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:
- it circumvents care navigation and the telephone-first triage model that most practices we spoke to have adopted
- infection control efforts meant they preferred to speak to citizens before they came into the practice
- they moved away from pre-booked appointments because they were unable to reliably predict future staff capacity due to staff regularly calling in sick with COVID
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:
- ask far too many questions of citizens
- put up too many barriers between citizens and the practice
- inappropriately redirect citizens to A&E
Some practices added that:
- some citizens view questions asked by this tool as intrusive, which can lead to individuals entering inaccurate information
- being asked these questions by a GP feels different, less intrusive and is more likely to elicit the right answers
- not everyone can articulate in words online what is wrong with them, often answering with a vague or inaccurate phrases
- the overall effect is to reduce the quality of the information gathered through this tool, with it then taking extra time for the practice to unpick the issue and determine the best course of action
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:
- video consultations are more fiddly and less reliable, being dependent on the quality of both parties’ equipment and internet connection
- many problems can be resolved over the phone, with a face-to-face consultation typically being required for those that cannot
It is less clear how citizens feel about phone versus video, with the study reporting mixed responses.
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.
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:
- lack of consistent information about what to expect from online tools in terms of speed and next steps
- not being aware of online appointment request tools until needing them
- hearing they should use them via the practice’s recorded phone message
- being unclear if triage processes at the practice were the same for contact made digitally
- being “sent round in circles” – phoning the practice, being redirected to the website and then struggling to find the right option
- being unclear what to enter in individual fields due to lack of an overview of what questions would be asked and when
- inefficient routing through questions perceived as irrelevant
- lack of support for some common tasks (organise a follow-up; act on behalf of another adult) or conditions
- access to appointment booking switched on/off at unpredictable times or for only short periods
- unclear and inconsistent messaging about response times (“ASAP, 48-72 hours,” and “in due course” from the same practice’s system for the same instance of use)
- no functionality to discuss seeing a particular GP (for faith, gender, language reasons) weighed up against urgency or the patient’s sense of risk about a particular health issue
- discomfort with sharing photographs of children with the practice
- digital tools being called by their brand names rather than descriptions of the task they should support citizens with
Other examples included a simple lack of awareness that digital options were available.
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:
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:
- how they will be understood, used, and experienced by citizens alongside the various other access channels available to them
- the diverse needs of the citizens using them for the variety of tasks they are designed to support, and how well products meet those needs
- how they will work with the existing practice systems and processes
- guidance and support for practices implementing new digital tools or adapting to deal with the new types of demand coming through them
- what unintended consequences might occur and how they might be predicted and resolved
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.