Understanding access to general practice through the lens of candidacy: a critical review of the literature

Why it matters

Improving access to healthcare is often framed around whether people can get an appointment with their GP quickly – or at all. While this is important, it doesn’t give a complete picture of all the factors that influence people’s access to general practice or their experiences of doing so. This narrow focus risks overlooking other important aspects of access to general practice care.

The Candidacy Framework has been developed to help explain access to healthcare for people in vulnerable groups. It recognises that getting access is a complex process influenced by many factors. The Framework identifies seven key aspects which demonstrate how people enter and move through the healthcare system as ‘candidates’ for care, which are:

• Identification – how people recognise that they need medical attention
• Navigation – knowing what services are available and having the resources to use them
• Permeability – how easily people can find and use services
• Appearances – being able to communicate symptoms and the impact they are having.
• Adjudications – professional opinions or decisions which influence patients’ access to healthcare
• Offers and resistance – Offers of care that are either accepted or refused by individuals
• Operating conditions – local influences on the production of candidacy including suitability of available resources.

Primary care faces many challenges, including a reduction in the number of GPs and an increased demand for healthcare services. These challenges have led to public dissatisfaction and a political interest in ‘fixing’ the problems. However, if all factors that influence how people choose to access general practice services are not addressed, any potential solutions may risk failure, could have unintended consequences, or might even increase the inequities in the healthcare system.

Our study explored whether using the Candidacy Framework could provide a more comprehensive way of understanding access to healthcare in the setting of general practice.

What we found

Our analysis found that the seven features of the Candidacy Framework are highly relevant to general practice and provide a valuable way of helping to understand how people access services.

The Framework demonstrates that access to general practice is not just about supply or speed of appointments. It’s also about how people perceive their symptoms and general practices’ ability to help them, whether they have the resources (cognitive, physical, and others) to find their way to them, and whether they can present their needs in a way that can be decided upon and then processed; all in an environment that is complex and resource-constrained.

Even though access to general practice in the UK is free at the point of care, there are still barriers for some people, especially disadvantaged groups. Looking at access to general practice through the concept of candidacy highlights how much it depends on various factors, including socio-economic influences, and how this dependency creates risks to access. Our analysis also shows that understanding access only in terms of timeliness or supply of appointments is misleading and unhelpful.

Using the Candidacy Framework may help people working in general practice, practice organisation, or policy to think about where improvements to access are most needed, understand why previous efforts have failed, and identify promising solutions. While it may help to inform debate, policy choice, and research, the current framework might also be improved if it were tailored specifically to general practice, along with input and feedback from stakeholders.