How do you solve problems relating to access to general practice?
Making sure that people have reliable and prompt access to primary care is, of course, a challenge politicians have been trying to solve for many decades. An analysis by THIS Institute and the Health Foundation identified what we called a “zombie solution” where some options are revisited time and time again even though they never seem to make a real difference for patients. So how can we do better?
THIS Institute is addressing this question through a programme of research led by senior clinical associate and GP, Carol Sinnott and her team on improving access to primary care.
The work we have been doing shows that the candidacy framework can potentially help us to understand access differently and develop new solutions to the problems with access to general practice. The distinctive feature of candidacy is that it looks at the influences on access holistically, drawing attention to how people perceive their symptoms, identify GP services as being able to help them, have the resources (cognitive, physical, and other) to find their way to the right services, and can present their needs in a way that can be decided on and then processed, all in complex environments with limited resources. Candidacy is important because it shows how factors like low income and ethnicity can shape access, while looking at access through a candidacy lens encourages analysis to go beyond whether it’s possible to get an appointment with a GP on the same day, or how many appointments are available.
If you measure access to general practice in terms of the speed or number of appointments available, then it looks as though access is improving. But patient satisfaction with access to general practice is disimproving. This contradiction happens because the traditionally used measures hide important aspects of patients’ needs for general practice services. The candidacy framework offers an alternative way of looking at access: it is patient-centred, spans the entire patient journey, places emphasis on the healthcare encounter and recognises the powerful influences of socio-economic and institutional conditions on access.”
Dr Carol Sinnott
According to Kath Checkland, Professor of Health Policy and Primary Care, University of Manchester, who spoke at the THIS Institute’s annual conference, THIS Space, a major challenge is that even though numbers of staff in NHS general practice is rising, more demand for their services can mean there’s not enough care to go around.
Another challenge is how patients can access that care. Helen Atherton, Professor of Primary Care Research at Southampton University, who also spoke at THIS Space, says it’s key to make sure there’s always a range of options available. Emphasising the need not to forget older people, minorities and disadvantaged groups who might struggle with IT-based options such as e-consulting, she says, “There are some practices using e-consult as their main way of offering patient access, but in areas of deprivation and where there are high numbers of ethnic minority patients whose first language isn’t English this is automatically excluding people.”
However, problems can also arise through having multiple ways of getting an appointment because ‘layers of access’ “like a lasagne” says Helen, can be confusing, leaving people not knowing what they’re supposed to do.
The THIS Space panel, which also included Jake Beech, Azeem Majeed and Akbar Ansari, discussed how the expanding number of options available to patients for contacting their practice might in some circumstances lead to “supply-induced” demand – for example, people might use e-consulting to ask about things they might not have called their GP about in the past.
Any solutions to access will also clearly need to consider receptionists and other GP staff along with patients and GPs themselves. THIS Institute is currently working with RAND Europe, using data from 70 interviews with patients and general practice staff to explore their views in this area.
Patients’ experiences of access are of course also influenced by the capacity of healthcare professionals to deal with their concerns in the time they have. However, research from THIS Institute has shown the multiple barriers that stop GPs doing their jobs, many a result of operational and technological systems that GPs must interact with. Carol Sinnott has also identified the difficulties of managing care comprehensively within a ‘ten minute consultation’ particularly when around 25% of that ten minutes is needed to simply call patients in, read their history and write up their notes.
Carol says, “As new ways of doing general practice – like remote consultations, enhanced skill-mix and digital access technologies – become embedded, we need to prioritise ensuring that patients feel as known, as cared for and as safe as they did in general practice of old. We need to bear diverse needs in mind and to think about the whole range of influences on access and how services can be designed to take account of these.”