The nurse is assisting the primary health care provider during renal ultrasonography

There is a well-established body of international evidence that suggests that high quality primary care is important for improving health outcomes, controlling health care spending, and reducing health care disparities [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]. Affiliation, which refers to having a usual source of care (doctor, nurse or medical centre) or primary care provider (PCP) one could go to if need arises, is considered to be one of the four critical features of primary care [14]. Affiliation with a PCP or “having a regular source of care” has been considered both a measure of access and a determinant of access in health services research. Aday et al. [15], [16], [17] treat having a regular source of care as a structural component of the health care system that demonstrates an individual's uninhibited entry into the system. However, others have also considered regular source of care as a determinant of access [14].

Defining the characteristics of those not affiliated with a PCP at the individual level is especially important in the light of the fact that a PCP is usually the first point of contact for patients, and PCPs are “gatekeepers” who regulate access to more costly secondary and tertiary care. Affiliation with a PCP does not necessarily mean actual utilisation of primary care services. Rather, following Aday et al. [15], [16], [17], this study uses it is as a measure of potential access that makes it more likely that care will be used [18], [19], [20], [21].

Studies, mainly from the US, have shown that potential access – having a regular provider of care – is strongly related to the likelihood of seeing a physician [15], [16], [22]; is one of the strongest predictors of access to health care services [17], [23]; has been associated with greater use of preventive health services [24], [25], [26] and with fewer emergency department visits [27]. In addition, some studies have also reported that having potential access is also associated with 25% lower total costs of care compared with those not having regular source of primary care [28], and with greater satisfaction with the health care received [15]. The influence of having a usual source of care seems to grow as use becomes more discretionary [18], [22]. For example, in the US Rundall and Wheeler found that the presence or absence of a usual source of care was more important than income in predicting use of preventive services among a sample of adults [22].

There is considerable policy interest in defining the characteristics of people who are affiliated/not affiliated with a PCP. First, there is evidence from the US that those not having a regular health care provider are more likely to rely on hospital outpatient and emergency departments as a regular source of care. This may increase costs to the publicly funded health care system [16], [29]. Second, research has also shown that people who use hospitals or emergency departments as the usual source of care face more substantial barriers to access to physicians [18] and have few alternatives to outpatient care [30], [31], [32], [33], [34], [35]. Many walk-in patients leave the emergency department without being seen because of long waiting periods [30], [31]. Third, persons who lack a regular source of care are more likely to experience delays in seeking preventive health care services [24], and are therefore at greater risk of chronic health conditions. If not having a regular provider of care is related to substantial barriers to receiving care and increased use of emergency departments in hospitals for non-emergency or minor problems, as some research suggests, then one strategy to improve access, quality of health care and reduce costs may be to promote affiliation with a PCP.

The objective of this study is to use national survey data to determine who is affiliated with a PCP in New Zealand. The specific aims of the study are to explore: (1) the demographic, (2) socioeconomic and (3) health behaviour and health characteristics of people who are affiliated/not affiliated with a PCP. We hypothesise that after adjusting for demographic, socio-economic and behavioural factors, those who have a greater need are more likely to be affiliated with a PCP. While identification of subgroups who are affiliated/not affiliated with a PCP is of interest in its own right, it is particularly important in the New Zealand context, mainly because the 2001 New Zealand Primary Health Care Strategy aims to reduce inequalities in health and ensure greater access to and use of preventive health services [36]. Secondly, the bulk of research on this area has been carried out mainly on European and American data and it is important to examine this issue outside the US and Europe to see whether the pattern established there applies elsewhere.

Data

This research used SoFIE-Health data, which is an add-on to the Statistics New Zealand-led Survey of Family, Income and Employment (SoFIE). SoFIE is a single fixed panel and is the largest longitudinal survey ever run in New Zealand. It is a nationally representative study of 22,000 adults drawn by random sampling of households, interviewed face-to-face. All adults in the original sample will be followed for a maximum duration of eight years starting from October 2002, even if their household

Results

Characteristics of those who were affiliated/not affiliated with a PCP are shown in Table 1, Table 2. Table 1 shows the bivariate association between the demographic variables and affiliation with a PCP. As can be seen, all associations are significant. Of the total of 18,320 respondents, 16,735 (91.3%) reported an affiliation with a PCP and 1515 (8.3%) reported no affiliation with a PCP. Region specific estimates of persons who were affiliated with a PCP ranged from 94.3% in rest of the South

Principal findings

Primary care in New Zealand is the most important gateway to the formal health care system, providing timely and comprehensive care and, when necessary, referrals for specialist care. Having an affiliation with a PCP or having a regular primary care provider has been used in this study as a measure of potential access that makes it more likely that services will be used.

The results of this study demonstrate the majority of our population reported having an affiliation with a PCP. However, the

Conclusions

In conclusion, this article examines the characteristics of those affiliated/not affiliated with a PCP and can serve as the baseline for other studies that use the newly available SoFIE-Health data to assess other aspects of primary health care. Some of the differences in affiliation with a PCP noted in this study suggest differential disadvantage in potential access to care (for example, Asian ethnicity), whereas others (age, gender) may reflect different patterns of health behaviour across

Statistics New Zealand security statement

Access to the data used in this study was provided by Statistics New Zealand in a secure environment designed to give effect to the confidentiality provisions of the Statistics Act, 1975. The results in this study and any errors contained therein are those of the authors, not Statistics New Zealand.

Acknowledgements

SoFIE-Health is primarily funded by the Health Research Council of New Zealand as part of the University of Otago's Health Inequalities Research Programme. Establishment funding was also received from the University of Otago, Accident Compensation Corporation of New Zealand (ACC), and the Alcohol Liquor Advisory Council (ALAC). Comments on this paper were received from Tony Blakely. We are grateful for the contribution of Ken Richardson and Kristie Carter in preparing the data set. We thank the

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  Affiliation with a PCP is especially important for improving a patient's overall health given that a PCP is usually the first point of contact, provides ongoing preventive care, and in New Zealand (NZ) and some other countries is a “gatekeeper” who facilitates access to more costly secondary and tertiary care (Goodyear-Smith et al., 2012). Our previous work has shown that male sex, never married, Asian ethnicity, current smokers, and having post school education were independently associated with lower odds of affiliation, while older age, reporting poor health and having one or more co-morbid conditions were associated with higher odds of affiliation (Jatrana and Crampton, 2009). While previous research broadly reports a positive association between the provision of primary care services and population health (Gulliford, 2002; Macinko et al., 2003; Shi, 1994; Shi and Starfield, 2001; Shi et al., 2002; Starfield, 1991; Starfield and Shi, 2002; Vogel and Ackermann, 1998), our research suggests a greater likelihood of poor health among those affiliated with a primary care provider (Jatrana and Crampton, 2009).

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  In particular there has been little research into the existing de-facto affiliation of patients with general practitioners (GPs) which may arise without the formality of enrolment, and little research into benefits of any existing informal affiliation. Affiliation with a single primary care provider, with the associated continuity of care, is considered to be one of the four critical features of primary care [6–8]. Studies have also found a strong negative relationship between affiliation and health expenditure for the most ill patients, and have showed that provider continuity reduces total health costs [8,9].

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