Understanding the Relationship Between the Social Determinants of Health, Paediatric Emergency Department use a the Provision of Primary Care: A Mixed Methods Analysis

Understanding the relationship between the social determinants of health (SDH) and
the use of emergency departments (ED) for triage priority 4 and 5 presentations, that
are discharged, that would be better serviced by primary care providers, rather than
an emergency response, is complex. The difficulty with a SDH approach, is in
determining appropriate measures. A number of researchers have addressed this
difficulty by focusing on the relationship between deprivation, as a measure, and
attendance at ED. This thesis provides an overview of relevant research on the
relationship between deprivation and attendance at a Paediatric Emergency
Department.
This research employed a mixed methods approach utilising Hospital Admission
Status data (HAS ED), Social Health Atlas data (demographic data), measures of
deprivation (Socioeconomic Index For Area [SEIFA] the Index of Relative Social
Disadvantage [IRSD]), levels of primary care provision data (epidemiological) and
parent and staff interviews to explore the factors relating to high attendances at a
paediatric ED in South Australia.
The qualitative findings indicate that a dearth of services, such as limited service
provision (lack of GP appointments), or after hours services and a lack of broader
community based primary services (for example the provision of blood tests, x-rays)
influences high Paediatric ED attendances rather than distance to ED, or cost. In
addition, the quantitative findings found the highest levels of primary care Paediatric
ED attendance were from areas with high levels of deprivation. Further, there were
significant positive relationships between possible primary care attendance and
discharge status, distance to ED, and attending ED using a private vehicle (rather
than emergency vehicle). The epidemiological data suggests that there is a dearth of
GP services in areas with higher than average levels of illness. Reasonably, this may
impact on the ability of parents to access timely and appropriate health care services
from primary care providers.
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The lack of a child specific skill set in GPs, no after hours GP services, and
differences in familial health access were some of the major qualitative findings from
the study. These findings differ from other studies that showed: intra-familial
consistency of ED use; and that parental anxiety increases ED use. Further, the
respondents described the influences and characteristics of service provision that
influence their use of ED for primary health care. These factors are of a structural
social determinants of health (SDH) nature. The changes to universal health care
provision impacting on paediatric ED use have occurred gradually over time. This is
termed here as ‘incremental structural inertia’ and has led in recent times to a
decrease in the provision of GP services that may have increased the use of ED for
primary health care. The most distinctive contribution this research makes to the
body of knowledge regarding health access is that despite the usefulness of the GP
Plus and GP Super Clinics in addressing some of the intermediary SDH such as
social support, parenting support and preventative health interventions, the GP Plus
and GP Super Clinics will not change the numbers of category 4 and 5 presentations
to ED unless there is an increase in the numbers of: GPs, paediatrically trained
community health care providers and after hours services.