General practice is a critical part of the NHS. Offering ‘cradle to grave’ continuous care, GPs and their teams are responsible for managing acute illness and long-term conditions, and providing preventative care. GPs also have a key role in coordinating patient care and ensuring appropriate referrals to urgent and routine hospital care. Poor access to general practice has a range of negative impacts, including unmet care needs, avoidable harm (for example via delayed diagnoses or referrals) and inappropriate use of other NHS services.
For all its importance, general practice in England has an access problem. Or – more accurately – access problems. In recent years, patient satisfaction with access to general practice has plummeted. Dissatisfaction covers multiple domains, including the experience of making an appointment, waiting times for appointments and the type of appointment offered (eg whether it is in-person or telephone). Meanwhile, pressures in general practice are high. Despite government promises to recruit more GPs, the number of fully qualified, permanent full-time equivalent (FTE) GPs has fallen since 2015. But patient demand is rising fast, and appointment numbers are at record highs, putting further strain on remaining GPs.
Improving access to general practice is a priority for all political parties, and policy ‘ideas’ are emerging. The Labour party, for example, suggests expanding self-referral schemes for some conditions and creating new ways to access primary care via ‘neighbourhood health centres’. The current government has tried to improve access via a mix of routes, including:
- increasing the number and range of health professionals working in general practice (giving patients access to professionals with different skillsets)
- requiring practices to work together to extend their opening times
- supporting practices to improve their telephony and triage systems.
But access is still a problem, and initiatives to improve it are unlikely to work unless they fully understand the problem they are trying to solve.
A major challenge is that access to general practice is traditionally seen through the lens of ‘supply’ – things like how many GPs there are, and the number of GP appointments available. These things are critical, of course: access to general practice can’t happen if there’s no capacity. They are also things the NHS routinely measures.
Yet thinking about access in this way can obscure broader factors that influence people’s access to care – things like how people decide what to do about symptoms, their knowledge of health services and the barriers they may face in reaching services. Thinking too narrowly about access also risks undermining different dimensions of access that matter to patients beyond simply getting a GP appointment – including its speed, convenience, whether it’s online or in-person, and more. The ‘candidacy framework’ – first developed by Mary Dixon-Woods and colleagues – is a broader way of understanding access to health care services.
This long read is the first in a series of outputs from a collaboration between the Health Foundation and researchers at The Healthcare Improvement Studies Institute (THIS Institute). We draw on the candidacy framework to build a more holistic understanding of general practice access issues. We first summarise headline data on access to general practice, introduce the candidacy framework, then analyse previous approaches to improving access, to inform future policy efforts.
We have also created an 'options list' (see Appendix 1), a resource that catalogues and categorises attempts to improve access to general practice with a view to informing future improvement efforts. The list includes interventions that have already been tried, are ongoing or have been proposed, and categorises them according to how they are intended to improve access to general practice.
