Conversations around general practice need to be about more than just access

20 years ago, when I started working in general practice, access meant navigating two heavy wooden doors that required a fair push to get them open.

After receiving a few comments from patients, we replaced them with a new electronically controlled front door that made access easier; the doors sensed patients approach and opened. That was great until the electronics malfunctioned and the door stayed fixed open, or sometimes, when the door wouldn’t open at all patients had to use a side door and narrow corridor with limited access for those with disabilities. Now, discussions about the ‘front door’ of general practice often focus on digital, rather than physical, access to care.

When patients visit a GP in a building, the front door is the first step in accessing care (and not the most significant). However, in a virtual world, there are many ways to access general practice including online (such as digital triage), via the phone (either directly to the practice, through call centres or indirectly via 111) and via professionals (for example, from A&E, or from ambulance service paramedics). These different methods can be confusing for patients to navigate and mean that there are multiple queues for a practice to deal with and ultimately, more methods that can malfunction (like the automatic doors). Increasing the number of entry points to general practice doesn’t result in more capacity to deal with patient need and, in fact, managing these processes may take up some capacity. If some methods offer faster or easier access for certain patient groups, there is also the potential for increasing inequalities, in particular digital exclusion.

'If some methods offer faster or easier access for certain patient groups, there is also the potential for increasing inequalities, in particular digital exclusion.'

While dealing with virtual options can potentially reduce capacity, some can help with demand. Some virtual methods of contacting general practice include signposting to support from other services and organisations, which is an active and interactive process. If it works well, patients quite correctly don’t even ‘get inside the building’, and this should in theory help with demand.

With the advent of population health and an increasing focus on health inequalities some patients are also actively being invited into GP practices, rather than seeking access themselves. This active ‘pull’ increases demand. Once ‘inside’ the building there may be more triaging, and an increasing number of professionals offering care and varying means to provide it including telephone, video and in person and online.

In general practice, it is not possible to separate accessing care from activities that happen before patients reach the ‘front door’ and after they enter it. The difference between access and care, and care and continuity, are not as distinct as sometimes portrayed and this is not likely to change with the increasing use of technology for both access to care and care delivery, more multidisciplinary roles and team working.

Focusing on appointments and access risks emphasis on transactional care and a commoditisation of health rather than recognising what general practice has to offer. General practice at its best, is relational and provides care across and individual’s lifespan and that gets lost in statistics about access.

We need to move away from talking about ‘the front door’ as a separate concept and focus attention on solutions that will improve access as part of understanding community need and providing good care. Access is only one part of the solution.

So, what is needed to make this happen? Integrated care systems are tasked with reframing health in communities, tackling inequalities and rooting this in population health. This means first, considering what a community needs, second, what care should be provided and third, how that care should be accessed. While changing the conversation about general practice will require national action around education, training, career development, workforce, funding and premises, it is also important for integrated care boards particularly at place level and general practices themselves to act. There is an opportunity for general practice to lead a conversation with local communities about what good care looks like within the resources that are available, and how to access it, not just within the practice but with other local care providers and within the community itself.

'We know that change works best with local ownership, with improvements based on local priorities.'

We know that change works best with local ownership, with improvements based on local priorities. Patients and staff need to be involved in this planning, recognising that it takes time, and nothing is going to be perfect. Change is hard and can be uncomfortable, however we can hardly describe the current worsening situation - falling public perception, a reduction in the number of GPs and increasing demand - as being ideal and it will not improve passively. It will require capacity and capability to engage with communities, co-design care and agree how it can be accessed. Practices will need to feel they own this work and steer it, rather than it being imposed.

While there are no easy answers and some problems pre-date Covid-19, if those working in general practice don’t address redesigning care, it won’t improve by itself.