Two Neighbourhoods, One Clinic
A regional health service runs one clinic serving two suburbs 6 km apart. Northbank has 8,000 residents, a median household income of $92,000, and a bus every 10 minutes. Southgate has 11,000 residents, median income $48,000, one bus every 45 minutes, and 22% of households without a car. The clinic offers weekday appointments 9am–4pm. Data show Southgate residents are three times more likely to miss appointments and twice as likely to present to the emergency department for conditions manageable in primary care. The clinic manager proposes a $15 no-show fee to reduce missed appointments. A community health worker says Southgate patients often miss appointments because of shift work, childcare and travel time. The clinic has a small budget and a waiting list of three weeks.
1. Analyse the no-show fee proposal. Who is likely to be affected and how does context shape the outcome?
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The fee treats non-attendance as an individual choice problem, but the data point to contextual barriers.
Who is affected:
- Southgate residents on low incomes, shift workers, carers and people without cars are most likely to miss appointments and therefore most likely to pay.
- Northbank residents with reliable transport and higher incomes are least affected.
How context shapes outcome:
- A $15 fee is a larger share of income for a $48,000 household than a $92,000 one; it is regressive.
- It may deter booking altogether, shifting demand to the emergency department - the opposite of the goal.
- It does not address the 45-minute bus frequency, the 9am–4pm window, or childcare.
Equity lens: a policy applied uniformly to unequally situated groups produces unequal burdens. The fee may reduce appointments without reducing unmet need, and could widen the gap between suburbs. It also risks eroding trust with a community already under-served.
2. Propose a package of changes that would improve access for Southgate, and explain how you would evaluate it.
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Package (multi-level):
- Access: extend hours to include two evenings and Saturday morning; offer telephone or video consults for follow-up.
- Transport: partner with a community transport service or subsidise taxi vouchers for people without cars; coordinate appointment clusters with the bus timetable.
- Reminders and flexibility: SMS reminders 48 hours ahead with a one-tap reschedule; allow same-week swaps.
- Outreach: a community health worker based in Southgate for navigation and preventive care.
- Drop the fee and replace it with a reminder-and-reschedule system.
Evaluation design:
- Outcomes: did-not-attend rate by suburb, ED presentations for ambulatory-care-sensitive conditions, proportion of Southgate residents with a regular GP.
- Process: uptake of evening slots, voucher use, time-to-appointment.
- Equity check: disaggregate results by suburb, income and car access to confirm the gap narrows rather than the average improving.
- Feasibility: cost per additional attended appointment; monitor waiting list so gains in one group do not displace another. Use a before-after comparison with a comparison clinic if possible, and report limitations.