Permeability – how easily do older people from ethnic minority backgrounds gain access to services?
Dixon-Woods’ original framing of this dimension of candidacy was specifically focussed on access to health services. She therefore fittingly used the analogy of a membrane through which those seeking a service must find their way to gain access to the service, in the same way as cells must find their way through membranes in the human body.
We move in this dimension from micro-level interaction and motivations to the meso-level, where systemic patterns of organisation start to influence access. The NHS has as a fundamental principle a free-at-point-of-access policy and a GP appointment system. In this sense it is a highly permeable service (Dixon-woods, 2005) requiring, beyond GP registration, only a phone call, or drop in to a GP surgery, to arrange an appointment for access. However, many older people from ethnic minorities experience a barrier at this point due to language difficulties. In the south of Glasgow, where there is a high concentration of non-English speaking people, NHS services are relatively well prepared to provide interpretation services. In addition, the study found that people from Pakistani, Indian and Afghan communities in the area were able to gain access to Doctors who shared their ethnic backgrounds and this greatly aided their experience.
One of the main barriers to accessing services experienced by the older people we spoke to was language. It was noted by some that there are lots of Pakistani and Indian doctors in Glasgow so language and culture is not as much of an issue when it comes to accessing health services as it is for social care services. People who have families can have them help with language if this is needed. Some people have found it difficult to get interpreters for appointments at times – Advocacy Connections report
The Afghan community, which is relatively small in Glasgow, was able to gain informal access to a medical Doctor who was part of their community and works in one of the hospitals in the area and although this was not their exclusive means of access to health services, they found this did increase the permeability of this service for them.
This level of resourcefulness was less apparent when it came to social services. Many participants displayed a level of suspicion and reluctance to engage with social work:
Reluctance to engage with social workers was apparent from many of the people who took part in the consultation. Specifically, there were people who wanted to access a service and were told they would need to do this through their social worker. Some people would rather not have the help they need than have contact with the social work department. Discussions indicated that many people see engagement with social work as an indication you have done something wrong – Advocacy Connections report
Religio-cultural influences in Muslim tradition suggest that accessing social services may be seen as “shameful” by relatives of older people as well as by older people themselves (see discussion under 1 – Identification above). This may be at the root of these findings regarding attitudes to social work. There is certainly no sign that they are based on direct experience of social work services as it is that very experience that is avoided.
This reluctance is reflected from the other side of the lens. Social work managers are aware of low numbers of presentations from older people from ethnic minorities – as well as from younger members, despite being able to point to initiatives aimed at increasing engagement from people from ethnic minorities, and the fact that some day centres used by older people from this group were only accessible through social services.
People tend to engage in health issues first. It seems to take a crisis – a health crisis – before we engage with people from ethnic minorities, usually through hospitals – Social work manager
The issue, specifically for engagement with social work services, is less about low permeability of the service than it is about identification of candidacy in the first place; there is a tendency among people from Islamist faiths – who make up the bulk of the population of people from ethnic minorities in the south of Glasgow – to avoid intentional engagement with social work for religio-cultural reasons.
No such reluctance existed among those participants in the study regarding accessing small, community based services. One of these provided a meeting place and a range of activities in a multi-cultural setting within a diverse cultural community and was well used by older people from a range of backgrounds. This service was highly permeable and attendees were able to take up the various services on offer as and when they desired. Drop-in advice and support services received similar patronage under similar conditions of access.
Day centre services were more complex. Of the four visited as part of this study, all of which were ethno-specific services, two were accessible via social work referral. Despite the foregoing discussion, these were well used by older people from ethnic minorities and had waiting lists of potential attendees. Demand was such that, if a place became temporarily available due, for example, to the illness of a regular attendee, this was filled on a temporary basis by someone from the waiting list. This suggests that the perceived desirability of the service on offer outweighs other considerations. These particular services offered socialising opportunities. They were places where people could mix informally, interact and take part in various socially based activities – all qualities that were highly valued by participants in this study. Their value motivated the older people and their families to overcome both the relatively strong low permeability of these services and their antipathy towards social services in order to gain access.