How the candidacy framework has been used in research on access to general practice

Why it matters

Access to general practice is a widespread health services concern, especially for patients, who increasingly report difficulty booking appointments, longer waiting times, and interactions that do not meet their needs.

Although researchers have found different ways to describe access to healthcare, one major barrier to real improvement is that public debate tends to focus on how many appointments are available, or how quickly someone can be seen.

One alternative to this is to try and understand access using the candidacy framework, which was first introduced in 2006. This approach looks at the multiple influences on access and how they are structured, and views access to care as something that changes depending on circumstances, rather than something fixed.

The framework highlights seven elements:

1. Identification of candidacy: how people realise they need care
2. Navigation: how they find their way through the system
3. Permeability of services: how easy services are to use or ‘get into’
4. Appearances at health services: how people present their needs to a service
5. Adjudications: how services and healthcare professionals judge those needs
6. Offers and resistance: how people respond to what is offered
7. Operating conditions: the wider conditions that affect how services operate

Our goal was to find out how this framework – and each of its seven parts – has been used and evaluated in research about general practice. We wanted to look at published research that has used the candidacy framework to study general practice, and ask two key questions:

• How has the candidacy framework been used in studies about general practice?
• How have studies using the candidacy framework in research on general practice regarded and engaged with each of the seven features of the framework?

What we found

We reviewed 73 published articles to understand how the candidacy framework has been used and critiqued in the academic literature on general practice.

Overall, we found that the concept of candidacy and its features are seen as valuable in revealing the varied influences on access to care amongst different social groups that extend beyond simply having enough appointments available.

Our analysis also shows that the candidacy framework is a useful way to help understand why improving access to general practice is such a difficult challenge. It explains, for example, why simply increasing the number of appointments in general practice may not solve the problem, because so many other features of candidacy – such as an ability to coherently describe one’s needs – also affect people’s experiences of access.

The literature we reviewed suggests ways in which candidacy might be improved or changed when used in the context of general practice, which include:

1. Emphasising that help-seeking is a repeating cycle shaped by past experiences and outcomes, which affect future expectations and behaviours.
2. Recognising that people may hold multiple, sometimes conflicting, “candidacies” based on their illnesses and socio-cultural identities (a sense of self and belonging shaped by social structures, cultural practices, and shared values, beliefs, and experiences.)
3. Paying more attention to the quality of patient-doctor relationships, trust and familiarity, continuity, and patient-centredness.

Some studies recommend changing the order of or interaction between different features, adding new features, adding new parts to existing features, or adding new features to better reflect today’s more complex and digital general practice environment.

There’s also evidence that researchers are applying the framework in different, sometimes overlapping ways, especially as general practices increasingly rely on digital technology and remote consultations to deliver care. As general practice care continues to evolve, the candidacy framework provides a useful tool for understanding access issues and informing the development of practical, actionable equity-based solutions for improving access.