When more isn't more: how process shapes access to primary care

There is an apparent disconnect in the data when it comes to the state of access and primary care. In October 2024, a record 38 million people saw their GP, with 15 million booking on the same day. Despite this, satisfaction with accessing primary care remains low, with issues to do with access being the most frequently cited cause. What's going on?

Access to primary care is important to the public: surveys by both the BSA and Policy Exchange consistently highlight that ‘making it easier to see a GP’ is a top priority for the public, with a majority prioritising access in this area over secondary care. Its political salience is also clear – primary care is the most frequently accessed part of the health care system, and our view of it often shapes our view of the NHS as a whole (and so the machine of government more broadly). For policy-makers, addressing this pain point therefore offers not just political rewards but also an opportunity to meet a genuine public need.

Making it easier to see a GP’ is not analogous to ‘making more appointments available in my local practice’. The former statement encapsulates availability, yes, but it may also involve the process of seeking an appointment, as well as who you are seeing. Both bear consideration. In this blog, I focus on the former, as the latter issue has been well covered in a recent report by the Nuffield Trust into the changing nature of the health care workforce.

Many people will have an anecdote about the burdensome process of seeking an appointment in general practice – whether that’s via the ‘8am rush’ or a convoluted online form. There’s an inherent disrespect for people’s time built into the system, and poor process is all too common for people using the NHS. In my clinical practice, patients routinely express more frustration with the complexity and inefficiency of the system than with wait times. Such anecdotal frustration is corroborated by recent research by the GP-SUS team at the Universities of Oxford and Warwick, with the process of booking an appointment feeling like a perverse game of snakes and ladders. You may be ready in the queue at 8am, helped by a friendly member of reception staff who knows you well, only for staff sickness to result in your appointment getting moved to a day when you don’t have childcare, forcing you to start the process all over again. Practices clearly don’t set out to offer such a dispiriting service, but the team’s research shows a disparity between practices’ desire to care for their population and the uncaring feel of the system that patients must contend with.

This is not just frustrating but inequitable. These systems may be harder to navigate for those with additional needs, or with less time, and these people may sit with their needs unmet. These issues may be compounded for those with multiple long-term conditions. Modern triage systems and e-consult services may ask such individuals to continually restate chronic health concerns. This repetition can be exhausting and impersonal, as it can feel as if the system does not remember them. But difficulty does not have to be the default, and process can be a facilitator when done well and designed with people.

A focus on activity metrics (such as the number of patients being seen, ie, how much the system is doing) has missed the qualitative aspect of accessing care. While efforts to improve access has largely focused on two strategies – altering pathways to appointments and increasing system capacity – the NHS has largely prioritised the latter. This may be because what is measured is what is prioritised, and so activity-based targets lead to activity-based interventions. Clearly, activity metrics alone are proving a poor surrogate marker of satisfaction with primary care. In the NHS, this choice to prioritise activity metrics may stem, in part, from the difficulty of measuring qualitative patient-centred outcomes, which are less readily quantified than activity data.

That said, there has been a welcome shift in focus recently. The 2025/26 planning guidance chooses patient experience as the outcome of choice when measuring improvements in access to primary care. This follows the elective recovery plan’s emphasis on timely, tailored information for patients, which represented a step in the right direction by recognising the importance of reducing the burden and frustration of navigating the system. This is a positive shift in direction, and improvements in this area may be more achievable than ramping up activity, as well as aligning with stated aims to shift to digital and improve patient choice.

However, gathering qualitative patient-centred data is hard and the choice of dataset may give concern. The GP Patient Survey (GPPS), for example, is a rich resource but one that only offers year-on-year data. Robust gold-standard data like this takes time. This has contributed to measures of activity being more obvious North Stars, as they are more readily available. The ONS Health Insight Survey is the metric of choice in this initial shift and like all data sets it has trade-offs: while it is collected monthly, it is smaller and less robust than the GPPS, with data that stretches to the primary care network level but not individual practices. That said, if the data point has shortcomings, these should be addressed by investing in improving the robustness of data or at least be accounted for when making evaluations of performance.

Looking ahead, the development of a 10-year plan provides an opportunity to double down on this shift in how access is measured and improved. Although convenient, activity metrics do not capture the whole story. To genuinely improve access, policy-makers must continue to prioritise improving the process and feel of care. Even if this is more challenging to measure, it also presents an alternate avenue to improving access, where activity alone has failed. Sustained progress will require a broader shift, not just in rhetoric but in focus – from measuring what is easy to what matters.