How can theory contribute to optimising access to general practice? A qualitative participatory case study in Greater Manchester

Problem

Access to general practice in the NHS receives much political attention through policies intended to ‘improve access.’ However, many do not clearly define access, nor consider relevant literature. Instead, they rely on an assumption of access as timely access. Compounding this, the problems of access are not adequately assessed before touted solutions are applied. Furthermore, the reasons ‘improving access’ are often absent or illogical. These efforts have unintended consequences, which can strain limited resources, confuse patients, raise expectations, and contribute to increasing health inequalities. We aimed to bridge the gap between the literature and interventions by using access theory in multiple ways. We embraced Leveque’s conceptual model of access as the fit between system accessibility and population abilities. We aimed to apply the theory to understand complex access problems before determining interventions. Our underlying aim is to optimise access to general practice—a valuable, strained resource—in order to reduce population health inequalities.

Approach

We focused on a single CCG area with significant health inequalities, as a case study. We combined our theory-informed approach with qualitative participatory research. We brought an annotated version of Levesque’s model to engagement meetings to build a research team of local stakeholders. We used the model as a visual prompt during interviews and focus groups with patients and healthcare staff, and during observation sessions in surgery reception areas and public meetings. We referred to the model during an on-going, iterative, inductive analysis process. This approach allowed us to further develop access theory.

Findings

Much of our data confirms the relevance of broad conceptualisations of access, rather than the narrow definitions assumed in policies. In addition to population abilities—affected by knowledge, health status, and health literacy—our findings recognise the crucial role of the abilities of people working within the healthcare system. We advance a theory of access as the interaction of the abilities of people working within the system—affected by resources, rules, and skills—with population abilities. Furthermore, we position continuity as an important component of access, rather than something at odds with access, as it is often assumed. We demonstrate how and why continuity is valued, and extend it to include receptionist continuity, which can supplement the challenge of clinician continuity. Finally, we describe specific place of access to general practice, to facilitate ideas to optimise this limited resource.

Consequences

Our utility and advancement of access theory can serve as a model for others trying to understand and address access problems in order to optimise NHS resources and reduce population health inequalities.