Understanding the experiences of black and minority ethnic service users in relation to access to National Health Service (NHS): a qualitative study in the UK.
Abstract: Improved access to health amongst Black and Minority Ethnic (BME) groups is a critical part of the overall strategy for reducing inequalities in the UK. Studies suggest that different ethnic individuals or groups tend to be more vulnerable than the overall population, but this tendency has not yet been documented from the perspective of BME service users. This paper, therefore, aims to explore the experiences of BME service users in relation to access to Primary Care services in the NHS in a Southern English county and explore the strategic and policy implications for such services. The research was conducted employing qualitative methods including focus group discussions and individual interviews, in order to elicit the perspectives and perceptions of BME service users. Using a non-probability purposive sampling, thirty-four individuals were recruited from Asian (16) and African (18) groups across the South East England region. Research uncovered the fact that respondents had mixed experiences associated with service access, utilisation and service delivery. Research also revealed those areas of concern which required improvement, and identified the barriers to implementing these improvements. This study concludes that the active involvement of users, practitioners, policy planners and decision makers in service planning and management would bring positive changes in the quality of health services.
Article Type: Report
Authors: Regmi, Krishna
Williams, Dele
Regmi, Sharada
Pub Date: 09/22/2009
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Fall, 2009 Source Volume: 24 Source Issue: 4
Topic: Event Code: 290 Public affairs
Accession Number: 307670893
Full Text: INTRODUCTION

Global interest in inequalities in health and its determinants has increased in recent years (Marmot et al., 1997; Gakidou & King, 2002). This interest reflects the persistence of inequalities between social groups both in developed and developing countries (Acheson, 1998; Anand et al., 2001). Beaglehole and Bonita (2008) pointed out that although global health may be improving, gross inequalities in health still persist within and between countries. It has been well documented that ethnic inequalities in health services exist in the UK (Erens et al., 2001; Sproston & Mindell, 2006). National Health Services (NHS) reported that Black and Minority Ethnic (BME) groups may experience poorer health care than the general white population, despite the improvement in NHS (Ward et al., 2008, Smith et al., 2009; ESRC, 2009). The nation's health has improved massively since the inception of NHS in 1948; for example, waiting lists and waiting times are at their lowest level ever, deaths from heart diseases have fallen by a third since 1997, cancer deaths by a sixth, inequalities between social groups have fallen by a seventh. The services in England, where the health sector reforms have moved fastest, are performing demonstrably better than the services in Scotland and Wales, and yet a man living in Manchester is still likely to die almost nine years before a man living in Royal Borough of Kennington and Chelsea (Appleby, 2008).

The proportion of Pakistani and Bangladeshi children in poverty remains over 50 per cent (Berthoud, 2009). Studies also show that increased migration to the UK in recent years poses further challenges for the NHS in meeting the diverse health needs of the population (Hopkins, 1993; Bahl, 1993; Rawaf, 1998; Bahl, 1998; Siegrist & Marmot, 2006). Immigrant mortality studies in the UK (Marmot et al., 1984) and elsewhere (Marmot et al., 1978; Singh, 2004; Miller, 2004) posed that the health status of migrants had bearing on their economic status, i.e. if healthier, then less likely to be disadvantaged in comparison to the general white population. Therefore, addressing health inequalities among ethnic groups is an important strategy for reducing inequalities in the UK. To gain a better understanding of the complex picture that is the NHS, this paper aims to examine and understand the experience of accessing or utilising English National Health Services, in terms of the perspectives and perceptions of BME service users.

BACKGROUND

Ethnic minorities make up 6.5 per cent of the population of Great Britain and account for 6.6 per cent of all people of working age (some 2.3 million). Asian and Indian are the largest ethnic minority groups, followed by Pakistani, African and Black Caribbean groups (Sly et al., 1999). Improved access to health services has been a major goal of much health legislation and planning. However, efforts to conceptualise and measure access have varied (Anderson et al., 1983). Since the publication of 'Black Report' in 1980 (Townsend & Davidson, 1982), a number of studies were carried out which analysed socio-economic factors, and focussed largely on the 'physical and biological' attributes, i.e. age, height, weight and disease. The poorer health profile measured the 'quantitative' attributes of those less advantaged BME groups (Smith et al., 2009). Although several studies have emphasised the inequalities in health delivery, it is surprising how little research evolved to encompass the perspectives of Afro-Asian BME users themselves, on NHS service access and utilisation policy (Great Britain. Parliament. House of Commons, 2009).

It is widely agreed that there is a widening gap between upper and lower 'social classes' across the world. Despite an overall rise in life expectancy in the UK and internationally, inequalities in health both within and between countries have, in significant respects, continued to widen in recent years (Department of Health (DoH), 2005; World Health Organisation (WHO), 2005). In the UK, a nearly two year gain in average life expectancy in the last ten years has been accompanied by a widening gap between the most advanced (Kennington and Chelsea) and least advanced (Glasgow) local authorities. The gap ranges from between nine and fifteen years for males (National Statistics, 2008). According to the director of public health in Birmingham, life expectancy for males in the most advantaged wards in Sutton Coldfield is over 78 years. In the two least advantaged wards of Soho and Nechells, it is 67.4 and 63.8 years respectively Chambers, 2005). When one considers that the average life expectancy in many developing counties is between 60 and 65 years (WHO, 2005), one gains a clearer sense of what it means to be male in Nechells. Therefore, health inequalities have now become an important agenda for public health initiative. The government under Thatcher explored 'variations' in health service provision and outcomes. Subsequently, the Blair and now the Brown government replaced these 'variations' with more class-oriented inequalities. Heller et al, (2004) strongly argue that 'unless the public health programmes are based on sound theoretical bases they will fail.'

The NHS was founded on the principle of providing access to adequate and essential health services, with the aim of improving the health of the entire population, as well as the population at risk, who are BME and hard-to-reach groups (Ham, 1999). Working selectively, the late Geoffrey Rose's astute observation, those small changes in the average for the whole population can bring great benefits to those at greater risk, provided the changes occur in the whole population has been ignored. (Rose, 1985; Heller et al., 2004). Killoran et al. (2006) and Marmot and Wilkinson (2006) strongly advocate that a person's health is influenced by the conditions in which she or he lives. Socio-economic conditions such as poverty, social exclusion, unemployment and poor housing, strongly influence health. Siegrist and Marmot (2006) further emphasised the fact that these socio-economic factors contribute to inequalities in health, thus why people living in poverty die sooner and get sick more often than those living in more privileged conditions. People in the UK still talk about, and measure, social class. Although the term 'socio-economic status' may be an example of political correctness, the fact is that class is still deemed an acceptable form of scientific terminology in the UK.

'It is posh to eat healthy food, and posh is a derogatory term. If men and women are born into such shackles of social conversion, their freedom to improve their health is distinctly limited' (Heller et al., 2004)

The concept of social class, theorised by Weber and Marx, is a complex system that involves consciousness of one's social position and sharing of values and outlooks within that group. The classes consist of the propertied upper class, the property less intelligentsia (white-collar workers), the petty bourgeoisie, and the manual working class (Scott, 1996).

The debate about equity and health services is complex and wide-ranging, and has an international component, in that all countries have inequality and inequity (Ward et al., 2008). Recent government report describes that 'health inequalities are not only apparent between different socio-economic groups, but they also exist between different genders and ethnic groups' (Great Britain. Parliament. House of Commons, 2009, p.5). Aday et al. (1980) considers access to be those dimensions which describe the potential to, and actual entry of, a given population to the health care delivery system. Equity of access to health exists when services are distributed on the basis of users' needs (Aday & Anderson, 1981). Inequity is suggested, however, when service distribution is based on the demographic attributes of race, family income, location, age, sex, education, coping style and diversity of conditions, rather than the real needs (Aday et al., 1980; Bensing et al., 2006). Whitehead (2007) raised a more widespread concern that inadequate access to health services is one of many determinants of the observed inequalities in health.

Street et al. (2007, 2008) notes that the importance of shared identify facilitates more positive health interactions. Furthermore, they found that the way health care practitioners (HP) perceive service users (SU) (for example, intelligent or compliant) affects how they treat them during the consultation. It has been reported that HPs also communicate with and treat their SUs differently according to their social attributes, such as social status, position and ethnicity. Bao et al. (2007) reported that physicians were less likely to discuss, for example, cancer screening tests among SUs who had a lower education level, and with lower socio-economic groups. Gorden et al. (2005) further noted that HPs were less likely to initiate psycho-angiography discussions during the consultations if SUs came from BME backgrounds, and similarly, BME SUs were also less likely to initiate this type of discussion with their health care practitioners. BME service users whose ethnicity was discordant with their health care practitioners were found to receive less information than the indigenous or racially concordant population. Similarly, Davey et al. (2000) reported that socio-cultural, biological and behavioural factors between and within different BME groups are differentially distributed. The UK government is also committed to using public views to improve services (DoH, 2005). Therefore, incorporating the different perspectives and perceptions of service users will serve to better our contextual understanding of BME groups and health services.

It is now more important than ever to explore all aspects of health inequalities, and how changes can be brought about which consider SU's social characteristics. This study seeks to provide a complementary 'insider' perspective on this health care situation, so that through recounting experiences, the provision of access to good quality services for the entire population can be improved.

METHODOLOGY

STUDY APPROACH:

A qualitative research approach was employed for the study, as the aim was to explore perceptions and capture perspectives of BME service users. A grounded theory (GT) approach was used in order to understand the service users' experiences, using the views, values and perspectives of the participant and the understanding and interpretation of the researcher (Charmaz, 2003). GT studies aim to develop the theory and understanding of social processes, to construct the meaning of social content and social reality (Denzin, 1989; Babbie, 2001; Somekh et al., 2005; Walker & Myrick, 2006). The intention of this approach is to use multiple sources of data in order to investigate the same phenomenon from different perspectives. This method is effective because social reality is contextually embedded, interpersonally forged, and necessarily limited (Neimeyer, 1993; Patton, 2002). The study adopted qualitative methods including focus group discussions and individual interviews, and GT analysis technique.

RECRUITMENT OF RESEARCH ASSISTANTS:

A team of four research assistants (RAs), two from Asian and two from African ethnic groups, has supported this study. Following the initial two-day long training, RAs were actively involved in arranging and conducting interviews and focus group discussions. The knowledge and contacts of RAs have given us access to groups and individuals that we may not otherwise have had.

PARTICIPANTS:

Between May and July 2007, five focus groups and ten in-depth interviews were conducted with BME service users (SUs) who were resident within the Berkshire areas. Group participants were recruited via local charities and civil societies. With their agreement the researcher attended their regular meeting and explained the purpose of study and asked for participation where we fixed the best time and venue for the group interview. Individual interview participants were recruited with the help of local health organization- NHS and BME focused charities. The participants were selected on the basis of non-probability purposive sampling (Bowling & Ebrahim, 2005) to achieve a theoretical sampling--an iterative process which allows 'development of relevant categories to emerge from the research process and decisions about sampling' (e.g. who, when and where) (Ritchie & Lewis, 2003, p.80). The final sample was determined by adopting a maximum variation strategy (Patton, 2002) i.e. a sample inclusive of the population and representative of the full range of demographic variables such as age, sex, ethnic group and marital status. The size of the sample was not fixed at the initial stage, so sample and data collection grew simultaneously, with sample size being based on the results of the data analysis (Glaser & Strauss, 1999). Recruitment (data collection) continued until saturation of emerging major themes was evident (Mason, 2002). The participants included thirty-four SUs (16 Asian & 18 African).

DATA COLLECTION:

Prior to the data collection, participants were given a schedule of topics focused on four key issues: (i) understanding and experience of assessing or using NHS, (ii) provision of services for BME, (iii) the problems and challenges faced, if any, while accessing NHS, and (iv) ways to improve the quality of services. A topic guide was developed based on the literature review and the researchers' reflection on their experience (Table 1). The topic guide was sufficiently flexible to allow any relevant issues to be discussed. The topic guide used in this study was piloted with five BME service users (two men and three women) in a non-study area, but with similar groups to establish face validity, as well as to improve the intrinsic aspects of the questions (Bowling & Ebrahim, 2005; Robson, 2002). Based on the feedback received, the guide was slightly revised and finalised for use in our study sites.

DATA ANALYSIS:

Focus group discussions and in-depth interviews were examined in relation to the perspectives and perceptions of service users regarding access to, utilisation and delivery of NHS facilities. The interviews and focus group discussions lasted between 40 and 90 minutes, depending on the individual contribution and were audio-taped using a digital voice recorder, where after they were transcribed verbatim, including 'pauses, emotional expressions, and annotations' to a Microsoft[R]Word2003 document (Crabtree & Miller, 1999). The data was analysed and interpreted using thematic content analysis. The interviews were imported to QSR[C]NVivo7 software for qualitative data management and analysed to reveal coding structures: categories, subcategories, themes and codes (Strauss & Corbin, 1990). NVivo7 enabled the exploration of each interview, and the identification of the words and phrases that formed the basis for the development of themes and codes. The program also enabled interviews to be interlinked (Ritchie & Lewis, 2003; Lewis & Silver, 2007). Transcribed versions were sent to the participants, who were requested to check whether they agreed with what had been written. One interpreter, who was familiar with Asian and African languages, was recruited in the study. Any inconsistencies were corrected accordingly.

ETHICAL APPROVAL:

Informed consent was obtained from individual participants before the study commenced, after they had read the participant information sheet. Permission to conduct this study was granted by the local ethics committee. Participants' confidentiality and anonymity were maintained throughout by ensuring that names were not reported in the findings. In addition, participants were free to participate, answer questions, decline to answer, or even terminate the discussion at any stage if they wished to.

RESULTS

CHARACTERISTICS OF THE RESPONDENTS

Five focus group discussions and ten in-depth interviews were carried out with BME SUs (n=34; 16 Asian and 18 African). Participants were stratified by demographic attributes: age, sex, education, ethnic group and marital status. Most of the participants were between the ages of 16 and 74 years and they fairly represented the major two ethnic groups in the UK. The demographic attributes are shown in Table 2.

FINDINGS FROM THE INTERVIEWS AND DISCUSSIONS

Upon analysis of the transcripts, from the interviews and discussions relating to BME peoples' experience of access to or utilisation of local NHS, a number of themes emerged. A core category was arrived at, based on two broad themes and categories identified from the data. These themes or categories are listed and described here, and are based on the validations performed by a translator, and by other subject experts. The themes are as follows:

Knowledge and perception of NHS

* Access to and use of services

Barriers to access or utilisation of NHS

* Appointment hurdle

* Ignorance of BME needs

* Service needs are complex and interconnected

* Poor service signposting

* Language and communication problem

* Users-centred services

These themes are not mutually exclusive, but overlap and contain contradictions, reflecting the complexity of the analysis within the wider sociocultural and political context.

Knowledge and perception of NHS

Information on the use and experience of NHS: General Practitioners (GPs), Primary Care Trusts (PCTs) and Foundation Hospitals or Trusts was obtained from respondents in interviews and focus group discussions. Interviewees had diverse perceptions of NHS services as a concept and shared no common definition of what they should entail. Their concept of NHS mostly appeared to be informed by the ways in which they currently attempted to access it.

Access and use of services

More than 75 per cent of respondents who were interviewed had seen their GP within the past 12-18 months, either for themselves or with their families and friends; it was not possible to identify the extent of service use for each of the participants, but they had all accessed the services at some time. Few respondents (two Asian and three African) reported meeting with their GPs on a regular basis for their long-term health conditions (diabetes and heart disease). Some respondents suggested that a GP was the most authoritative source for dealing with any health concerns. The majority of the respondents were generally found to be positive about the NHS services offered at different levels.

Many of the potential advantages expressed were:

'I would not have got a medical opinion elsewhere so I needed to see my doctor at GP surgery.' (Participant As4)

'We agree with NHS values of universal access, free at the point of use, located close to home, run by the state.' (Participant Af10)

'Marking services to the poor through local health facilities' (Participants As7, Af9 and Af10)

'NHS [hospital] is offering a great service, as it saved my husband's life when he got a serious illness [Lung Cancer]. Doctors and nurses kept up full support and care for months, but they did not charge us anything. We were so happy and thankful to the doctors and their team, and also to UK government who to make the services free for people like us. They even came to visit our house to get feedback. What kind of service do I and my family like? Amazing!' (Participant As14)

'GP service is really good, as it bridges the gap between NHS hospitals and the local community. People there are very friendly and helpful.' (Participant Af13)

'I don't know what it really meant, but I know services were much better than back home-quick services, with reliable, kind people [health professionals] and service is within a few minutes distance. In fact, for me, it was more about 'cost saving' and 'time saving' (Participant Af10)

There were some concerns, however, expressed by a number of respondents over NHS. Some believe this 'traditional' model is outdated in the 21st century, and can not meet everyone's needs and interests, due to the pressures of an aging population, migrant and immigrant population, and high tech medical advances.

'In fact, NHS is very costly and underperforming ... and failing to meet the targets and our [public] expectations. In addition, we have to pay [pounds sterling] xx just to get few tablets of pain killer [paracetamol or Ibuprofen].' (Participant As7 & Af3,6)

We came here [GP surgery] to see my doctor, but often I was not allowed to see him, as the nurse treated my child and I with over-the-counter medicines for minor illnesses. (Participant As11)

'Money is not spent effectively, and too little actually goes to patient care.' (Participant As9)

I don't know who is a senior doctor (GP) or a practice nurse? I had seen a GP once when I had complications after an accident. I was repeatedly referred to the practice nurse--for a condition which I felt required consultation with a GP.' (Participant Af17)

BARRIERS TO ACCESS OR UTILISATION OF NHS

Appointment hurdle

The measurement of access to health care in NHS is dominated by waiting list and waiting time targets, which rest on the collection and publication of a wide range of government statistics (Ward et al., 2008; Godden & Pollack, 2009). Godden and Pollack (2009) argue that waiting time might be used as an indicator of assessment for a range of purposes, for instance, to measure performance, for local planning and to provide information to the patients themselves on access to health care. In response to this issue, a number of respondents expressed their dissatisfaction and their given reasons were:

'Getting an appointment was a real Problem ... no weekend appointments ... restricted opening hours and busy surgeries. I should go and book in early, otherwise you won't get it. I'm terrible at keeping appointments ...' (Participant As9,10,13 & Af11, 13, 17, 19)

'Reception staff are the gatekeepers; it was difficult to pass the reception staff to get an appointment with the GP.' (Participant As9,11,14, 13 & Af 8, 15, 17)

'Sometimes, it is wasting my time and someone else's time, really.' (Participant As10)

'My GP often didn't refer patients to the hospital. I required a referral to A&E for a neurological problem, but was advised by the GP to wait and see the nurse in a few days time. Was that due to an issue of the GPs competency?' (Participant As13)

Ignorance of BME needs

The majority of the respondents felt that NHS is one of the best bureaucratic machines, which is run by top-level managers and bureaucrats. Staff working in NHS are mostly motivated by a 'medicalised approach', which has concern only for the physical illness, and not for the wholeness or 'well-ness' target of the patient.

'Many staff working in NHS are from nonwhite background and they are not aware, or

I would rather say ... ignorant of my needs' (Participant As12)

'I have noticed that they were biased ... when I was waiting at NHS there were few white people, and the receptionist was very open with these groups. She even sent one patient [maybe he was her fiend] in my turn ... giving the reason was I had missed it.' In fact I was there for more than two hours ...' (Participant Af13)

'Being an immigrant, I can't speak English as well as other white people. When I had an appointment with a GP for my chest problem, she didn't quite understand about my problems and she just prescribed me some tablets of pain-killer. I think there should be someone at the GP who can fairly understand our languages.' (Participant As17)

Many respondents believe that centrally imposed targets underscored the ability of the medical and nursing staff to deliver the needs of BME clients.

'Of course ... they have these government set targets, and we have to adhere to them as well. There is less space for manoeuvre, which has stopped them giving patients driven or responsive care.' (Participant As10 & Af12)

Similarly, another respondent felt that:

'Priorities of NHS now are just to get things done. Users' interest ranks quite low. It's all about time ... reducing waiting times!'

(Participant As10 & Af8)

Service needs are complex and interconnected

The opinion that individual' health service needs are complex, and interconnected to their family and community was expressed by some respondents. Therefore, they suggested that to address the complexity of meeting needs, different organisations should work together to better serve the BME community.

Quicker problem solving was seen as a potential benefit:

'... it will take a very short time to resolve any problems that arise in the implementation level if we [BME] people are at the centre of public service planning and management.' (Participant As10, 11, 17 & Af12, 16)

'I think that we should be involved in education and child services meetings in future.' (Participant Af15)

Two respondents noticed that a 'fragmented approach' to service delivery was the main problem.

'We sometimes have to repeat our problems and medical cases a number of times to many different people and organisations.' (Participant As 14)

'One common forum in which people needing health and social care services can share is essential.' (Participant Af 17)

Poor service signposting

Many participants found that the NHS staff were not aware of who else to refer them to with other problems or needs:

'We were never called for the community meetings, either by voluntary organisations or by the NHS GP, and we don't know where to go if I have need of social services.' (Participant As16)

'I have been regularly attending GPs for 15 years for my diabetes, they [GP staff] never discuss my personal health and social care needs. That's awful.' (Participant Af13)

'I think that GPs should have a good customer advice and support service--if they can't help directly, they will help find someone who can.' (Participant As11)

'Local authority should develop an internet based forum where users can find essential information for health services, public services, community groups, voluntary organisations, and statutory sector services (for example: NHS, DEfS, DAP, Jobcentre, etc.)' (Participant As14, 16 & Af7, 11)

Language and communication problem

Some respondents who experienced difficulty in communicating in English reported that they encountered difficulties while explaining their problems to GPs, and in understanding their advice.

White noting the language barriers, some participants were concerned that:

'Language services are not always available when we need them. We had to use a family member to translate.' (Participant As8 & Af7)

'Although GP's efforts to communicate were helpful, sometimes we could not understand what the GPs were talking about, as they didn't speak in our languages.' (Participant As10, 11, 12 & Af15)

'There is no information available in alternative formats and languages.' (Participant As10)

'Although NHS is now providing patient advice and liaison service, they do not translate information into our local languages on request.' (Participant As10 & Af 9) 'Services offered, such as housing, community care and NHS should be properly translated and interpreted.' (Participant As4,5,6 & Af 12)

'I think NHS at least should provide customers information about their interpretation and translation services in at least five community languages, and some essential health services provided at the local level should be from BME origin.' (Participant Af15)

Users-centred services

There was a concern, expressed by a number of respondents, that NHS is not responsive to the concerns of BME needs and services. One respondent stated,

'we want to hear back promptly from services even if only to hear that no action has yet been taken. We want to know we have not been forgotten.' (Participant As7)

Other concerns are:

'NHS is not efficient at keeping users informed anymore.' (Participant As5 & Af7)

Therefore, some respondents suggested that,

'NHS services should reach out more to communities; market their services and canvas their opinions so that we can help them.' (Participant As9, 10 & Af11)

'We really want to see the local borough and NHS services providers out in our communities.' (Participant Af1, 4)

'I have not seen any community events to market their services and hear our voices.' (Participant As5)

'Each day I got so many papers, newsletters and so on about 'businesses', 'markets' and 'sales', but never any about NHS, or from GPs, and, local doctors' surgeries to hear the view of local people on their health services.' (Participant As2)

'I think NHS is not very keen at all on processes which would make them more efficient and more community focused. I think, keeping us [users] informed on our involvement should be one of the key themes.' (Participant As1, 2, 15 & Af11, 18)

[FIGURE 1 OMITTED]

One respondent says:

'NHS is really money oriented. It seems to me that there is hardly any humanity left in the NHS! There is no human compassion really. Where is the user in the NHS system? Nowhere!' (Participant Af10)

OTHER COMMENTS

While responding to concerns about improving NHS service access and quality, the vast majority of the respondents (31 of 34) pointed out two important points. First, NHS should be more sensitive while dealing with BME health needs, as their needs are not only linked with their physical entity, but rather linked with a wider picture of socio-cultural, language and political aspects. Second, due to the existence of an institutional barrier of racism and discrimination, the degree of achievement has been compromised. DoH (2002, p.25) strongly argued that 'ideological boundaries or institutional barriers should not stand in the way of better care of NHS patients'.

Some of the relevant concerns with NHS service quality, and suggestions for improvements on quality and access for the whole population are below:

'One of the key barriers to health services was the limited number of Black and Minority Ethnic GPs from migrants' countries of origin.' (Participant Af 9)

'... need to increase awareness of BME sociocultural and health needs amongst GPs, and they need to respond effectively.' (Participant As12 & Af 14)

'It is important to identify and share good practice with all our GPs and their practices.' (Participant Af2)

'Recognising, valuing and celebrating diversity in the NHS health workforce is an essential.' (Participant As14)

'User centred programme reviewing, improving, planning and commissioning of services seems mandatory.' (Participant As1,3 & Af 11)

DISCUSSION

The study reveals a complex picture, highlighting the diverse relations between BME service users and the NHS, in terms of access to and utilisation of local NHS services. One of the outcomes of this extended analysis is the conceptual framework (Fig. 1), which offers a framework for viewing reported BME attitudes toward and experiences of NHS. Furthermore, we found that there are complex interlinked relationships between different individual, community and institutional factors. This paper also explores some structural access barriers to NHS, such as the lack of easily accessible, linguistically and culturally appropriate information on institutions and services provided for BME needs. Health inequalities have multidimensional determinants, and this should be addressed by working with different stakeholders at different levels (Evans et al., 2001). Therefore, to deal with the access barriers, involvement, engagement, development and mobilisation of the community groups, the establishment of BME partnership forums and networks with different statutory, civil and voluntary organisations is important.

The results of the current study confirm and enhance those of previous studies (Aday et al., 1980; Acheson, 1998; Anand et al., 2001; Erens et al., 2001; Sproston & Mindell, 2006; Bensing et al., 2006; Ward et al., 2008) giving further evidence to support the benefit of NHS among different BME groups. Research reveals that a responsive health service contributes to health improvement by being more conductive for the needs of its service users (Williams, 1994; Evans et al., 2001). It can also contribute to increased utilisation in settings where people might choose not to use available services because of their low responsiveness (Haddad et al., 1998). Taylor-Gooby (2008, p.30) found in a national attitude survey that 'people feel most involved in the way the NHS sets priorities if they are convinced that they are meeting peoples' needs when they are vulnerable.' A strength of this study was that it gave BME groups the opportunity to say what they liked, and to feel that it was an important contribution. Unlike previous studies, however, this study drew selected participants from two major ethnic groups from South East England in the UK. In addition, recruitment of RAs from the study population and recruitment of bilingual interpreters added trustworthiness to the validity of the findings (Lincoln & Guba, 1985). The involvement of the RAs has enabled us to come closer to the knowledge and experience of the target groups in relation to the barriers of access to NHS. The knowledge and contacts of RAs have also given us access to groups and individuals that we may not have otherwise have had. The recruitment of two independent bilingual interpreters, who were familiar with Asian and African language, has helped to verify and determine the trustworthiness of translations (Wallin & Ahlstrom, 2006).

This study has however several caveats. As everyone belongs to an ethnic minority group (including the 'white' population), this study was restricted to the non-white BME groups as defined in 1991 (Gill et al., n.d.). In addition, this study did not compare the experiences of those two study groups, nor did it capture the experiences and concerns of other minority groups, such as refugees and asylum seekers, lesbians, gays, bisexuals and transgendered people, gypsies, romanies and travellers in the UK (Gill et al., n.d.). This study was limited to a small sample size and specific geographical location, specifically towards Asian and African populations, and therefore wider generalisation cannot be established. Although the recruitment of local RAs from the representative ethnic groups provided rich information, there could be some bias in results, as they could have given more emphasis to accounts from the persons affected, or have been too sympathetic to the plights of the respondents. This study must therefore be viewed within the constraints of the study setting. Quantitative study could have provided a more representative view, but would not have reached the depth of this approach.

The study further indicates that those involved in the study arrangements perceived a mixed experience, as access to service is seen as a very broad and complex phenomena. A variety of approaches have been used to define and measure access to health services (Woods et al., 2005). Some authors have emphasised the overall supply of available of services, others have argued on the characteristics of the users (income, education and gender). More recently, the issue of access has been considered as 'intermediate outcome measure', such as the rate of service use or assessing the experience and perception of users' satisfactory level with health services (Aday & Anderson, 1981). Roghmann et al., (1979) asserted that satisfaction was a determinant of service access or utilisation. White paper 'Our Healthier Nation (DoH, 1998, p.12) recommends that, 'tackling inequalities generally is the best way of tackling health inequalities.' Wilkinson and Marmot (2003, p.9), also suggested that 'tackling some of the material and social injustices, policy will not improve health and well-being but may also reduce a range of other social problems that flourish alongside ill health and are rooted in the same socio-economic processes.' Therefore, the challenge is to address the issue of access to NHS services, as well as health inequality. Providing more training and increasing the awareness of PCTs staff, helping them to recognise those BME health problems that could be due in part to social development, will help the NHS to provide access to good quality services for all its users. One service access challenge experienced among the study groups is acknowledgement of the diversity in workforce; therefore 'BME users' forums for NHS are needed in local community so that experiences and practices can be shared. An ongoing system of services delivery monitoring by local bodies, making the outcomes available to the public including BME service users, is suggested for promoting equity and quality of health services.

CONCLUSION

Although NHS policy aimed to improve access to and provision of primary care to all BMEs, there are still personal, policy and structural barriers due to lack of awareness of the NHS systems and practice. This study concludes that NHS creates both opportunities as well as challenges for BME people. Caution, however, needs to be taken when interpretating the findings and generalising to a wider population, because of the limited sample size and relative under-representation of the respondents. However, we believe that this study is a valuable contribution to the debate of 'access to quality health services'. The study uses public views to improve services, targets under-researched ethnic groups, and makes the information accessible to those who need it in the UK and internationally. Evidence from this study concludes that, although NHS is considered the best available health system, it is not perfect. Increased efforts therefore should be made to improve the quality of services considering the needs of BME groups ensuring that their needs are appropriately addressed in planning and management of health services.

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Krishna Regmi MPH, PGDipHE, PGCert (SocDev), FHEA, PhD, is a PhD Researcher, University of the West of England, UK. Dele Williams MSc, LLB, is a Executive Director at National Institute for African Studies, TVU, UK, Sharada Regmi RGN, BN, BEd, is a Senior Nurse at Royal Berkshire NHS Foundation Hospital, Reading, UK. Please send all correspondence to: Krishna Regmi, Liverpool Road, Reading, RG1 3PH, UK. Tel.: +44(0)7723366598. E-mail: kregmi@yahoo.com
Table 1. Topic guide

* Tell us about your understanding of NHS.
How often do use or seek them?

* Describe your experience of assessing or using NHS?
What about the provision of services for BME?

* Have you ever encountered any problems or challenges
while assessing or using NHS?

* Can you tell us how we can improve service access,
utilisation and quality of NHS?

* Are there any other issues you would like to raise?

Table 2. Frequency distributions showing the number of
respondents by age, sex, education, ethnicity, marital status

                Distribution                   Respondent

Age group                        16-24             2 (6%)
                                 25-34           18 (53%)
                                 35-49             7(20%)
                                 50-64             4(12%)
                                 65-74              3(9%)

Sex
                                  Male           22 (65%)
                                Female           12 (35%)

Entry qualifications
                            Below GCSC                --
                               A-level             4(12%)
                         Undergraduate            17(50%)
                          Postgraduate           13 (38%)

Ethnic groups
                                 Asian           16 (47%)
Indian                             (4)
                         Pakistani (3)
                       Bangladeshi (4)
                          Nepalese (5)
                               African           18 (53%)
                             Kenya (3)
                           Nigeria (6)
                      South Africa (2)
                            Zambia (2)
                          Zimbabwe (4)
                           Somalia (1)

Marital status
                              Married            25 (73%)
                               Single             6 (18%)
                                Widow              3 (9%)
Total                                           34 (100%)
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