiveness with which members of the community demand maternity services.'

Tackling the issues requires close working with communities to understand how they experience services, putting changes in place and providing feedback on the results, she says.

In Manchester - another Race for Health PCT - chief executive Laura Roberts emphasises the importance of race impact assessments.

'Ethnicity in isolation does not explain the differences in patient experience. We need to understand the significance of language barriers, cultural, religious and other factors, age, gender and disability.'

Early action to assess the impact of services or changes to services does not require huge additional resource, she says. 'If you embed it at the outset it's not about huge tranches of money, it's about putting the thinking in early to design it so it's as accessible as it can be.'

Tower Hamlets PCT in London has also been working to design services that are appropriate to its large Bangladeshi population Director of strategic commissioning Jeremy Burden says the PCT is keen to feed into the government's review. It has already drafted an access action plan.

'I don't think there's any problem with access in terms of the amount of capacity we have in the system, I think it goes back to the other drivers: is it ethnicity, is it deprivation, is it cultural belief?'

He refers to a PCT-sponsored liaison worker at the London Muslim Council in Whitechapel as an example of the ways the trust is trying to tailor its services.

'This person will effectively bring initiatives into the PCT from the council and bring forward ideas from the mosque into our commissioning processes.'

Ms Thorlby says given the lack of data, the only option for PCTs is to go out and talk to their communities. They need to understand what is driving lower satisfaction rates.

She calls on the government review to start a process of further research, rather than rush into early conclusions.

'I think it's quite a tight timescale to get to the bottom of what's driving this. The danger is that you end up throwing money at the wrong part of the solution,' she warns.

The message to Dr Lakhani is clear: getting it right is vital, not just for the health of those BME communities who are dissatisfied, but for all patients.