Adjudications and tinkering with care for socially vulnerable patients with type 2 diabetes in general practice

Abstract

Objective

To analyse the mechanisms at play in the adjudications made by professionals and socially vulnerable patients with type 2 diabetes about their eligibility for care.

Design, setting and subjects

The study included 14 patients and 10 health professionals in seven general practice surgeries in deprived areas in Greater Copenhagen. The study data consist of 17 semi-structured interviews with patients and 22 with health professionals immediately after observation of 23 consultations. Our analytical approach was inspired by Systematic Text Condensation and the concept of ‘candidacy’ for access to health care.

Results

Adjudications of patients not being candidates for services were common, but we also found that both patients and health professionals worked to align the services to the needs of the patients. This could include using services differently than was intended by the providers or by changing routines to make it easier for patients to use the services. We discuss these processes as ‘tinkering’. This usually implies that the best individual solution for the patient is aimed for, and in this study, the best solution sometimes meant not focusing on diabetes.

Conclusion

The study adds to existing knowledge about access to services for socially vulnerable patients by demonstrating that both patients and professionals in general practice engage in tinkering processes to make services work.

KEY POINTS

Unequal use and benefits of health services play a significant role in relation to social inequality in health

• Flexibility in services and alternatives to school-like rehabilitation are needed to reduce inequality in access to health care

• Patients were sometimes judged as unsuitable for available routine services, but professionals ‘tinkered’ with services to make them fit

• Adaptation of services by professionals in general practice implies a longer time frame for obtaining goals

Keywords:

• Health inequities
• socioeconomic factors
• health services accessibility
• general practice
• family practice
• candidacy
• tinkering

Acknowledgements

The authors would like to thank the patients and the health professionals who kindly participated in the study. They would also like to thank Tværspuljen- Region Hovedstaden, The Vissing Foundation, Læge Sofus Carl Emil Friis og Hustru Olga Friis’ Legat, Praktiserende Lægers Uddannelses- og Udviklingsfond (Danish College of General Practitioners), and the Committee of Multipractice Studies in General Practice for financial support.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Tværspuljen- Region Hovedstaden, The Vissing Foundation, Læge Sofus Carl Emil Friis og Hustru Olga Friis’ Legat, Praktiserende Lægers Uddannelses- og Udviklingsfond (Danish College of General Practitioners)