Primary Care Pathfinder: discovery report – changes to access
5.8 Practices are changing how citizens access services
GP surgery staff spoke of a public perception (validated by research with citizens, among other sources) that GP surgeries were not seeing anyone face-to-face, when in fact they “never closed their doors”.
Practices described how the pandemic had changed how they handled appointments in the following ways:
- most appointments were conducted face-to-face, although some practices had moved to a telephone-first model (described in section 5.3) to better manage demand
- online bookings were often available for all kinds of appointments (bookable in advance) and some raised issues around citizens booking the wrong appointment to get a “foot in the door”
During the pandemic:
- all appointments became telephone-first triages for infection control reasons – only carrying out in-person consultations later with those who needed them and did not have COVID symptoms
- practices that resisted telephone consultations pre-pandemic discovered that they could do more than they thought through telephone consultations – so it is now as much about managing demand as it is about infection control
- most practices stopped using online bookings when the pandemic began because of the move to a telephone-first approach, the need to control who comes into the practice and planning capacity in advance
- some practices are slowly moving back to opening online bookings for routine and health campaign generated appointments, such as reviews, smears, and flu vaccinations
- there remains some concern that citizens will continue to book into the wrong type of appointment – one practice solves this by someone checking routine appointments to ensure that only those eligible are booked in and, where not, contacting those individuals to make alternative arrangements
- there is recognition of the need for a blended model that gives citizens choices about how they interact with their practice
‘Changes without explanation’
Experiences from citizens highlighted how, in their view, practices had introduced changes without attempts to explain or raise awareness about how new systems worked.
Some people were looking for reassurance that using new channels (a digital tool, for example) would not put them at a disadvantage to those using the phone. Where in doubt, they would try all or any channels they could.
Some people managed this well; others said the experience made them feel let down and, in some cases, angry that they were expected to absorb new ways of doing things that did not appear to have been designed with patients in mind.
The impact of these changes has strained doctor-patient relations. We heard both warm praise and real concern from citizens about the way practices were managing their services in 2022, with several interviewed blaming politics, austerity and social changes for the mismatch between demand and supply of GPs.
One said he was “pleasantly surprised and grateful” that anyone at the practice responded to his request early in the pandemic. Another was visibly upset by the process introduced over the same period at a practice in the same area of Wales:
In interviews with practices we heard how, from their perspective, they are working extremely hard to manage during challenging times and with limited resources. Some practice staff hope patients will cooperate, sometimes voicing frustration that not everybody understands what is happening backstage.
Emotional and practical support
It is also clear from citizens and some GPs we spoke to that many doctors have consciously adapted their language and processes to provide emotional, therapeutic and practical support where they have noticed someone in need. Our research emphasised how important it is to use language and processes citizens understand and to provide emotional and therapeutic, as well as clinical, support.
We heard many times that some digital tools were not meeting various user needs, including those of basic efficiency and appropriate options for certain types of requests.
One online consultation tool proved particularly onerous, asking “the same question five times”. It also did not provide routes for standard tasks such as booking follow-up appointments, only allowing ‘yes/no’ options for answers at times where nuance would have been helpful.
5.9 Citizens’ preferences for accessing services depend on the context
There is compelling evidence in research of the need for choice over how services can be accessed by citizens. While the nature and severity of a person’s health condition is a clear factor when determining preferences for making and attending appointments, our user research heard how other aspects of patients’ lives (location, transport options, capabilities) also mattered significantly.
We heard how, on a case-by-case basis, an in-person appointment or remote conversation was strongly preferred by the same individual.
One citizen who worked long hours in a demanding job, described past irritation at long waits at the practice for face-to-face appointments in the past:
This person went on to describe how the process for phone appointments needed greater consideration, particularly when expected call-back times were missed by the GP, meaning the patient missed the phone call when it did come.
Ringing back, they were told they would have to rebook the appointment “as the doctor can only call once”. They felt this was an inflexible approach.
Others interviewed expressed similar experiences; one patient whose detailed understanding of a serious, chronic condition – and the implications of leaving it untreated during flare-ups – meant they pressed for an in-person appointment where treatment had to be administered in person.
Outside such relapses, the same person voiced a strong preference for telephone consultations with their secondary care specialist to avoid a tiring and painful journey:
This person was not offered a video call but said they would have preferred that over other options for check-up appointments, “because the consultant’s actually looking at you”.
They felt the visual element to be important to communication and in helping the doctor to read their condition.
Others felt remote communication was not only acceptable but preferred in certain circumstances, including:
- those whose conditions made leaving the house difficult
- those whose caring responsibilities made travel difficult
- where access to the practice was difficult
It became clear that there are opportunities to reduce the effort needed to travel to face-to-face appointments by using telephone and video consultations, provided that practices consider individual circumstances and preferences when offering these options to citizens.
The overriding consideration in each case was the nature of the reason for contact, with “high stakes” situations (any potential bad news diagnosis) more likely to need an in-person appointment.
Our research findings support recommendations from Healthwatch England, Five principles for post-COVID digital healthcare (Healthwatch England, 2021):
- Maintain traditional models of care alongside remote methods and support people to choose the most appropriate appointment type to meet their needs.
- Invest in support programmes to give as many people as possible the skills to access remote care.
- Clarify patients’ rights regarding remote care, ensuring people with support or access needs are not disadvantaged when accessing care remotely.
- Enable practices to be proactive about inclusion by recording people’s support needs.
- Commit to digital inclusion by treating the internet as a universal right.
Some of the practices we spoke to recognised the need for a blended model in future, which gives citizens a choice of how they want to interact with GP surgeries.
Some also noted that new channels like online consultations have led to groups of citizens presenting that would not have done so previously: