Primary Care Pathfinder: discovery report – access and inequities


5.10 Different access models may lead to inequities 

We observed significant local variation in how GP services are accessed during our research. This may have become more pronounced during the pandemic.

Practices are widely trying to manage demand by time-limiting, or completely turning off, access to online consultation tools. Many have turned off the ability to book appointments online. Some have limited the ability to book appointments so that the only option is for citizens to phone in the morning to request a same-day appointment.

These actions are understandable given the struggle to meet demand and the specific challenges of the pandemic. However, these are not citizen-centred decisions and they do risk disadvantaging some citizens.

Channel choice may increase diversity

We saw some evidence that the variation in access models (see section 5.7) may affect health outcomes for citizens from practice to practice. Those that had opened online consultation services reported increased diversity in the groups of people presenting through these new channels. The implication is that offering a choice of channels can improve presentation rates for certain groups, potentially improving health outcomes and reducing cost in the wider health and care system. Limiting options may be having the reverse effect.

Also, a study into the effects of COVID in Wales (the Locked out report, 2021) describes how inequality has become even sharper for disabled people since 2019. Access to healthcare is one of many areas significantly affected. Root causes include simple lack of consideration about the impact of recent changes, says the report.

As demand has grown, one area where inequality may be increasing is where citizens who would be considered vulnerable due to their health conditions are not recognised as such by a “one size fits all” appointment booking process. Two participants with severe, chronic illness, reported receiving no preferential treatment when trying to see a GP. After long waits on hold on the phone, they were put through the same care navigation process as everyone else.

5.11 Digital tools have not been consistently successful

Many public-facing digital products have been introduced by GP surgeries in Wales. This started before the pandemic and accelerated sharply when national lockdowns were introduced in March 2020. This gave participants in this study at least two years of experience to reflect on.

We received mixed feedback from GP surgeries on the digital technology currently being used.

We found many practices had turned off online appointment booking. Reasons included:

Some described starting to reinstate the ability to book planned or routine appointments in advance online when the pandemic stabilised somewhat.

Online tools add demand

Online consultation tools were frequently reported to add new demand, particularly out-of-hours, without reducing the demand coming through traditional channels. This was made worse if the online consultation tool failed to integrate with the practice’s IT system, requiring information to be transferred manually by an administrator. As a result, some practices either turned these tools off altogether, or started limiting when they could be accessed.

This is an interesting finding requiring more investigation. A 2022 study of 7.5 million patient requests by the Health Foundation, Access to and delivery of general practice services, found that availability of online consultations did not stimulate additional demand. It noted that “this contrasts with anecdotal reports of supply-induced demand as a result of expanded access to general practice”. However, the study did not cover the point at which online consultations were first introduced into surgeries.

Participants told us of a specific online consultation tool that gives a poor user experience. It was reported by some practices to:

Some practices added that:

84 screens to get a prescription

In our own experiment with this tool, it took 84 screens to request a prescription for over-the-counter medicine for an existing health condition. The process would have been completed much faster and more easily by phone.

Video consulting has generally fallen out of favour with GPs. This was evident from stakeholder and practice staff interviews, as well as the Health Foundation study mentioned above. The recurring themes were:

It is less clear how citizens feel about phone versus video, with the study reporting mixed responses.

Video consulting

A specific example of a video consulting tool was criticised by practice staff. They reported that it took the control of video consultations away from GPs and did not integrate with their IT systems, meaning information had to be manually transferred between the two.

Some smaller, for example, single-handed practices were not using any public-facing digital tools beyond a simple website. They did not see the need to offer online options when operating with one GP and successfully managing demand by telephone.

We found a consensus among our citizen participants that digital tools introduced by practices were not proving difficult because they were digital, but for other reasons: how they were introduced, managed, and supported; then, how there was an absence of communication to citizens to say they were there and explain how they worked.

We believe this because everyone in the sample group had the skills to participate in a video call, use email and other devices or apps.

Mixed results

Despite this digital proficiency, participants described using the specific tools available to interact with their GP surgery with mixed results, often finding them inefficient and unsatisfactory.

Reasons we heard included:

Other examples included a simple lack of awareness that digital options were available.

‘The receptionist told me one time, ‘You do realise we’ve got an app?’ She gave me a code, I downloaded the app, it was really straightforward. Comms is purely word of mouth’


For some people in specific situations, digital systems offer clear benefits for privacy and remaining anonymous. Communicating online removes any awkwardness of talking about a condition aloud, particularly knowing you could be overheard in a practice waiting room:

‘When I’m calling for an appointment being asked why by receptionists – I don’t like being asked – it’s personal. It’s private’


One participant mentioned she also thought hard before telling the practice about her anxiety symptoms – and that she did this by email rather than over the phone.

Overall, while digital tools have not been consistently successful in primary care, we largely found clear and avoidable reasons for that. It was evident that digital products have been sourced and then ‘bolted on’ to existing GP surgery operating models without sufficient knowledge of, or consideration for:

Digital tools should remain an important part of plans to address access and demand challenges in primary care. We should learn lessons from the experiences of introducing digital tools during the pandemic. Many participants we spoke to across all areas of our research feel now is the time to intensify efforts to use digital tools more effectively in primary care.

Next: Opportunities for further work and next steps