Access to general practice in a time of austerity

TENSIONS IN MANAGING ACCESS

Now, more than ever, we need to understand more about the complexities of managing access to primary care. In this issue, three articles focus on the topic of access. Making good use of diverse qualitative methodologies, the articles uncover some of the tensions involved.

Drinkwater et al investigated how health professionals responded to policies intended to reduce the use of unscheduled care by people with long-term conditions, through proactive and preventive management in primary care. Staff at the sharp end described conflicts between their responsibilities for responding to what they saw as genuine and legitimate needs for care, and for acting in line with policy directives to reduce unscheduled care use.4 Hammond et al undertook an ethnographic study of receptionists, observing and talking with them in order to document and understand their roles, including the management of access.5 Receptionists similarly described a difficult tension between their role in managing demand in accordance with practice policies, and a sense of responsibility for helping patients navigate the system. They managed this tension by making informal judgements about the legitimacy of patients and their requests, and described going out of their way to help those patients that they perceived as genuinely needy to gain access. Campbell et al6 used ‘mystery shoppers’ to investigate whether access scores from the GP Patient Survey reflected patients’ ability to get an appointment. They did, confirming that patient survey reports about access, including findings of inequities between patient groups in their experiences of access, are valid.

POLICY AND PERSONAL INTERACTIONS

Access connects to a wider set of issues including patients’ approach to self-management, their knowledge and experience of services, and their skills and resources in choosing and navigating their way into services. When patients present at services, staff have to make difficult decisions about which patients are deserving, and how best to support them to gain access, in the face of pressures to manage demand. In this context, policy, whether national or at practice level, is subject to interpretation in negotiations between professionals and patients. It is here that some groups of patients, who may lack the resources or skills needed to present themselves as deserving patients, or have limited knowledge about how they are expected to use services, can be disadvantaged.7

Policymakers need to better understand what happens when the policies they lay down come face to face with sick and anxious people, and the healthcare staff who are trying to help them. These papers highlight the importance of working with patients and frontline staff in developing local and national policies on access, so that the realities of managing access as it occurs can be taken into account. But policy changes alone are not enough to solve the problems of access. Practices need to be committed at an organisational level to enabling access for vulnerable patients, to ensure their systems facilitate this, and to train and support their reception staff to operate these systems flexibly.

MONITORING ACCESS FOR DISADVANTAGED GROUPS

In the future, practices will have to give a higher priority to monitoring and managing access. The Patient Survey can be relied on to provide valid information, but the explanation for poor access scores will vary. Some practices will have particularly high demand for care because the population has high levels of chronic disease as a consequence of deprivation, or large numbers of older patients. All practices need to be aware of patient groups that have greater difficulty in accessing care. Such patients include the housebound, people with disabilities, people with chronic mental illness, the homeless, travellers, and many other groups. It is unusual for practices to be able to identify and enumerate the patients they have in these categories, but this needs to change, and be followed by practice processes to protect access for these groups. When there is pressure on access, they are most likely to suffer first.

While individual practices can work to improve their responsiveness to the needs of vulnerable and disadvantaged groups, increasing demand will continue to be a challenge. The solution may be to find better ways of matching the supply of primary care to the needs of the population. Federations or large groups of practices may be better placed than individual practices to direct resources to where they are most needed, although the creation of such groups of practices will face many challenges and have profound implications for the structure of general practice.

Ready access to primary care, and in particular, to a ‘usual GP’, has important consequences for the health system, including lower use of emergency departments and fewer emergency admissions.8 Policymakers must do their utmost to maintain the capacity of general practice to meet demand, otherwise hospitals will be swamped and the sustainability of the NHS in today’s climate of austerity will be brought into question.

Conclusion

In the coming decade, resources for the expansion of general practice will be severely constrained, and practices will need to pay close attention to those patients who find negotiating their access to care most difficult. Much may be done in the day-to-day exchanges between patients and receptionists to ensure equality in access, and GPs and practice managers have key responsibilities in agreeing practice policies with receptionists and supporting them in enacting these policies in a flexible way. Policymakers at national level must facilitate the development of such practice-level policies, and practices should monitor the extent to which vulnerable patients obtain the access they need.