Is ‘Candidacy’ a Useful Concept for Understanding Journeys through Public Services? A Critical Interpretive Literature Synthesis

Abstract

Across the public sector there is concern that service uptake is inequitably distributed by socioeconomic circumstances and that public provision exacerbates the existence of inequalities either because services are not allocated by need or because of differential patterns of uptake between the most and least affluent groups. A concept that offers potential to understand access and utilization is 'candidacy' which has been used to explain access to, and utilization of, healthcare. The concept suggests that an individual's identification of his or her 'candidacy' for health services is structurally, culturally, organizationally and professionally constructed, and helps to explain why those in deprived circumstances make less use of services than the more affluent. In this article we assess the fit of candidacy to other public services using a Critical Interpretive Synthesis of three case studies literatures relating to: domestic abuse, higher education and environmental services. We find high levels of congruence between 'candidacy' and the sampled literatures on access/ utilization of services. We find, however, that the concept needs to be refined. In particular, we distinguish between micro, meso and macro factors that play into the identification, sustaining and resolution of candidacy, and demonstrate the plural nature of candidacies. We argue that this refined model of candidacy should be tested empirically beyond and within health. More specifically, in the current economic context, we suggest that it becomes imperative to better understand how access to public services is influenced by multiple factors including changing discourses of deservedness and fairness, and by stringent reductions in the public purse. levels of service uptake are inequitably distributed by socio-economic circumstances -the 'sharp elbowed middle classes' (or at least the relatively more advantaged) appear able to benefit disproportionately from provision across a range of public services including health, education, housing, leisure and cultural services (Le Grand 1982;Gal 1998). Indeed, across a range of services there is evidence that universal public provision, which often paradoxically operates with explicit goals to reduce inequalities, can exacerbate the existence and experience of such inequalities through a range of implicit mechanisms that advantage the most privileged. These mechanisms include those associated with both supply and demand factors.Supply factors include the extent to which services are sufficiently resourced to target need, the degree to which systems work to overcome barriers of accessibility and the ways in which individual workers practice inclusiveness (Meier and Stewart 1991;Gal 1998;Rummery and Glendinning 2000;Priestley et al. 2010). On the demand side, explanations focus on the different perceived relevance of services and differential capacity of the wealthiest and poorest groups in society to make the best use of services. This in turn can lead to a stigmatizing discourse about those who do not eng...

What works and why in the identification and referral of adults with comorbid obesity in primary care: A realist review

“…Table explains the seven candidacy constructs in relation to access to WMS, drawing on the findings from this review. It is worth reiterating here that, while the constructs are presented in an apparently linear fashion (for the sake of simplicity), the process is inherently dynamic and iterative …”

How can socioeconomic inequalities in hospital admissions be explained? A cohort study

“…In the UK, the flat distribution of GPs across areas of widely contrasting socioeconomic status rations the time available to address the higher prevalence of multimorbidity in deprived areas, reducing the scope to prevent or postpone emergency admissions 23 30 32. The lower expectations of people in deprived areas33 34 may also explain their less than expected use of non-emergency cardiology services 35…”

Illness identity as an important component of candidacy: Contrasting experiences of help-seeking and access to care in cancer and heart disease

“…For instance, other researchers have extended Dixon-Woods' concept and adopted the Candidacy lens when exploring healthcare access across a range of social groups (Hunter et al, 2013;Klassen et al, 2008;Koehn, 2009;Kovandzic et al, 2011;Mackenzie et al, 2013;Purcell et al, 2014) and propose additional dimensions (race, gender, symptom-type), often alongside social disadvantage, that similarly impinge on the Candidacy process.…”

“…Such utilisation approaches contend that if services are made available, the potential for use is present and access is possible. Others have argued that even universal healthcare systems, albeit unintentionally, foster (if not exacerbate) health inequalities and there is a need therefore to dig beneath the surface of access (Gal, 1998;Le Grand, 1982;Mackenzie et al, 2013).…”