Medical Geography

Pergamon

Health & Placr. Vol. I, No. I, pp. 41-50, lYY5 Elsevier Science Ltd

Printed in Great Britain

1353~8292/95 SY.50 + 0.00

1353-8292(95)00005-4

On the outside looking in: medical geography, medical geographers and access to health care

Martin Powell Division of Social Sciences, University of Hertfordshire, Hatfield, Herts AL10 9AB, UK

Access to health care is an area of interest for a number of disciplines and sub-disciplines in, for example, medical sociology and health policy. However, an examination of texts in these areas shows that the sub-disciplines are mainly aspatial. When space is addressed, it is often problematic in that earlier geographical work is not cited. By tending to ignore the existing literature and proceeding to reinvent the wheel, it has reproduced some of the conceptual and methodological problems associated with some of the earlier literature. This paper reviews the spatial work in medical sociology and health policy texts and journal articles on the theme of access to and utilization of health care, paying particular attention to the contribution of medical geography and medical geographers. It then examines the potential contribution of medical geography, by attempting to locate space in its wider context.

Keywords: medical geography, space, access, utilization

Introduction

This paper is based on the assumption that the contribution of a discipline or sub-discipline dealing with multi-disciplinary issues is best judged by its impact on other disciplines. In this sense, medical geography’s contribution towards the study of accessibility and utilization of health care facilities must be seen as a failure. If we define medical geography as work on health and health care with a spatial component, and medical geographers as persons who hold some disciplinary identity, then the contribution of medical geography to the outside world on the topic of interest is very little and that of medical geographers even smaller. Ironically, medical geographic work cited in other disciplines tends to be carried out by writers other than medical geographers, and medical geographers are cited mainly for aspatial work. Moreover, medical geographers have been largely absent from some major spatial debates in health and health care.

This paper examines one topic within the much broader area of the geography of health care (as opposed to the geography of health). It investi- gates how far medical geography and medical

geographers are recognized by sub-disciplines such as medical sociology and health policy on the topics of accessibility to and utilization of health care. It is written by a ‘spatially aware’ social policy analyst, hence the title of the paper.

Mills (1970) wrote of the ‘sociological imagination’. In very crude terms, this means locating the individual within the broader structures of society: whether an issue is largely individual or structural. The study of access to and utilization of health care similarly requires a ‘geographical’ or a ‘spatial’ ‘imagination’. For example, a particular area with low utilization of health care may be influenced by space (an area with poor accessibility to health care) or merely located in space ( a social structure composed of people with low propensities to consult). Following Mills, the geographical imagination requires the capacity to shift from one perspective to another, and to consider the intersection between disciplines. It requires emphasizing space when it is important, and downgrading it when it is not. The task and the promise of medical geography, in the context of broader social research, is not to over- concentrate on or ignore the spatial perspective, but to take space seriously.

41

On the outside looking in: M. Powell

Table 1. Coverage of medical geography and medical geographers

Title

Medical sociology Armstrong (1983) Fitzpatrick et al. (1984) Morgan el al. (1985) Hart (1985) Hannay (1988) Scambler (1991) Stacey (1991) Taylor and Field (1993) Bond and Bond (1994)

Pages of spatial issues in index

Aspatial index Aspatial index Region (2%) Region (2%) Distance (0.5%) Access, region (1%) Aspatial index Aspatial index Aspatial index

Percentage of citations of medical geographers

0.7 0 0 0 0 0.25 0.15 2.0 0.3

Health policy Allsop (1984) Region (2%) 0 Ham (1992) Aspatial index 0 Klein (1989) Aspatial index 0 Leathard (1990) Aspatial index 0.3 Baggott (1994) Geography, region (1%) 0.9 Ranade (1994) Aspatial index 0.3

Medical geography Phillips (1981) Access, accessibility availability

distance, region (48%) 20 Joseph and Phillips (1984) Access, distance, mobility (51%) 17 Eyles (1987) Accessibility, region (12%) 6 Haynes (1987) Access, distance, mobility,

region (29%) 15 Jones and Moon (1987) Accessibility (4%) II

Key: (n) = percentage of pages on which the defined spatial keywords occur; aspatial index = none of the above in index.

This paper examines the impact of medical geography and medical geographers on medical sociology and health policy . This is achieved by examining texts and research articles in these sub-disciplines which cover the topics of access to and utilization of services. Access is examined at both the ‘macro’ level, the inter-area availability of provision and at the ‘micro’ level in terms of intra-area accessibility. The use of space in these areas is then critically evaluated, and this leads on to a discussion of the potential contribution of medical geography to the sub-disciplines in question.

The received wisdom: an examination of texts

The starting point is an examination of recent, readily available and currently used British medical sociology and health policy texts in order to discover whether they include a geographical perspective. These books are intended to be a ‘population’ of higher education texts in the above areas. This will give an impression of the degree to which students of medical sociology and health policy are informed about spatial issues. Analysis incorporates a quantitative and qualitative element. Two quantitative indicators are constructed as crude measures of the visibility of medical geography and medical geographers, re-

42

spectively. First, counts are made of the number of pages in the index which contain a defined key word that indicates a spatial perspective. Second, citations of medical geographers as a percentage of all authors in the bibliography are calculated. Formal citation analysis was not carried out for a number of reasons. First, it remains a controver- sial enterprise (e.g. Whitehand, 1985; Wrigley and Matthews, 1986 and the following debate in Area, 1987). Second, citation analysis seems best suited to examining the impact of individuals and journals, and seems more problematic for deter- mining the impact of one discipline on another (Whitehand, 1985). Third, it quickly emerged that given the very low level of citations, the threshold of a ‘citation classic’ could be a single citation.

It is clear that the medical sociology and health policy texts have largely ignored medical geographers and medical geography. Indeed, a similar point could be made about some of the ‘control group’ of medical geography texts. Even the most explicitly spatial texts index spatial issues on about half their pages, and citations of medical geographers account for only about a fifth of all references. Often, ‘medical geographers’ have been cited in the other sub-disciplines for largely aspatial work and/or found in ‘non-geographical’ works. For example, citations to Phillips (1980)


of physical distance in going to see the doctor (Haynes and Bentham, 1982). The ‘inverse care law’ also appears. This states that there is an inverse correlation between need and provision. In other words, high need areas tend to receive less provision (Hart, 1971). However, this ‘law’ is in fact a hypothesis (Powell, 1990). It is refreshing to note that Armstrong claims that finding evidence to support the assertion that working-class people have fewer health resources available to them is difficult (p. 131). For a critical social science, medical sociology has found it remark- ably easy to swallow the inverse care law despite the lack of convincing evidence (see Powell, 1990).

Fitzpatrick et al. (1984, pp. 59, 64) briefly mention transport problems, giving Le Grand (1982) as the reference.

Morgan et al. (1985) examine regional inequalities in provision in some detail, citing the Ministry of Health (1962), Hart (1971), West and Lowe (1976), Rickard (1976), DHSS (1975, 1976, 1981) and Townsend and Davidson (1982). Hart (1985, p. 61) states that there are regional inequalities in provision, with London and the South East hav- ing better facilities than elsewhere.

Hannay (1988, p. 67) writes that unequal use of service may be partly due to geographical distribution, and then refers to the inverse care law (p. 67). Moreover, Hannay (p. 149) found that people who lived further from the surgery were more likely to be part of the ‘medical iceberg’ (untreated symptoms).

Scambler (1991, p. 289) notes that the UK has the least regional inequality in the geographical distribution of doctors when compared with France, Germany and Holland (Townsend and Davidson, 1982). He claims (p. 42), without reference, that empirical support for the inverse care ‘law’ has accumulated steadily. He also claims that, as the distance between home and general practice increases, the likelihood of consultation diminishes; this is particularly true for elderly or disabled people, who are relatively immobile (Whitehead, 1987).

In contrast, Stacey (1991) does not mention spatial issues. Taylor and Field (1993) state that there are geographic inequalities in the provision of services. Historically, NHS expenditure has been greatest in regions of the country with the highest proportion of middle-class people. Stan- dards of premises, equipment and general practitioner (GP) training are significantly worse in inner city areas and in some local authority estates (p. 60, no references). Transport costs may be important for those on low incomes (P. 64).

According to Bond and Bond (1994), use of services is related to their availability (Knox, 1979). Other cited work includes Whitehouse

and Knox (1979) are to fairly brief ‘summary’ articles in the Journal of the Royal College of General Practitioners (see Whitehouse, 1985) rather than to more substantial work elsewhere in the geographical literature. This suggests that geographers wishing to communicate with other disciplines must publish in places other than geography journals (cf. Wrigley and Matthews, 1986). What is perhaps of more interest is that in the few cases where ‘medical geography’ in the sense of a spatial perspective has been recognized, it has been by other disciplines. Thus, this crude analysis confirms the more general findings of Wrigley and Matthews (1986) that the low level of cross-disciplinary impact of geographic research is disturbing. In other words, the contribution of medical geographers to medical geography as recognized by the ‘outside world’ is negligible.

The low profile of the work of medical geographers would not be of great importance if medical geography, irrespective of the disciplinary identity of the writer, were adequately covered by the relevant sub-disciplines. However, many of the texts devote little attention to space. Geographical differences in access to facilities receive little attention as opposed to social class, gender and ethnicity. Access, accessibility, geography, mobility, region and space rarely appear in indexes. When they are mentioned, attention is perfunctory, and often restricted to a few dated, often deficient, studies or sometimes anecdote or assertion masquerading as evidence.

The overall impression from the medical sociology and health policy texts is that space is of little relevance to the utilization of health care. This is surprising for two main reasons. First, spatial inequalities were an important component in the argument of the need for the National Health Service (NHS) and for the particular form which the NHS took (Powell, 1992). Second, a number of early models recognize, explicitly or implicitly, that spatial issues should be counted as factors which may influence use of services (see Phillips, 1986; Joseph and Phillips, 1984).

Medical sociology and the spatial perspective

While the author and index count are suggestive, it is necessary to examine the medical sociology and health policy texts in more detail to search for any spatial perspective. This qualitative element involves a complete reading of the texts (as opposed to any kind of ‘textual analysis’).

In these sections discussion of each main text mentioned in Table I is discussed in a single paragraph. All page references refer to the listed texts. Other references are mainly citations given in the listed texts. Taking the medical sociology texts first, Armstrong (1983, p. 16) mentions under ‘Further Reading’ that there are problems

43


(1985) who examined the deterent effect of distance and Ritchie et al. (1981) who examined access to primary health care.

The medical sociology texts, then, examine spatial issues in a cursory manner. Some attention is paid both to the macro and micro scale: issues of regional inequalities and the inverse care law on one hand and ‘distance decay’ on the other, but rarely in the same text. In other words, the geographical content is piecemeal. There is no coherent, integrative treatment of space. As for the quality of the analysis, referencing is thin and often dated, and detail is often lacking.

Health policy and the spatial perspective

A similar neglect of spatial issues is apparent in the health policy texts. Allsop (1984) refers to a number of studies (by economists) during the 1960s and 1970s that highlighted regional inequalities in the distribution of resources in health care. This leads into a discussion of the Resource Allocation Working Party (RAWP), the formula used to allocate health resources geographically which has now been replaced by a capitation- based approach (pp. 92-96). The inverse care law is mentioned (pp. 165-166).

Despite an aspatial index, Klein (1989) gives a detailed discussion of inter-authority inequalities. He points out the pattern of geographical inequalities in an historical framework: incremental resource allocation meant that the inherited pattern of geographical inequalities remained largely undisturbed (p. 52). He then examines the transi- tion from equality-planning by norm-to equity-planning by formula (pp. 81-82). Geog- raphical equity still remains to be fully achieved. Variations exist at the Area Health Authority (AHA) level. Some of this apparent inequality is due to the teaching hospitals and cross-boundary flow, but ‘the evidence confirms the persistence of inequalities in the distribution of resources’ (p. 149). Moreover, Klein writes that inequalities in the distribution of resources are compounded by differences in local policies and clinical practices. For example, while the West Midlands region, towards the bottom end of the resource league, provides hospital in-patient treatment for varicose veins at the rate of 4.9 cases per 10 000 population, the equivalent figure for the South- East Thames region, nearer the top of the resource league, is 9.7. To an extent, the kind of treatment people receive still depends on where they live (pp. 149-150).

Leathard (1990, p. 71), as an example of regional inequality, points to the wide variation in the provision of NHS abortion, sterilization and vasectomy services between NHS regions where facilities and their access were much influenced by the resources available and the views of the

professionals involved in these sometimes con- troversial matters (Leathard, 1985).

Ham (1992) examines geographical differences within the context of RAWP, finding ‘considerable variation in spending per capita between the different regions of England’ (p. 63). He later presents tables showing the regional distribution of expenditure and staffing, illustrating a variation of at worst almost two-fold. However, this does not allow for differential need, and the translation of equality into equity leads into a discussion of RAWP (pp. 192-198).

Ranade (1994) points to the inverse care law (p. 12) and presents a brief discusson of RAWP, with particular reference to the problems of cross- boundary flows (p. 56).

Finally, Baggott (1994) gives little discussion of the geography of health care.

The health policy texts deal only briefly with medical geography and even less with medical geographers. Availability is dealt with largely at the regional level and in relation to expenditure. There is little extension to sub-regional levels or translating inputs into outputs. In other words, there is little attempt to examine the effect of geography at any meaningful level.

The Black Report and the spatial perspective

What of the Black Report (Townsend and David- son, 1982), the ‘most important critique of the health service and general health standards written in this country since the war’? It was recognized that one important channel by which social inequality permeates the NHS was ‘differences in sheer availability and, at least to some extent, in the quality of care available in different localities’ (p. 81). Two pages (78-79) were devoted to the ‘interaction of geographic and social disparities’. Some evidence of inequalities of expenditure was presented (Rickard, 1976; Buxton and Klein, 1975; Jones and Masterman, 1976). However, these data referred to the NHS units before the 1974 reorganization, making this evidence dated . The inverse care law was invoked, together with the supporting evidence of West and Lowe (1976) and Noyce et al. (1974). Again, this evidence was dated, and has been subject to critique (Powell, 1990). This important document, then, was little troubled by the evidence of medical geography and medical geographers did not feature at all.

In the updated version of the ‘Health Divide’ (found in Townsend et al., 1992), Knox (1979) and Carmichael (1985) were cited as giving evidence of poorer services being available to poorer areas for GP and dental services, respectively. Whitehouse (1985) was cited as showing that transport difficulties appeared to have a deterrent effect on the use of GP services, while a national survey appeared to suggest that difficulties of

44


ferences may not be of substantive importance. For the whole population, the differences in consultation and attendance were not particularly large: 5.1 to 3.5 and 6.3 to 5.5. The pattern was more clearly statistically significant for consultation than for attendance, implying that the major effect of distance was on consultation rather than attendance: the decision to consult at all rather than the decisions of how frequently to consult. Again, the only contribution from medical geographers cited was the review by Shannon et al. (1969). This study has again been cited uncritically by geographers (Joseph and Phillips, 1984).

Whitehouse (1985) divided his practice population into three area, the first approximately within */3 of a mile from the surgery, the second between this limit and 2% miles away, the third all other areas. However, a map showed bus routes, and that some parts of area 3 were closer than area 2. In other words, there appeared to be considerable variation in intra-zone accessibility, implying that the distance variable was poorly specified. Whitehouse claimed that there was some evidence of distance decay for females, but no obvious pattern for males. ‘Distance seems to be a slight deterrent, and this is sup- ported by the fact that women, children and patients in social classes IV and V, groups for whom transport might be expected to be a problem, show the greatest variation in use’ (p. 361). ‘Studies in a wider selection of practices are needed, however, to confirm the evidence that distance is a deterrent for certain groups of patients’ (p. 361). The alternative explanation adv- anced was that higher consultation rates in the first area are associated with social deprivation (p. 351). There appears to be a large social class difference between the areas. and while the author claims that differences remain after standar- dization, the data given by social class and area show no obvious pattern of distance decay (p. 361). The distance variable is poorly concep- tualized and measured, and distance effects are neither clear nor strong. As Jones and Moon (1987, p. 240) note, this approach is obviously limited. However, this was not so obvious to other writers, as this study forms a major plank of evidence in secondary texts (Townsend et al., 1992). Thus, most of the cited evidence of distance decay in Britain is concerned with general practice, and tends to be limited (see Joseph and Phillips, 1984; Phillips, 1986, for a more general discussion).

A study which has not generally found its way into the secondary literature is that of Gibson et al. (1985) who discovered (or thought they discovered) distance decay: ‘the crucial variable in our theory will be the distance people have to travel to the point of service provision’ (p. 109). The basic model measured straight-line distance to a

access to the service were small: fewer than 10% of respondents reported difficulty, and age, sex and social class appeared to be more important than distance per se (Ritchie et al., 1981). Haynes (1991) was cited as a source of evidence that lack of car transport was an inhibiting factor for the sick in rural areas. Other evidence suggested that more innovative GP practices tended to be located in more affluent areas (Leese and Bosan- quet, 1989). Finally, the fact that ‘avoidable death’ varied widely between the old AHA units (Charlton et al., 1983) was tentatively linked to differential quality of service. Again, medical geography and medical geographers appear on a piecemeal basis.

The cutting edge: an examination of research articles

To a large extent, texts are dependent on relevant journal articles. This section moves from secondary to primary material and examines the cutting edge of research with some spatial component. A review of earlier articles which have been in- corporated in the texts, and later articles which have not, will give an impression of the degree to which researchers in medical sociology and health policy are informed about spatial issues.

The micro level

First, micro or intra-area level studies are examined. The main theme here is ‘distance decay’. Hopkins et al. (1968) examined concentric zones with radii of less than 0.25 mile, 0.25-0.50, 0.50- 0.75. 0.75-1.0, l-2 miles and over 2 miles from the surgery. There was clear evidence of differential use in the zones, but no clear pattern of distance decay. Indeed, home visits increased for the zones up to 1 mile. Despite its problems, this study has been uncritically cited by some geographers (Knox, 1978; Joseph and Phillips, 1984).

Parkin (1979) divided distance into three concentric zones: under 0.25 mile, 0.25-0.625 mile and over 0.625 mile. Consultation rates in the third zone were statistically significantly different from the other zones. This applied to the population as a whole, and for all sub-groups except males aged 15-64. This was explained by the workplace and the journey to work being the more important than the home base. For the attendance rate (those who consulted) there was evidence of distance decay only for groups with high attendance rates, namely females, the elderly and Social Classes III-V (a high proportion of all consultations).

Thus, ‘distances from patients’ homes to the surgery did deter the population both from con- sulting at all with the doctor, and also from attending frequently’ (p. 97). However, the dif-

45


facility, dichotomized at the 5 km point. A logit regression model included measures of age and education, and it was found that the probability of use declined in the more distant zone. There are two puzzles. First, why did a sophisticated model measure distance in such a crude fashion? Second, why, in over 50 references, was there only one citation of medical geography: a 1969 review article by Shannon et al.? This may be related to the authors’ claim that empirical evidence was needed on questions such as: do take- up rates decay with distance and, indeed, more sharply for the poor than the non-poor? (p. 121). The transportation survey may be returning to fashion. For example, Parkin and Henderson (1987) show that some people travel further than others, some make more effort than others and costs are more for some than for others. This merely tells us that people live in different locations. The impact on visiting was unclear: ‘Our judgement is that distance probably did not have a negative effect on visiting, but our data did not permit us to analyse this in detail’ (p. 26). By definition, this type of study can tell us nothing about non-utilizers or non-visitors.

The macro level

In contrast to the rather limited work at the micro level, there has been a wealth of studies at the macro level examining differences in health care activity at a number of spatial scales. Variations have been found between and within countries. It has been shown that there are large variations in treatment rates at the regional level (McPherson et al., 1981; Ham, 1988). There has been less work on lower spatial scales, but it appears that there are also large variations at such levels (Ham, 1988). Moreover, rates of treatment cannot easily be explained by morbidity or supply factors. In other words, spatial variations in treatment are not simply a reflection of spatial variations in health care expenditure (Ham, 1988). Waiting lists also show large spatial variations (Yates, 1987). Thus, a person’s chances of getting treated and their wait for treatment may depend, to some extent, on where they live. These differences may increase, or at least become more visible, in the reformed NHS ‘internal market’ in the UK.

The conclusion from an examination of the texts and research studies is clearly that medical geography has been neglected. In some cases, this is for good reasons. Medical geographers have made little contribtion to some important geographical debates at the macro or area level, on such topics as geographical variation in need (Jarman, 1983; Townsend et al., 1988; but see Senior, 1991), avoidable deaths (Charlton et al., 1983) area variations in medical practice

(McPherson et al., 1981; Ham, 1988). However, at the micro level the work of medical geographers has been ignored. Other disciplines have reinvented the wheel, and in some cases reinvented it badly. They have not learned from medical geography’s mistakes: first, that ‘as the crow flies’ straight line distance may be an appropriate variable for crows, but not for people for whom issues of mobility, cost, time and effort may be more important. Second, there has been a search for distance effects where they are unlikely to be present or where aspatial factors assume much greater importance than distance. In the UK, it is likely that many journeys to GPs are conducted on ‘proximity plateaus’. In other words, distances are relatively short, and below some critical value at which distance decay may begin to operate. In the USA, socio-economic access (income, insurance cover) may be more important for some people than physical access. Why are these hard-learned lessons not being assimilated by other disciplines? To some extent, it may be due to their insularity, but they do import material from disciplines such as medicine and economics. The more important reason, then, may be the credibility factor: the feeling that medical geography and medical geographers have nothing to say. The following section argues that this view is mistaken.

The potential contribution of medical geography It is clear that accessibility and utilization depend on a number of factors, traditionally the preserve of different discipliniary specialisms. Isolated treatment, wrenching variables from their wider context, will yield misleading answers. Studies based on ‘ceteris pa&us’ assumptions are limited in situations where the ‘other things’ are clearly not equal. Studies of utilization must examine enabling, predisposing and health factors. Gener- ally, medical sociologists have studied predisposing factors at the individual or group level, health policy analysts have examined system variables, and medical geographers have examined enabling factors such as distance. There is a need to examine all variables together. From the framework of Penchansky and Thomas (1981) we can divide access into availability (at the area level), spatial accessibility (at the intra-area level) and social accessibility (Powell, 1986, 1987).

It has long been established that different spatial units have different levels of health care provision (Coates and Rawstron, 1971). How- ever, many of these studies suffer from a number of problems. First, the spatial scale is generally crude: units such as regions hide a great deal of internal variation. Inferences based on aggregate data at the regional level may not hold at other

46


decay. It is likely that this will vary for different contexts-places, services and people. Thus, a search for this mythical beast will, at best, discover a crude and almost meaningless average value, with almost no practical importance (Powell, 1986; Olsson, 1980).

It is probably a waste of effort to search for distance decay in all circumstances. First, the more meaningful variables tend to be time, cost, effort, which are often related more to mode of transport and personal mobility than to distance per se. This is hardly a new finding. Wreford Watson who termed geography the ‘discipline in distance’ in 1955 clearly saw the variable in socio- economic rather than in geometric terms (Wat- son, 1955; Johnston, 1993). It follows that in many cases spatial accessibility models-based on straight line distance-tell us little more than a quick ‘eyeballing’ of a map would. Calculating separate accessibility surfaces for households with and without cars does not advance analysis very far. Ownership of a car does not necessarily mean that it is available to all members of the household. If it is available, distance is unlikely to deter use. If it is not, a local public transport timetable gives much more meaningful information for journeys of above walking distance. This illus- trates that space and time must be considered together. A car may be available at some times, but not at others. Facilities may not be open at convenient times. A closed facility next door is as useless as an inaccessible facility. The need to use certain facilities within specific times has been termed a ‘coupling constraint’ in the parlance of ‘time geography’ (Hagerstrand, 1970; New and Senior, 1991).

Moreover, it has been shown that ‘inaccessible’ locations are often not perceived as such by the inhabitants (Simpson, 1978; Ritchie et al., 1981; Powell, 1987). In these cases, what do we believe: the negative exponential or the testimony of individuals? As Haynes (1987, p. 159) states. ‘For most people, a trip to the doctor, dentist or hospital is of sufficient priority to make consid- erations of cost, time or inconvenience relatively trivial.’ He notes two main exceptions in Britain: the most isolated rural areas, where the return journey to hospital could exceed 200 miles and might involve an overnight stay, and regular journeys to hospital for out-patient treatment such as radiotherapy. More obvious examples may be found in areas such as remote rural regions of the USA and Canada.

Neither should we waste our time looking for unequal geographical access given that access is inevitably unequal: we all occupy different points in space. Rather than searching for unequal access it is more important to examine the degree of that inequality, and to search for locations and groups where severe access problems and great

aggregate levels (such as the District Health Authority-DHA) or at the individual level. In other words, poorly resourced regions may contain well-resourced districts and well-served individuals. Second, many studies are concerned with inputs, such as expenditure or staffing, rather than outputs or activity, such as the number of treatments. Third, many studies do not consider the need for health care. As need is likely to vary over space, their conclusions are concerned with equality rather than equity. In short, few studies have demonstrated the consequences of living in different areas. Those that do have been carried out by non-geographers, dealing with avoidable death (Charlton et al., 1983), abortion and con- traception (Leathard, 1985), operations (Ham, 1988) and dental treatment (Carmichael, 1983). In the reformed NHS in the UK, the place of residence-DHA X rather than Y-could account for the difference between a longer or shorter waiting period for treatment, or between being treated or not (e.g. IVF, varicose veins, etc.).

At the intra-area level, spatial accessibility to services could be important-access to good or bad GPs or hospitals, and in the case of the increasing centralization of accident and emergency (A&E) departments, could be a matter of life or death. In all cases, distance alone is an insufficient variable. In the majority of cases, mode of transport, bus routes, mobility, temporal, genderrole constraints, etc. are likely to be more important than straight-line distance. For example, the work of Senior and colleagues has suggested that geographical influences tended to be insignificant deterrents to attendance at im- munization appointments (Senior et al., 1993a, b). For this reason, it is necessary to develop beyond the concept of distance decay (Powell, 1986). Distance is best translated into effort or cost-in terms of money, time, etc. The friction of distance must be considered in relation to different types of service and the severity of the condition (Phillips, 1986, p. 222). For example, some people may seek essential treatment over- seas. There have been cases of people from the UK travelling to places such as the USA and Hungary. Ceteris paribus, distance will deter. Information is needed on the relative effect of distance (or effort) in relation to other factors. This was recognized by Gross (1972, p. 75) over 20 years ago: ‘we need to know a lot more about the relative explanatory powers of behavioural or predisposing variables, the enabling variables (in- cluding financial and spatial-temporal accessibility measures) and health level indicators on the utilization of health services’. We also need to know about the deterrent effect of distance for different groups. At the very least, this should dispose of the idea of ‘the negative exponential’: one universal value of the exponent of distance

JHRP ,:1-c 47


inconvenience are encountered. Second, it is important to examine cases where

access may make a difference: for example accessibility to ambulance services or A&E departments may result in different outcomes of treatment. However, most access studies in Britain have been for general practice and hospital services, where access probably makes little difference to outcome. In any case, spatial accessibility must always be linked with social accessibility. In most cases, ‘person’ characteristics are more important than ‘location’ characteristics-the ‘who’ (class, age, gender, race) rather than the ‘where’ question. Jones and Moon (1987, p. 245) warn that geographers should not ignore wider aspatial factors and that they may attach too much importance to the superficial issue of spatial variation. Geographers are aware that factors beyond space must be considered (Joseph and Phillips, 1984, Ch. 6; Phillips, 1986), but they must be examined together (Bradley et al., 1978; Kirby, 1982). This is obviously the case in a fee-based health care system, where income overshadows distance; financial access is more important than spatial access. A US text, often regarded as typifying the spatial perspective, argued ‘Attempts to deter- mine parameters associated with physical location . . . have little utility in light of the current laissez-faire attitude towards the delivery of medicine and the present framework of non- commitment to a philosophy of health care as a human right’ (Shannon and Dever, 1974). A study of distance alone is as meaningless in such a system as would be a geographic study of accessibility to libel actions in terms of distances from solicitor’s offices. As Smith (1977, pp. 313-315) notes, physical accessibility is meaningless if the key to effective access is money or race. More- over, geographical proximity is of little value for a wheelchair user without access to a building (or, anecdotally, to a Health Maintenance Organiza- tion office deliberately located on the upper floor of a building) or for a potential hospital patient who is ‘too old’ to be treated. ‘Only in a true public service can race and class discrimination be reduced to the point that spatial discrimination revealed by measures of physical accessibility emerge as the major problem’ (Smith, 1977, p. 315). This means attention must be paid to the non-geographical variables that may be dominant in many cases. In a quantitative study, the sample must be large enough to standardize or analyse by sub-group. Why some people consult and others do not remains a key, but unanswered, question in medical sociology. It is likely that the main reasons are to be found in aspatial factors such as ‘lack of proper cause’: not wanting to ‘bother the doctor’ (Eyles and Donovan, 1990). Once some- one has decided that a consultation is necessary, it is unlikely that space deters him or her from going

ahead. However, it is important to discover in what circumstances space may make a difference. This should be investigated empirically (Bradley et al., 1978; Senior et al., 1993b) in a range of geographical and social environments. Space should neither be accorded a false importance nor neglected by default.

Conclusion

The main conclusion of this paper is that geographical issues must be considered alongside other issues in any study of accessibility and utilization of health care. In some cases, geography will be a relatively unimportant factor, but in others it will not. The importance of geography needs to be considered in each study rather than being deemed of great or of no importance by default. The obvious starting point is to consider whether outcomes are merely reflected in space or more directly produced by space: between compositional and contextual factors (Duncan et al., 1993), people and place poverty (Smith, 1977)) location-specific and class-specific deprivation (Kirby, 1982). For example, a lower consultation rate in a particular area may result from a particular class, gender, race or age structure. These factors must be allowed for or standardized before any spatial explanation is accepted. On the other hand, after social factors have been examined, a remote rural area or an isolated hous- ing estate may suffer from poor spatial access, although even here the ability to overcome space may be related more to personal mobility, time and cost than to distance per se. A research agenda for medical geography’s contribution to the study of access and utilization of health care should focus on two broad concerns. First, an examination of the impact of ‘location specific in situ deprivation’ (Kirby, 1982): the effect of living in administrative area X rather than Y, rather than merely pointing out that X and Y are unequal. Second, an examination of the relative effect of space on utilization, as compared with aspatial factors. In particular, this may be most fruitfully explored where there is some reason to think that space may have some importance. Medical geography must reject crude spatialism. As Kirby (1982, p. 47) points out, looking at things from a spatial perspective can be as meaningless as stating that the Titanic sank in the late afternoon. Recognition of this should lead not to rejecting the spatial perspective, but to redefining and refining it. This debate has begun elsewhere (Macintyre et al., 1993; Jones and Moon, 1993). There is a place for space within the geographical imagination, and that place is within its broader economic, social and political context. A research problem such as access to health care cannot be addressed within the boundaries of one

48


Hart, N. (1985) The Sociology of Health and Medicine, Ormskirk: Causeway.

Haynes, R. (1987) The Geography of Health Services in Britain, London: Croom Helm.

discipline. Again, this is hardly an original finding (Shannon, 1980; Phillips, 1981). A socio-spatial problem needs both social and spatial inputs, steming from a greater interaction between medical geography and other disciplines. The challenge for medical geography is both internal and external: to make meaningful contributions within geography and, more importantly, to per- suade other disciplines of the efficacy of a geographical perspective.

References

Allsop, J. (1984) Health Policy and the National Health &vice, Harlow: Longman. _

Armstrone. D. (1983) An Outline of Socioloav as Apulied to Medic&, 2nd‘ edn: Bristol: Wright. -’ ’ 1

Baggott, R. (1994) Health and Health Care in Britain, Basing- stoke: Macmillan.

Bond. J. and Bond, S. (1994) Sociology and Health Care Edinburgh: Churchill Livingstone.

Bradley, J., Kirby, A. and Taylor, P. (1978) ‘Distance decay and dental decay’, Regional Studies, 12, pp. 529-540.

Buxton, M. and Klein, R. (1975) ‘Distribution of hospital provision: policy themes and resource variations’, British Medical Journal, 1, pp. 345-349.

Carmichael, C. (1983) ‘General dental service care in the northern region’, British Dental Journal, 154, pp. 337-339.

Carmichael, C. (1985) ‘Inner city Britain: a challenge for the dental profession’, British Dental Journal, 159, pp. 24-27.

Charlton, J. R. H. et. al. (1983) ‘Geographical variation in mortality from conditions amenable to medical intervention in England and Wales’, Lancet, 1, pp. 691-696.

Coates, B. and Rawstron, E. (1971) Regional Variations in Britain, London: Batsford.

DHSS (1975) First Interim Report of the Resource Allocation Working Party, London: HMSO.

DHSS (1976) Sharing Resources for Health in England (Report of the Resource Allocation Working Party), London: HMSO.

DHSS (1981) Primary Health Care in Inner London (The Acheson Report), London: HMSO.

Duncan, C., Jones, K. and Moon, G. (1993) ‘Do places matter? A multi-level analysis of regional variations in health-related behaviour in Britain’, Social Science & Medi- cine, 37, pp. 725-733.

Eyles, J. (1987) The Geography of the Nationul Health, London: Croom Helm.

Eylcs. J. and Donovan, J. (1990) The Social Effects of Health Policy, Aldershot: Avebury.

Fitzpatrick, R., Hinton, J. Newman, S., Scambler, G. and Thompson, G. (1984) The Experience of Illness, London: Tavistock.

Gibson, D., Goodin. R. and Le Grand, L. (1985) ’ “Come and get it”: distributional biases in social service delivery systems’. Policy and Politics, 13, pp. 109125.

Gross. P. (1972) ‘Urban health disorders, spatial analysis and thz economics of health facility location’, International Journul of Health Services, 2, pp. 63-84.

Hagerstrand, T. (1970) ‘What about people in regional science‘?‘. Papers of the Regionul Science Association, 24, pp. 7-21.

Ham, C. (cd.) (1988) Health Cure Variafionst Assessing the Evidence. London: King’s Fund Institute.

Ham, C. (1992) Health Policy in Brituin, 3rd edn, Basing- stoke: Macmillan.

Hannay, D. (1988) Lecture Notes on Medical Sociology, Oxford: Blackwell.

Hart. J. T. (1971) ‘The inverse care law’, Lancet, 1. pp. 4OS- 412.

Haynes, R. (1991) ‘Inequalities in health and health service use: evidence from the General Household Survey’, Social Science & Medicine, 33, pp. 361-368.

Haynes, R. M. and Bentham, C. G. (1982) ‘The effects of accessibility on general practitioner consultations, out- patient attendances and in-patient admissions in Norfolk, England’, Social Science & Medicine, 16, pp. 561-569.

Hopkins, E., Pye, A., Solomon, M. and Solomon, S. (1968) ‘The relation of patients’ age, sex and distance from surgery to the demand on the family doctor’, Journal of the Royal College of General Practitioners, 16, pp. 368-378.

Jarman, B. (1983) ‘Identification of underprivileged areas’, British Medical Journal, 286, pp. 1705-1709.

Johnston, R. (1993) ‘The geographer’s degrees of freedom: Wreford Watson, postwar progress in human geography, and the future of scholarship in UK geography’. Progress in Human Geography, 17, pp: 319-332. - _

Jones. D. R. and Masterman. S. (1976) ‘NHS Resources: scales of variation’, British Journal of Preventive ond Social Medicine. 30, pp. 244-250.

Jones, K. and Moon, G. (1987) Health, Disease and Society, London: Routledge and Kegan Paul.

Jones, K. and Moon, G. (1993) ‘Medical geography: taking space seriously’, Progress in Human Geography, 17, pp. 515-524.

Joseph, A. and Phillips, D. (1984) Accessibility and Htihzation, New York: Harper & Row.

Kirby, A. (1982) The Politics of Locution, London: Methuen. Klein, R. (1989) The Politics of the NHS. 2nd edn. Harlow:

Longman. Knox, P. (1978) ‘The intra-urban ecology of primary medical

care: patterns of accessibility and their policy implications’, Environment and Planning A, IO, pp. 415-435.

Knox, P. (1979) ‘The accessibility of primary care to urban patients: a geographical analysis’, Journal of the Rqval College of General Practitioners, 29, pp. 160-168.

Leathard, A. (1985) District Health Authority Family Planning Services, London: Family Planning Association.

Leathard, A. (1990) Health Care Provision, London: Chap- man and Hall.

Leese, B. and Bosanquet. N. (1989) ‘High and low incomes in general practice’, British Medical Journal. 29X, pp. 932- 934.

Le Grand, J. (1982) The Strutegy ofEquulity. London: George Allen and Unwin.

Macintyre, S., Mclver, S. and Sooman, A. (1093) ‘Area, class and health: should we be focusing on places or people?‘, Journal of Social Policy, 22, pp. 213-234.

McPherson, K., Strong, P., Epstein, A. and Jones, L. (1981) ‘Regional variations in the use of common surgical proce- dures: within and between England and Wales, Canada and the United States of America’ . Socicrl Science R Medicine, 15A, pp. 273-288.

Mills, C. W. (1970, first published 1959) The Soctological /mugination, Harmondsworth: Penguin.

Ministry of Health (1962) Hospitul Plun /or Enghmd und Wules, Cmnd 1604, London: HMSO.

Morgan, M., Calnan, M. and Manning, N. (1988. first published 1985) Sociological Approaches to Health und Medi- tine. London: Routledge.

New. S. and Senior. M. flYY1) ’ “I don’t belicvc in needles”: qualitative aspects of‘a study into the uptake of infant immunisation in two English health authorities’. Sociul Science & Medicine, 33, pp. 509-518.

Noyce, J.. Snaith, A. H. and Trickey. A. (1974) ‘Regional variations in the allocation of financial resources to the community health services’, Luncet. 1, pp. 554-557.

Olsson, G. (1980) Birds in Egg/Eggs in Bird. London: Pion. Parkin. D. (197’)) ‘Distance as an influence on demand in

49


general practice’, Journal of Epidemiology and Community Health, 33, pp. 9699.

Parkin, D. and Henderson, J. (1987) ‘How important is equality of access to hospital? A case study of patients’ and visitors’ travel costs’, Hospital and Health Services Review, pp. 23-27.

Penchansky, R. and Thomas, J. W. (1981) ‘The Concept of Access’, Medical Care, 19, pp. 127-140.

Phillips, D. (1980) ‘Spatial patterns of surgery attendance: some implications for the provision of primary health care’, Journal of the Royal College of General Practitioners, 30, pp. 688-695.

Phillips, D. (1981) Contemporary Issues in the Geography of Health Care, Norwich: Geobooks.

Phillips, D. (1986) ‘The demand and utilization of health services’, in Medical Geography: Progress and Prospect, London: Croom Helm, pp. 200-247.

Powell, M. A. (1986) ‘Beyond distance decay?‘, paper presented to the 3rd International Symposium on Medical Geography, Rutgers University, New Jersey.

Powell, M. A. (1987) ‘Access to primary health care in London’, unpublished Ph.D. thesis, University of London.

Powell, M. A. (1990) ‘Need and provision in the NHS: an inverse care law?‘, Policy and Politics, 18, pp. 31-37.

Powell, M. A. (1992) ‘A tale of two cities: a critical evaluation of the geographical provision of health care before the NHS’, Public Administration, 70, pp. 67-80.

Ranade, W. (1994) A Fufure for the NHS?, Harlow: Long- man.

Rickard, J. H. (1976) ‘Per capita expenditure of the English Area Health Authorities’, British Medical Journal, 1, pp. 299-300.

Ritchie, J., Jacoby, A. and Bone, M. (1981) Access to Primary Health Care, London: HMSO.

Scambler, G. (ed.) (1991) Sociology as Applied to Medicine, 3rd edn, London: Balliere Tindall.

Senior, M. (1991) ‘Deprivation payments to GPs: not what the doctor ordered’, Government and Policy, 9, pp. 79-94.

Senior, M., New, S., Gatrell, A. and Francis, B. (1993a) ‘Geographic influences on the uptake of infant immunisa- tions: 1. Concepts, models and aggregate analyses’, En- vironment and Planning A, 25, pp. 425-436.

Senior, M., New, S., Gatrell, A. and Francis, B. (1993b)

‘Geographic influences on the uptake of infant immunisa- tions: 2. Disaggregate analyses’, Environment and Planning A, 25, pp. 467-479.

Shannon, G. (1980) ‘The utility of medical aeogranhy research’, Social Science & Medicine, 14D, pp_ 1-2. . .

Shannon. G.. Bashur. R. and Metzner. C. (1969) ‘Review \ , article: the concept of distance as a factor in the accessibility and utilisation of health care’, Medical Cure Review, 26, pp. 143-161.

Shannon, G. and Dever, G. (1974) Health Care Delivery; Spatial Perspectives, New York: McGraw-Hill.

Simpson, R. (1978) Access to Primary Care, London: HMSO. Smith, D. (1977) Human Geography: a Welfare Approach,

London: Edward Arnold. Stacey, M. (1991) The Sociology of Health and Healing,

London: Routledge. Taylor, S. and Field, D. (1993) Sociology of Health and Health

Cure, Oxford: Blackwell. Townsend, P. and Davidson, N. (1982) Inequalities in Health,

Harmondsworth: Penguin. Townsend, P., Davidson, N. and Whitehead, M. (1992)

Inequalities in Health: the Black Report and the Health Divide, Harmondsworth: Penguin.

Townsend, P., Phillimore, P. and Beattie, A. (1988) Health and Deprivation, London: Croom Helm.

Watson, J. W. (1955) ‘Geography-a discipline in distance’, - . _ Scottish Geographical Magazine, 71, pp. ‘l-13.

West, R. and Lowe, C. (1976) ‘Regional variations in need for and provision and use of child health services in England and Wales’, British Medical Journal, 2, pp. 84>846.

Whitehand. J. (198.5) ‘Contributions to the recent develoo- ~ , ment and influence of human geography: what citation analysis suggests’, Transactions, Institute of British Geog- raphers, 10, pp. 222-234.

Whitehead, M. (1987) The Health Divide, London: Health Education Council.

Whitehouse, C. (1985) ‘Effect of distance from surgery on consultation rates in an urban practice’, British Medical Journal, 290, pp. 359362.

Wrigley, N. and Matthews, S. (1986) ‘Citation classics and citation levels in geography’, Area, 18, pp. 185194.

Yates, J. (1987) Why Are We Waiting?, Oxford: Oxford University Press.

50

Documents

Medical Geography