Primary Care Pathfinder: discovery report – access to GP services
5.6 Access to GP services remains the main challenge for citizens
Participants who took part in interviews for this study were contacted in February 2022, after two years of the COVID-19 pandemic.
They said they understood health services were under pressure both before and since the pandemic started and agreed that prioritising certain people was important. Funding and resources were widely understood to be constraints.
What they found concerning, however, was being driven through the same process to talk to a GP, regardless of the reason for making contact or of their individual health backgrounds.
‘Potluck’ on phonelines
They struggled with getting through on busy phonelines, which relied heavily on what some called “potluck” or sheer persistence. Some described having to redial to join the call queue or to queue for 20-50 minutes each time they called, or both. Some found it more efficient to visit the practice in person.
Another talked about trying to access online bookings, constantly refreshing the webpage “like when you’re buying tickets for a concert” to check whether more appointment slots had become available.
Citizens felt practices had introduced barriers to access at a time when they were most in need, less able to cope and frequently without enough effort to forewarn them.
Our findings are supported by the results of a survey commissioned by DSPP, asking people in Wales about their experience of using NHS services, published in December 2021. 406 citizens participated in this study. It found that:
The two main reasons given by respondents were:
These findings were reinforced by NatCen’s 2021 British Social Attitudes survey, Public satisfaction with the NHS and social care 2021, published in March 2022. This study surveyed a nationally representative sample (across England, Scotland and Wales) of 3,112 people.
5.7 Managing demand is the main challenge for practices
The GP surgeries we interviewed were all struggling to cope with demand. By ‘demand’, we mean any external request to do something, and all the subsequent activity carried out by the practice to fulfil that request.
The primary care model for Wales recognises this challenge. It has several features aimed at reducing the level of demand coming into general practice in the longer term (described in section 5.2). However, we found there is only limited thinking around how practices can better manage the demand that does reach them. This is behind the curve in comparison with many other sectors, where digital technologies have been used to better manage demand for over a decade.
The practice initiatives we encountered included:
- care navigation being carried out by those answering the phones or fielding walk-in requests (described in section 5.3)
- a telephone-first appointment model (described in section 5.3)
- online appointment booking
- online consultations of various types
- making summary health records available to citizens online
The presence and practical implementation of each of these initiatives was very variable between practices. But critically, each of them was often being considered in isolation, rather than in the context of the whole access model that a practice presents to citizens.
By ‘access model’ we mean:
- the policies around when and how citizens can interact with the practice
- the channels through which citizens can interact with the practice
- how access options are communicated to citizens, for example, through practice websites
Access models are supported and affected by:
- how the processes used for those interactions are handled
- the staff that handle the demand
- the training and tools that support those staff
GP surgeries are largely free to shape their own access models. While there are national access standards, they are very high level.
A service’s access model influences how the service provider will experience demand. For example, depending on the type of demand, a provider may want to:
- divert an individual to another service where that specific need is better served
- route the request through specific communication channels because different types of demand are better served in different ways
- encourage the individual to serve themselves through digital channels, under certain circumstances
An access model can be designed to support and encourage these actions. The challenge is ensuring that all aspects of the model work together as a whole, for it to be as effective as possible at managing demand.
The model used needs to:
- be clearly communicated to and easily understood by the user
- guide the user to the best option for common tasks
- be clear about the purpose and relevant benefits of each option
- include clear messaging in each channel that is consistent with and supportive of the wider model
- balance meeting both the user’s and provider’s needs at every stage of a user’s task
A parallel example is local authorities where most citizen contact is for the same core tasks. Local authorities have identified these tasks and put them front-and-centre on their website home pages. They design their websites to be the first-choice destination for those wanting to make contact, and support and encourage self-service through digital channels wherever possible. This is typically faster and easier for the citizen as well as more efficient for the local authority.
General practice also serves a small set of common tasks that most citizens’ requests fall into. However, most practices do not have the expertise, time or money to design and implement a cohesive, multi-channel access model. Instead, they add new interventions to their existing systems over time, creating a changeable mix of options that have not necessarily been designed to work together.
Our research shows that this is confusing for citizens and may be adding to the demand problem rather than helping to manage it. This is because some demand is unintentionally generated by a practice’s failure to either do something or do something right for the citizen in the first place.
Lack of consultation clarity
An example of this might be someone visiting a practice website and then phoning the practice rather than making a request online, because it was unclear what they should expect from the online consultation. The individual may have preferred to use the online consultation rather than phone the practice. However, the lack of clarity forced the individual to use their traditional way of making contact.
This is a problematic consequence of GP surgeries being independent small businesses. Well-designed access models benefit from economies of scale. There are approximately 400 GP surgeries in Wales. An organisation with over 400 physical locations would routinely invest in the user-centred design and implementation of a cohesive access model across all locations, with enough flexibility built in to allow for variations in local needs. This is because the benefits gained from managing demand better would far outweigh the cost. This does not work for independent practices because they are individually responsible for their own access models.
Practices themselves acknowledged that being able to contact the surgery is a hurdle for many citizens, with one GP commenting: